Every finding on record at Sante of Chandler

Based on interview and review of facility records, policy, and procedure, the facility failed ensure payroll based journal was submitted according to federal requirement. The deficient practice could lead to inability of a third party to audit the facility's staffing.Review of Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing data report dated April 1 - June 30, 2025, revealed the facility failed to submit staffing data for the quarter.An interview was conducted with the facility administrator (Staff #6) on February 18, 2026, at 9:43 a.m. who stated that the facility's process for submitting the PBJ staffing data is through electronic submission, and to submit it by a deadline date. The administrator stated that for the quarter April 1 - June 30, 2025, that the facility tried to submit the staffing data but missed the deadline. The administrator stated that the facility's new process moving forward is to submit the PBJ staffing data a week early to ensure the deadline is not missed.Review of the facility policy titled Reporting Direct-Care Staffing Information (Payroll-Based Journal), dated October 2017, revealed staffing and census information will be reported electronically to CMS through the Payroll-Based Journal system in compliance with 6106 of the Affordable Care Act. Policy interpretation and implementation included:1. Beginning with the fiscal quarter of 2016 (beginning July 1, 2016), direct-care staffing and census information will be reported electronically to CMS through the Payroll-Based Journal (PBJ) system.2. Direct-care staffing information includes staff hired directly by the facility, those hired through an agency, and contract employees.3. Providers who are employed by the facility (including physicians) are included in direct-care staffing information; providers who bill Medicare directly are not included.4. For auditing purposes, reported staffing information is based on payroll records, or other verifiable information.5. Information may be uploaded to the PBJ system manually, or through a payroll time and attendance system, or a combination of both.6. The PBJ system is accessed through the QIES at https://www.qtso.com/.

Based on observation, staff interviews and review of the clinical record, the facility failed to ensure that services met professional standards of quality by failing to prepare medications according to provider orders, requiring surveyor intervention prior to medication administration to one of six sampled residents (#21). The deficient practice has the potential for the resident not receiving the appropriate treatment and for additional errors in treatment administration. Findings include: During medication administration observation conducted on February 19, 2026 at 9:23 a.m., a Licensed Practical Nurse (LPN/staff #118) was observed to review Resident #21's order in the electronic medical record (EMR) and then place two Buspirone HCL 15mg (milligram) tablets in a clear medication cup for Resident #21. The LPN proceeded to remove a medication card out of the medication cart, and began to place the medication into the same medication cup with the two Buspirone. At this time, the surveyor stopped the LPN and asked for clarification of the order for Buspirone. The LPN reviewed the order and stated that the resident was ordered 1/2 of a 30 mg tablet, which would be 15 mg. She stated that she had not read the order accurately and placed two 15mg Buspirone tablets in the medication cup, which would total 30mg. The LPN immediately removed one of the 15mg Buspirone tablets and placed it in the waste receptacle. An interview was conducted on February 19, 2026 with the LPN (staff #118) at 9:40 a.m. directly after administration of Resident #21's medications. The LPN stated that she would have administered the Buspirone medication in error if the surveyor had not intervened. She stated that this did not follow the facility policy, and that the expectation is to follow physician orders as written. She stated that she did not follow the orders or the facility policy for medication administration. An interview was conducted with the Assistant Director of Nursing (ADON/staff #1) on February 19, 2026 at 11:18 a.m. She stated that medications should be administered following physician orders, exactly as the provider ordered. She stated that the risk of administering Buspirone outside of physician orders could result in side effects that may include sleepiness/tiredness. The ADON reviewed Resident #21's medical record and stated that there was an order dated January 21, 2026 for Buspirone HCL Oral tablet 30 mg, to give 1/2 tab twice a day at 8:00 a.m. and 2:00 p.m., which would be 15 mg twice a day. She stated that if the nurse placed two 15mg tablets in a medication cup to administer to the resident then that would be a medication error variance. She stated that this would not meet the facility policy for medication administration. A policy titled, Administering Medications, revealed that medications shall be administered in a safe and timely manner, and as prescribed. Medications must be administered in accordance with the orders. The individual administering medication must check the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on observations, interviews, and policy review, the facility failed to ensure that services met professional standards of practice during medication administration using a pill cutter. The deficient practice could result in cross-contamination of medications. Findings include: During an observation of medication administration on May 30, 2024 at 8:33 A.M. the licensed practical nurse (LPN/staff #3) was observed cutting the large pills she identified as hydralazine, vitamin C, and amlodipine using a white pill cutter. After breaking the pills, she returned the pill cutter in the top drawer of the medication cart without first cleaning it. An interview was conducted on May 30, 2024 at 9:14 A.M. with an LPN (staff #3). The LPN stated that there was only one pill cutter in the drawer and that she was not familiar with the process after using it to cut medications. An interview was conducted on May 30, 2024 at 9:19 A.M. with the Director of Nursing (DON/staff #143). The DON stated that to cut big pills, a pill cutter was used and the medication was given to the resident one at a time. She stated that there was a pill cutter in the medication cart. Further, the DON stated that after using the pill cutter to cut a medication the nurse had to wipe it with a tissue or clean it with bleach wipes before putting it back in the medication cart. In addition, the DON said that the risk for not cleaning the pill cutter was that medication left in the pill cutter can mix with other medications and possibly cause an interaction. The DON said her expectation was for staff to clean a pill cutter after each use.

Based on observation, clinical record review, staff interviews, and policy reviews, the facility failed to ensure one resident (#269) was assessed to determine clinical appropriateness to self-administer medications. The deficient practice could result in medications not being taken as ordered. Findings include: Resident #269 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure with hypoxia, congestive heart failure and asthma. Review of the physician order summary revealed an order dated May 25, 2024 for albuterol sulfate HFA (hydrofluoroalkane) inhalation 2 inhalation inhale orally every 6 hours as needed for cough, azelastine HCL (hydrochloride) nasal solution 1 spray in both nostrils one time a day for allergies, Budesonide-Formoterol Fumarate Inhalation Aerosol 2 inhalation inhale orally two times a day for interstitial lung disease rinse mouth and throat after use, and Latanoprost Ophthalmic Solution 0.005% Instill 1 drop in both eyes one time a day for glaucoma. Further review of the physician order revealed no order for the resident to self-administer medications. During an observation on May 28, 2024 at 9:46 A.M. in resident #269's room, a light blueish inhaler and a nasal spray was observed on the resident's over the bedside table and an eye drop was observed on top of the round table in his room. There were no staff present. At 9:52 A.M. licensed practical nurse (LPN/staff #76) was asked to come in resident #269's room and he identified the items as an inhaler, nasal spray, and an eye drop. Review of clinical records revealed no documentation that the resident was assessed by the interdisciplinary team (IDT) as a candidate to self-administer. Review of the care plan revealed no evidence that self-administration of medication was part of resident's care planning. An interview was conducted on May 30, 2024 at 10:29 A.M. with LPN (staff #57). The LPN stated that when administering medications, she makes sure that it is the right patient, route, dose, and documentation. Further, the LPN stated that she does not leave the medications with the resident but instead observes the resident take the medication. The LPN said the reason for that was the patient might not take the medication or somebody might come and take it from the resident. The LPN said she could be written up if she left the medication with the resident. An interview was conducted on May 31, 2024 at 10:01 A.M. with the Director of Nursing (DON/staff #143). The DON stated that a doctor's note or order was required in order for residents to self-administer medication. In addition, the DON stated that the resident would require an assessment by a nurse to self-administer a medication and if they can the medications were locked up in the resident's room and the staff would hold the key. The DON further stated that medications are not supposed to be left at the bedside without a doctor's order or assessment. The potential risk for leaving medications at bedside was overdose, interactions with other medications, and the medications can be taken incorrectly, for example, an eye drop might be taken orally. Review of the facility's policy title, Administering Medications, revised December 2012 revealed, Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. Review of the facility's policy titled, Self-Administration of Medication, revised December 2016 revealed Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so.

Based on observation, interviews, and records review the facility failed to ensure 1 of 1 sampled resident (#57) received appropriate indwelling catheter care and treatment. The deficient practice could result in residents developing complications related to indwelling catheter. The findings include: Resident #57 was admitted to the facility on [DATE] for diagnoses of fracture of sacrum, low back pain, chronic obstructive pulmonary disease, atrial fibrillation, and long-term use of anticoagulants. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. The assessment also coded the resident had an indwelling catheter. Review of the physician order dated May 11, 2024 revealed the following orders: -Catheter size 16 French/10 cubic centimeters balloon for diagnosis of retention/failed void trial -Catheter care as needed for catheter maintenance. -Catheter care every shift, every day and night shift for catheter maintenance. -Change catheter for dislodgement/clogging as needed for catheter maintenance. Review of the care plan for the use of an indwelling Foley catheter revealed the resident had an altered elimination related to urinary retention with failed voiding trial. Interventions included routine catheter care every shift and as needed. An observation of catheter care was conducted on May 30, 2024 at 1:13 P.M. with certified nursing assistant (CNA/staff #108). During the catheter care, the outside of the tube had a collection of a white substance, approximately 2 inches from the penile meatus. The CNA (staff #108) applied pressure to remove the white substance. The CNA used a clean white wash cloth with soap and water to cleanse the resident's penis and groin. After cleaning the resident, the used white wash cloth was slightly brown. After the catheter care, the resident asked the CNA to be repositioned. An interview was conducted on May 30, 2024 at approximately 1:30 P.M. with resident #57 after the catheter care observation. The resident stated that catheter care had not been completed prior to the observation nor was it done daily. An interview was conducted on May 30, 2024 at 1:31 P.M. with a CNA (staff #108) regarding the catheter care she completed. According to the CNA, based on the buildup on the catheter tubing and her observation of the resident's perineal area, the resident had not had catheter care today or within the last 12 hours. The CNA stated that the resident was at risk for urinary tract infection (UTI) if catheter care was not done daily. The CNA verified the resident's medical record and identified that no other CNAs had performed catheter care yet that morning. The physician order for catheter care every shift, every day and night shift for catheter maintenance was transcribed in the Treatment Administration Record and revealed that on May 30, 2024, catheter care had been documented as completed by a Licensed Practical Nurse (LPN/staff #68). An interview was conducted on May 30, 2024 at 1:42 P.M. with LPN/staff #68. The LPN stated that she had completed catheter care at approximately 10:20 A.M. that morning and that she was accompanied by LPN/staff #60. An interview was conducted on May 30, 2024 at 1:45 P.M. with an LPN (staff #60). The LPN stated that she had assisted staff #68 with resident #57's wound care. The LPN (staff #60) stated she did not recall being involved in the catheter care for resident #57 while they were in the room and that their main focus while in the room was treating the resident's wound. Review of the staff schedule for May 30, 2024 revealed LPNs staff #68 and #60 were assigned to complete treatments. An interview was conducted on May 30, 2024 at 2:03 P.M. with the Director of Nursing (DON). The DON stated that catheter care was done to prevent bacteria from backing up causing a UTI. The DON stated that the expectation was for staff to perform catheter care and then chart that it was completed. The DON also stated that it did not meet her expectations when staff charted catheter care was completed when it was not. On May 30, 2024 at 4:11 P.M. an interview was conducted with a CNA (staff #87) who stated that nurses completed catheter care and thought it was done in the morning. An interview was conducted on May 31, 2024 at 8:56 A.M. with a CNA (Staff #149) who stated that CNAs completed catheter care every shift. The CNA stated that when she opens Point Click Care (database for storing electronic records), she was triggered to complete catheter care once a shift. The CNA stated that sometimes treatment nurses would complete the catheter care for the CNAs because they were already in the room performing wound care and then they would let the CNAs know that it had been done. The CNA stated that the process for catheter care included putting on a gown and gloves because the resident would be on enhanced barrier precaution and used soap and water in a basin or perispray (perineal spray) with a wash cloth. The CNA continued and stated to then pull foreskin back, depending if the male resident was circumcised or not, and clean around the area. The CNA stated that cleaning would start from the penis then down to the catheter tube--cleaning away from the penis. The CNA said the risk for not cleaning thoroughly was that resident could develop a UTI. A follow up interview was conducted with LPN (staff #60) on May 31, 2024 at 9:53 A.M. who stated that every staff completed catheter care. The LPN added that male resident had exudates around the catheter tubing at the entrance where the tubing entered the body. Regarding catheter care, the LPN said she would bring all the items she needed, which included hygiene wipes, spray cleaner for pericare (perineal care). The LPN said she would start the process by washing her hands and putting on PPE (personal protective equipment), for that particular person (referring to resident #57) she would put on gown and gloves. Then, the LPN added, clean from where the tubing goes into the penis outward, using multiple wipes, and if there were a lot of exudate she would use the spray to loosen it. The LPN stated it must be cleaned starting from the penis outward to prevent pushing bacteria into the body and cause an infection. A follow up interview was conducted with the DON on May 31, 2024 at 10:23 A.M. regarding the process for catheter care. The DON stated that staff must first introduce themselves, then sanitize hands and put on gown and gloves. The DON said if the male resident had foreskin to retract and clean. The DON then said she would have to review the process on how to perform catheter care because it had been so long since she had done one but her expectation was for staff to follow the steps on catheter care. The DON added that nurses and CNAs completed an annual skills review that included catheter care. A telephone interview was conducted on May 31, 2024 at 11:14 A.M. with LPN/staff#68. The LPN stated the process for catheter care for male residents was to pull skin back and clean area and then the Foley line, then clean the scrotum and groin. The LPN stated that yesterday, May 30, 2024 she only cleaned the line and it was not total catheter care. The LPN said the expectation was to pull skin back and clean everything. The LPN stated she did not clean the resident's penis, just the line. The LPN said she should not have marked the TAR for catheter care as completed because it was not a thorough catheter care and the risk for not performing a thorough catheter care was infection. Another interview was conducted on May 31, 2024 at 11:27 A.M. with the DON who stated she reviewed catheter care process which included getting a wash basin with water and soap. The DON added, to clean the groin first then the penis, retract the foreskin, hold catheter and clean around the shaft and get another wash cloth with water and soap and clean down the tube, then dry with dry wash cloth. Review of the facility's policy titled, Urinary Catheter Care revised on August 2022 revealed, the purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. Perineal care - use soap and water or bathing wipes for routine daily hygiene. Clean the area under the foreskin in uncircumcised males daily; and The following information should be recorded in the resident's medical record: 1) the date and time that catheter care was given, and 2) The name and title of the individual (s) giving the catheter care.

Based on observations, staff interviews, and policy review, the facility failed to ensure food was served in accordance with professional standards for food service safety. The deficient practice could result in foodborne illnesses. Findings include: During an observation for lunch preparation on May 30, 2024 at 11:46 A.M. dietary staff #59 was using a food thermometer to check the temperature of a chicken for a chicken sandwich while the sandwich was on top of a white cutting board. At 11:47 A.M. the staff left the thermometer on top of the white cutting board used to cut the chicken sandwich. At 11:51 A.M. another staff (#36) was observed entering the kitchen and proceeded to scoop soup from a pot using a ladle without performing hand hygiene. After scooping the soup, the staff (#36) then attempted to open a plastic bag before washing her hands in the kitchen sink then left the kitchen with the container of soup. At approximately 11:55 A.M. an interview was conducted with staff #36 and she stated that she should have washed her hands before she scooped the soup from the pot. During a continuous observation of lunch preparation, staff #144 was observed leaving the kitchen and walking towards the dining area while holding a Styrofoam container. At 12:07 P.M. staff #144 came back in the kitchen without performing hand hygiene and proceeded to the tray line where the food trays were lined up. Staff #144 then opened the refrigerator door and removed milk cartoons out of the refrigerator without performing hand hygiene. At 12:09 P.M. staff #144 then washed his hands. During a dining room observation on May 30, 2024 at 12:14 P.M. there was a small sink in the corner of the dining room with an empty soap and paper towel dispenser. An interview was conducted on May 30, 2024 at 1:16 P.M. with a cook (staff #115). He stated that the dining area did not have a sink for guests to wash their hands but that there were bathrooms. An interview was conducted on May 30, 2024 at 4:29 P.M. with certified nursing assistant (CNA/staff #87). She stated that the residents could wash their hands using the sink in the dining area in the mini corner, and residents were assisted with hand hygiene before going to the dining room area and leaving the dining room. She added that there was no hand sanitizer in the dining room. An interview was conducted on May 31, 2024 at 9:07 A.M. with Culinary Service Director (CSD/staff #144). He stated that they have different color-coded cutting boards and that everything was wiped down in the morning, and sanitized before starting work. The CSD stated that every staff must wash their hands before performing any kitchen duties. He added that staff washed their hands every time after they touch their face, touch paper that comes from the outside, and every time they touch any products to avoid cross-contamination. Further, the CSD said if the staff come into the kitchen, they must wear hairnet and wash their hands. When someone goes outside the kitchen, they have to wash their hands when they come back to the kitchen. The CSD also stated that staff must sanitize the stem of the thermometer probe and the thermometer should not be on the counter but on the wall of the refrigerator because it has a magnet. He added, it was cross contamination if the thermometer was left on the cutting board. The facility's policy titled, Handwashing/Hand Hygiene, revised October 2023 revealed All personnel are expected to adhere to hand hygiene policies and procedures to help prevent the spread of infections to other personnel, residents, and visitors.

Based on observation, interviews, and records review the facility failed to ensure appropriate infection control practices were used during catheter care for one resident (#57). The deficient practice could result in the spread of multi-drug resistant organisms (MDROs) to residents. The findings include: Resident #57 was admitted to the facility on [DATE] for diagnoses of fracture of sacrum, low back pain, chronic obstructive pulmonary disease, atrial fibrillation, and long-term use of anticoagulants. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. The assessment also coded the resident had an indwelling catheter. Review of the physician order dated May 11, 2024 revealed the following orders: -Catheter size 16 French/10 cubic centimeters balloon for diagnosis of retention/failed void trial -Catheter care as needed for catheter maintenance. -Catheter care every shift, every day and night shift for catheter maintenance. -Change catheter for dislodgement/clogging as needed for catheter maintenance. Review of the physician order dated May 29, 2024 revealed an order to maintain enhanced barrier precautions per facility policies and procedure; however, medical records reveal a Foley catheter was started on May 11, 2024 for resident #57. An observation was conducted on May 30, 2024 at 1:05 P.M., an enhanced barrier precaution (EBP) signage on the resident #57's door frame. An observation of catheter care was conducted on May 30, 2024 at 1:13 P.M. with certified nursing assistant (CNA/staff #108). During the catheter care the CNA's scrubs were touching the resident and the CNA was not wearing a gown. After the catheter care was completed the resident asked the CNA to be repositioned. The CNA (staff #108) left the room to get another CNA (staff #148) to assist with repositioning the resident. Both CNAs were not wearing a gown while repositioning the resident. An interview was conducted on May 30, 2024 at 1: 30 P.M. with a CNA (staff #148) who stated the sign on the door meant the resident was on precaution and that gown and gloves had to be work to protect staff from exposure to bodily fluids. The CNA stated that they should have worn a gown when repositioning the resident. An interview was conducted on May 30, 2024 at 1:31 P.M. with a CNA (staff #108) while standing outside of resident #57's room. The CNA stated that the signage on the door meant the resident was on EBP. The CNA stated that the sign meant a gown and gloves had to be work when residents had an IV (intravenous line), Foley catheter, or ostomy. The CNA added that she should have worn a gown when handling resident #57's Foley catheter. The CNA stated wearing a gown protected him (referring to the resident). The CNA stated that PPE (personal protective equipment) did not have to be worn to reposition the resident. An interview was conducted on May 30, 2024 at 2:03 P.M. with the Director of Nursing/Infection Preventionist (DON/IP). The DON/IP stated that residents who had Foley catheters, IVs, tube feedings, and an open wound were placed on EBP to help prevent the spread of MDRO (multidrug resistant organism). The DON/IP stated that when providing care, transferring, toileting, and any other physical contact with residents on EBP the staff had to wear a gown and gloves. The DON/IP also stated that staff would need to wear a gown when performing catheter care because of the potential risk of spreading anything in their urine. The DON/IP stated that the process of putting on PPE for EBP for any patient care was to don gown and gloves and after patient care was completed, doff gown and gloves before leaving the room. On May 30, 2024 at 4:11 P.M. an interview was conducted with a CNA (staff #87). The CNA stated that residents with Foley catheters and open wounds were on EBP and that gloves and a gown were worn when providing care for those residents. The CNA stated that staff should wear a gown and gloves when repositioning residents in bed because staff are touching the resident's sheets and it was close contact. An interview was conducted on May 31, 2024 at 8:56 A.M. with a CNA (staff #149). The CNA stated that the process for catheter care included putting on a gown and gloves because the resident would be on enhanced barrier precaution. A follow up interview was conducted with LPN (staff #60) on May 31, 2024 at 9:53 A.M. regarding catheter care. The LPN said she would start the process by washing her hands and putting on PPE, for that particular person (referring to resident #57) she would put on gown and gloves. A follow up interview was conducted with the DON/IP on May 31, 2024 at 10:23 A.M. regarding the process for catheter care. The DON stated that staff must first introduce themselves, then sanitize hands and put on gown and gloves. Review of the facility's policy titled, Enhanced Barrier Precautions revised on August 2022 revealed that it is EBP are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. Gloves and gown are applied prior to performing the high contact resident care activity. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: transferring, providing hygiene, changing linens, device care or use (urinary catheter). EBPs remain in place for the duration of the resident's stay or discontinuation of the indwelling medical device that places them at increased risk.

Based on observations, staff interviews, the glucometer guide, and review of policy and procedures, the facility failed to ensure infection control standards were maintained regarding glucometers and hand hygiene. The deficient practice could result in transmission of infection. Findings include: Regarding the glucometer A medication administration observation was conducted on March 8, 2022 at 12:05 p.m. with a Licensed Practical Nurse (LPN/staff #200). The LPN took a glucometer from the medication cart drawer and placed it on top of the medication cart. The LPN then entered the resident's room and was observed to check a resident's blood glucose level, exited the room and placed the glucometer directly on top of the medication cart. The LPN was then observed to take one alcohol pad (saturated with 70% Isopropyl Alcohol) and wiped the front of the glucometer. After this procedure she placed the glucometer in the medication cart. An interview was immediately conducted with staff #200, who stated that cleaning the glucometer with an alcohol pad is the normal practice in the facility. An interview was conducted on March 8, 2022 at 12:54 p.m. with an LPN (staff #93). Staff #93 stated the process of checking a resident's blood sugar included wiping the glucometer with an alcohol pad before and after use because it dries quicker. The LPN also stated that sometimes he uses a bleach wipe. An interview was conducted on March 9, 2022 at 11:02 a.m. with the Director of Nursing (DON/staff #17), who stated that his expectation for cleaning the glucometer included the use of bleach wipes with a kill time of 3 minutes before and after use. On March 9, 2022, the DON provided the Professional Operator's Manual and In-Service Guide for the glucometer. The glucometer cleaning and disinfecting guidelines listed only EPA (Environmental Protection Agency) approved products. The 70% Isopropyl Alcohol pads were not included on the EPA list of approved disinfecting products. Regarding hand hygiene -A [MEDICATION(S)] insulin medication administration observation was conducted on March 8, 2022 at 12:05 p.m. with an LPN (staff #200). The LPN was observed donning a clean pair of gloves without performing hand hygiene. Staff #200 then prepared the insulin injection on top of the medication cart. The LPN administered the injection, doffed the pair of gloves, held the dirty needle with the ungloved right hand, exited the room and disposed of the needle in the sharps' container on the medication cart. Immediately, without performing hand hygiene, the LPN donned a clean pair of gloves, prepared a [MEDICATION(S)] insulin medication and was observed to administer the injection to the same resident. The LPN was then observed to doff the pair of gloves, hold the used needle with the ungloved right hand, and exit the room. The LPN disposed of the needle in the sharps' container located on the medication cart. The LPN was observed cleaning the injection pen with ungloved hands. Staff #200 then placed it back in the medication cart. No hand hygiene was observed after the procedure was completed. -A medication administration observation was conducted on March 8, 2022 at 12:40 p.m. with an LPN (staff #93). Staff #93 was not observed to perform hand hygiene prior to donning a clean pair of gloves. He then prepared and administered medications to a resident. While waiting for the resident to take the medications one at a time, staff #93 took off the dirty pair of gloves, and placed his hands inside his uniform's pants pockets. Staff #93 used an ABHR (alcohol-based hand rub) before exiting the room. An interview was immediately conducted with staff #93, who stated the normal procedure for a medication pass included hand washing before and after medication administration and before leaving the room. An interview was conducted on March 9, 2022 at 11:02 a.m. with the DON (staff #17). The DON stated the process of medication administration included hand hygiene with ABHR, then checking for the right resident, right dose, right time, right route, and knocking prior to entering the resident's room. Staff #17 stated that after medication administration, ABHR must be done prior to leaving the resident's room. The DON also stated that his expectation during medication pass included hand hygiene before and after contact with a resident, and different route of administrations. A facility policy, Handwashing/Hand Hygiene, stated the facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. The policy also stated to use an ABHR before and after direct contact with the resident, before and after preparing or handling medications, after removing gloves, and after contact with a resident's intact skin.

Based on clinical record review, staff interviews, and review of policies, the facility failed to ensure that a physician's order was obtained and care and services were provided to one of two sampled residents (#255) admitted with an indwelling urinary catheter. The deficient practice could result in residents not having an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Resident #255 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The initial Admission Evaluation dated February 23, 2022 at 11:31 p.m. revealed the resident was able to correctly state name, birthdate, current date, place, and occurrence. It also revealed the resident had an indwelling urinary catheter in place. Review of the initial admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of nursing skilled notes dated February 24 and 28, 2022, revealed the resident had an indwelling Foley catheter. The admission Minimum Data Set assessment dated [DATE] revealed a score of 15 on the Brief Interview for Mental Status which indicated the resident was cognitively intact. The MDS included the resident had an indwelling catheter and the diagnosis [CONDITION(S)]. A physician order dated March 1, 2022 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . However, no catheter size was included on the physician order. A care plan initiated on March 1, 2022 revealed the resident has altered elimination as exhibited by indwelling Foley catheter usage. The interventions included providing routine catheter care every shift and as needed. However, further review of the clinical record revealed evidence catheter care was provided every shift in March 2022, but did not reveal evidence that catheter care was provided every shift for February 2022. An interview was conducted on March 10, 2022 at 10:30 a.m. with the Director of Nurses (DON/staff #17). The DON stated the process and his expectation when admitting a resident with a Foley catheter is there must be an order. The DON stated the nursing admission assessment included the Foley catheter and that if there was no order for the catheter, the nurse conducting the admission assessment must call the physician for an order. The DON stated the Foley catheter order must include the size, diagnosis, Foley care every shift and as needed, and changing the drainage bag as needed. An interview was conducted on March 10, 2022 at 12:07 p.m. with a Licensed Practical Nurse (LPN/staff #57). The LPN stated the process for when admitting a resident with a Foley catheter includes an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The LPN stated if she observed a resident with a Foley catheter and there was no order for the Foley catheter, she would call the physician to obtain an order. The LPN stated the licensed nurses and/or certified nursing assistants can provide catheter care. The LPN further stated catheter care is done every shift and as needed and is documented on the TAR (Treatment Administration Record). The facility's policy Urinary Catheter Care revised September 2014 stated to review the resident's care plan to assess for any special needs of the resident. The date and time that catheter care was given should be recorded in the resident's medical record. The policy also stated if the resident refused the procedure, the reason(s) why and the intervention taken should be recorded in the resident's clinical record. A review of the facility's policy titled Medication and Treatment Orders revised July 2016 revealed orders for medications and treatments will be consistent with principles of safe and effective order writing. Review of the facility's policy Charting and Documentation revised July 2017 revealed documentation in the medical record may be electronic, manual or a combination. Treatments or services performed are to be documented in the resident medical record.

Based on observations, clinical record review, resident and staff interviews, and policy review, the facility failed to ensure one resident (#52) with wounds was provided a clean and homelike environment, by failing to ensure the resident's soiled bed linens were changed timely. The sample size was 16. The deficient practice could result in residents not being provided clean bed linens. Findings include: Resident #52 was admitted to the facility on [DATE] with diagnoses that included [CONDITION(S)], depressive disorder, surgical wound on right foot and hypertension. Review of the care plan initiated on 02/19/2022 revealed the resident had multiple stage 4 pressure ulcers and wound to the bilateral lower extremities, buttock, thigh and scrotum and was at risk for new skin injury related to mobility decline, history of prior pressure ulcers with graft, and digit amputation. The goals were that the resident would have improved skin integrity by participating in the rehab plan to improve mobility and using preventative skin treatments, would not develop further skin breakdown, and the wounds would show signs and symptoms of healing. Interventions included administer treatment to wound/skin impairment per physician's order and encourage off-loading or frequent shifting of position while in bed or chair. Review of the clinical record revealed a physician order dated 03/03/22 to cleanse the right heel and plantar foot with wound spray, pat dry, apply medical grade honey, cover with [MEDICATION(S)] and DD, and wrap with Kerlix every Tuesday, Thursday and Saturday on the day shift and to monitor for changes. During an observation of the resident's room conducted on 03/07/22 at 1:19 PM, the resident was observed on a Bariatric bed. A brownish, red stain that appeared to be dried blood was observed on the resident's bed sheet just below the resident's right foot and was approximately 10 centimeters by 12 centimeters in size. During the observation, an interview was conducted with resident #52, who stated he believes the stain is blood from the last wound dressing change. The resident stated that he has not asked that the bed sheet be changed because he does not like to get out of bed. Resident #52 also stated that he does not remember when the lower bed sheet was last changed. A review of the nurses notes from admission on 2/19/22 through 3/7/22 revealed no mention of blood or other spilled fluid on the resident's sheets. Another observation was conducted of the resident on 03/08/22 at 12:20 PM. The lower bed sheet was observed to still have a brownish, red stain at the foot. The resident stated that the staff offered to change the bed sheets, but he refused. The resident stated that he does not know how long it had been since the staff changed the sheets. An interview was conducted on 3/08/22 at 1:02 PM with the Certified Nursing Assistant (CNA/staff #137) providing care for the resident. Staff #137 stated that she changes residents' sheets daily. The CNA stated that she had not noticed the dried blood stain on the sheet until the resident brought it to her attention a few minutes ago. She stated she attempted to change the sheet only to find that the sheet was attached to the bariatric mattress and she could not change the sheet. Staff #137 stated that she notified the nurse manager who is looking into the matter. The CNA stated that she does not remember changing the resident's sheets before. An interview was conducted on 03/08/22 at 1:23 PM with the Licensed Practical Nurse (LPN/staff #93) providing care to the resident. The LPN stated that she administered the resident's morning medications but did not notice the dried blood on the sheet. The LPN also stated that the dressing change was done that morning by the resource/wound nurse. On 03/08/22 at 1:30 PM, an interview was conducted with the resource/wound nurse (staff #64). The nurse stated that she changed the resident's dressing that morning and did not notice the dried blood on the sheet. Staff #64 stated it was brought to her attention by staff #137 that there was dried blood on the sheet and the sheet could not be changed without replacing the mattress. The nurse stated the company that delivered the bed was notified and would be coming to change it. When asked if the lower bed sheet had been changed before, she stated that she thinks it has, but is not sure. She stated the bed sheets should be changed if there is any stain on them. Staff #64 added that she does not remember spilling blood on the sheet or if the resident's dressings were taken off or soiled before. Another interview was conducted with resident #52 on 03/10/22 at 09:02 AM. The resident stated that the lower bed sheet was changed. The resident stated that he had to be transferred to another bed so they could change out the mattress. The resident added that this was the first time he had been transferred out of bed and had the lower mattress/sheet changed before. An interview was conducted with the Director of Nursing (DON/staff #34) on 03/10/22 at 10:06 AM. The DON stated that the resident's sheet should be changed frequently and immediately if it is stained with blood. She added that it is her expectation that the CNAs and nurses be aware of the resident's linen and sheets. The DON stated that the resident's bed sheets should have been changed many times since being admitted . A review of the facility policy titled Quality of Life - Homelike Environment (revised May 2017) stated staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs. This policy included providing clean bed linens and a sanitary environment.

Based on clinical record review, resident and staff interviews, and policy and procedure review, the facility failed to ensure one of two sampled residents (#107) received pain medications per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Finding include: Resident #107 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's note dated March 6, 2022 stated the resident was oriented to person, place, time and situation. Review of the Order Summary Report revealed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan initiated on March 7, 2022 revealed the resident has the potential/actual alteration in comfort/pain related to recent hospitalization , deconditioning, and has a [MEDICATION(S)] pain pump with bolus ability every 2 hours. The goals were that the resident would have relief from discomfort or pain and the discomfort/pain would not interrupt the resident's daily routine. Interventions included administering analgesics as ordered, observing for breakthrough pain and reporting, and reviewing pain medication efficacy to ensure desired therapeutic effect is achieved. Continued review of the Order Summary Report revealed the following physician orders: -Acetaminophen 325 mg (milligrams) two tablets by mouth every 6 hours as needed for pain 1-5/10 on pain scale of 0-10/10 dated March 7, 2022. -[MEDICATION(S)] 5-325 mg one tablet by mouth every 6 hours as needed for pain 1-10 on pain scale of 1-10/10 ordered March 7, 2022 and discontinued on March 7, 2022. -[MEDICATION(S)] 5-325 mg one tablet by mouth every 6 hours as needed for pain 6-10 on pain scale 0-10/10 ordered March 7, 2022 and reordered on March 8, 2022. Review of the Medication Administration Record (MAR) dated March 2022 revealed the resident's pain level was 5/0-10 during the day shift on March 7, 2022. Continued review of the clinical record did not reveal if Acetaminophen or [MEDICATION(S)] was offered to the resident or if the resident declined the medication on the day shift on March 7, 2022. During an interview conducted with resident #107 on March 7, 2022 at 2:18 p.m., the resident stated that he had asked for pain medication at 9:00 a.m. that morning and still had not received it. The resident said that he had pain throughout his body and knows that he is supposed to get [MEDICATION(S)]. On March 8, 2022 at 1:44 p.m., an interview was conducted with a Registered Nurse (RN/staff #23). She stated that she assesses the resident for pain and asks the resident for the pain level. The RN stated that then she asks if the resident wants pain medication, and if so the pain medication is administered based on the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted on March 8, 2022 at 1:52 p.m. with the Director of Nursing (DON/staff #34). He stated it is his expectation that staff assess pain every shift. The DON stated generalized pain is treated with pain medication based on a pain scale, which is included on the order. He stated staff should follow-up and document if the pain medication was effective in the MAR. He reviewed the MAR for March 2022 and observed that the residents' pain level was 5 during the day shift and stated that staff should have followed up with the pain medication order. He reviewed the orders and stated that the order for Acetaminophen was not ordered until March 7, 2022 at 11:30 p.m., so it was not available for the resident on the morning of March 7, 2022, but the [MEDICATION(S)] was ordered at 2:30 a.m. and was not discontinued until 11:30 p.m. on March 7, 2022, so staff would have been able to offer the [MEDICATION(S)] to the resident the morning of March 7, 2022. The DON reviewed the MAR and said the [MEDICATION(S)] was not administered to the resident. He continued to review the resident's clinical record and stated that there was no documentation showing the resident was offered or declined pain medication on March 7, 2022. The facility's policy, Pain Assessment and Management, revised March 2015 stated strategies that may be employed when establishing the medication regimen include: -Combining long-acting medications with PRNs for breakthrough pain; -Combining several analgesics or analgesics with other drug classes. Implement the medication regimen as ordered, carefully documenting the results of the interventions.

Based on clinical record review, staff interviews, and policy and procedure review, the facility failed to ensure one of two sampled residents (#54) had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Resident #54 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Brief Interview for Mental Status dated December 28, 2021 revealed a score of 10 indicating the resident a moderate cognitive impairment. Review of the Oxygen Saturation Summary revealed oxygen was administered to the resident from December 23, 2021 through January 2, 2022 and oxygen saturation levels were between 91% and 98%. However, review of the Order Summary Report did not reveal a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan for oxygen therapy initiated on January 4, 2022 revealed interventions to monitor for signs and symptoms of respiratory distress and report to the physician as needed, and oxygen settings: (specify: The resident has oxygen via nasal prongs/mask at (X)L continuously/frequently. An interview was conducted on March 9, 2022 at 10:03 a.m. with a Licensed Practical Nurse (LPN/staff #96), who stated that she would check the resident's oxygen level, and contact the physician to obtain an order before administering oxygen. She reviewed the resident's orders and stated the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Then, she reviewed the oxygen saturation levels and said the resident was given oxygen prior to the order on January 3, 2022. On March 9, 2022 at 10:30 a.m., an interview was conducted with the Director of Nursing (DON/staff #34). He stated that an order is needed for oxygen unless it is an emergency. Then he reviewed the oxygen saturation levels for the resident and stated that oxygen was administered to the resident throughout the resident's stay. The DON stated that when the resident arrived from the hospital, the resident was on oxygen and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON acknowledged that an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's policy, Oxygen Administration, revised October 2010 stated to verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.

Based on observations, interviews, facility policy, and Centers for Disease Control (CDC) guidelines, the facility failed to ensure proper infection prevention and control practices were followed when cleaning an isolation room. The facility census was 65 residents. The deficient practice could result in transmission of infections, including COVID-19, in the facility. Findings include: An interview was conducted with the administrator (staff #52) on February 8, 2021 at 8:30 a.m. She stated that the facility did not have any current COVID-19 positive residents, but that the residents in one wing of the building (including rooms 101 through 135) were on isolation/observation as they were either new admissions or were suspected to have COVID-19. The rest of the facility contained COVID-19 negative residents and residents who had recovered from COVID-19. An observation was conducted in the isolation wing (rooms 101 through 135) on February 8, 2021 at 11:11 a.m. A housekeeper (staff #18) was observed cleaning a resident's room wearing Personal Protective Equipment (PPE) including a mask, gloves, and goggles, but the housekeeper did not have on an isolation gown. A sign on the unit door indicated that this was a closed observation unit requiring PPE to enter. An interview was conducted with the housekeeper (staff #18) on February 8, 2021 at 11:13 a.m. He stated that he was not sure if he needed to wear a gown because the resident had been discharged . The housekeeper also stated that he would need to check the facilty policy because he is unsure. He stated that he should have checked with the nurse before entering the room to clean it without a gown. An interview was conducted with the administrator (staff #52) on February 8, 2021 at 11:30 a.m. She stated that all staff who enter a room in the isolation wing should wear a mask, goggles, and an isolation gown as their PPE. She also stated that it is her expectation that everyone follows this protocol. An interview was conducted with the Infection Preventionist (IP/staff #105) on February 8, 2021 at 2:55 p.m. She stated that all staff have been trained on PPE requirements and that the housekeeper should have been wearing a gown while cleaning the room regardless if the resident was discharged or not. Review of the facility's COVID-19 infection prevention and control measures policy, dated April 2020, revealed that the facility follows recommended standard and transmission-based precautions to prevent the transmission of COVID-19 within the facility. The policy implementation included that for a resident with an undiagnosed respiratory infection, standard, contact, and droplet precautions were to be implemented. This included that staff don a facemask, gloves, and isolation gown before contact with the resident and/or the resident's environment. The policy included that signage of the appropriate PPE for staff should be posted in designated locations in the facility (e.g., outside of a resident's room, wing, or facility-wide). Review of CDC guidance for preparing for COVID-19 in nursing homes, updated November 20, 2020, revealed that facilities should create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. The guidance included that staff should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection, gloves, and gown when caring for these residents.

Based on clinical record review, staff interview and policy review, the facility failed to ensure that recommendations from the pharmacist were acted upon by the physician for one of five sampled residents (#5). The deficient practice could result in residents receiving unnecessary medications. Findings include: Resident #5 was readmitted to the facility on (MONTH) 10, 2019, with [DIAGNOSES REDACTED]. An order dated (MONTH) 10, 2019 included for apixaban (anticoagulant) 5 milligrams (mg) two times a day. Review of a care plan dated (MONTH) 10, 2019, revealed the resident was receiving anticoagulant therapy, with a goal that the resident would be free from discomfort or adverse reactions related to anticoagulant use through the review date. Interventions included a daily skin inspection, and to monitor, document and report to the provider any signs or symptoms of anticoagulant complications such as: blood tinged urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, sudden changes in mental status, or significant or sudden changes in vital signs. A pharmacist consultation report dated (MONTH) 12, 2019, included the resident received apixaban and had two or more of the following characteristics: -age greater than or equal to [AGE] years -body weight less that or equal to 60 kilograms (kg) -serum creatinine greater than or equal to 1.5 milligrams per deciliter The report further included a pharmacy recommendation to decrease apixaban to 2.5 mg twice a day with the following rationale: a dose adjustment is recommended when certain patient characteristics are present to reduce the risk of adverse events (bleeding). Per the report, if this therapy is to continue, it is recommended that the prescriber document an assessment of risk versus benefit, indicating it continues to be a valid therapeutic intervention for this individual. Further review of the report revealed that the provider declined the recommendation and signed the report, however the provider did not include a rationale for declining the recommendation. Review of the (MONTH) 2019 Medication Administration Record [REDACTED]. Review of the clinical record revealed no evidence of a risk versus benefits assessment or any documentation by the physician of the rationale for the continued use of apixaban 5 mg twice a day. An interview was conducted on (MONTH) 31, 2019 at 12:45 p.m., with the Director of Nursing (DON/staff #15). She stated the consultant pharmacist reviews residents' medication regimens on admission, monthly and as needed. She stated the pharmacist consultation reports are given to the provider for review. She said if the provider disagreed with the recommendation, they would sign the report and write the reason for declining on the report. She said if the provider did not include a rationale on the report, there might be more information in the provider's progress notes, or the resource nurse would be expected to follow up with the provider. She said the pharmacist might send another report with follow-up questions. She said sometimes the most difficult part of the pharmacist medication reviews was obtaining documentation of a response from the provider in a timely manner. Review of the facility's policy for medication regimen reviews revealed the primary purpose of the medication review was to help the facility maintain each resident's highest practicable level of functioning, by helping them use medications appropriately and prevent or minimize adverse consequences. The consultant pharmacist will provide a written report to physicians for each resident with an identified irregularity. Copies of medication regimen review reports, including physician responses, would be maintained as part of the permanent medical record.

Based on clinical record review, staff interviews, and the Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS- , the facility failed to ensure a NOMNC form was accurately dated for one of two sampled residents (#145). The deficient practice could result in residents' clinical records not being accurate. Findings include: Resident #145 was admitted on [DATE], with [DIAGNOSES REDACTED]. The resident was discharged on (MONTH) 8, 2019. Review of the NOMNC meeting summary and notes dated 9/20/19 at 11:46 a.m., revealed the participants included the resident and the resident's family members x 2. The note included the resident's family member was presented with the NOMNC form and stated that they had also received the information via phone last night (9/19/19). The note also included that the NOMNC form was signed and that the family member was informed that the NOMNC form will be dated 9/19/19 since they were notified via phone on that date regarding the discharge date . A review of the NOMNC CMS- form revealed the Medicare skilled services would end (MONTH) 21, 2019. The NOMNC form included the family member was notified via phone on 9/19/19 at 2:24 p.m. The form also included the family member's signature with the date 9/19/19. An interview was conducted with a case manager (staff #149) on (MONTH) 19, 2019 at 08:33 AM. Staff #149 stated that she was not the resident's case manager for the resident and could not comment to the date when the NOMNC form was signed. She stated the case manager who was assigned to the resident was currently out of the country. An interview was conducted with the administrator (staff #123) on 10/30/19 at 11:38 AM. The administrator stated that she believes the NOMNC form was presented to the resident's family member on 9/20/19. The administrator also stated that the NOMNC form may have been backdated to 9/19/19 by the case manager because that is when the family member was notified of the NOMNC via phone. The administrator stated that if the form was backdated, she would not consider that to be an acceptable practice. The Form Instructions for the NOMNC CMS- revealed the resident or the resident's representative must sign the signature line and must fill in the date that he or she signed the document.

Based on clinical record review, staff interviews and policy review, the facility failed to ensure one of five sampled residents (#5) was informed of the risks and benefits of [MEDICAL CONDITION] medications, prior to administration. The deficient practice could result in residents/representatives not being aware of the benefits and risks of taking psychoactive medications. Findings include: Resident #5 was readmitted to the facility on (MONTH) 10, 2019, with [DIAGNOSES REDACTED]. Regarding [MEDICATION NAME]: A physician's orders [REDACTED]. A care plan dated (MONTH) 11, 2019 included the resident used antidepressant medication. The goal was for the resident to be free from discomfort or adverse reactions related to antidepressant therapy through the review date. Interventions included to administer antidepressant medications as ordered and to provide education to the resident and/or family about risks, benefits and the side effects of medications administered. Review of the (MONTH) 2019 Medication Administration Record [REDACTED]. A physician's orders [REDACTED]. The admission Minimum Data Set (MDS) assessment dated (MONTH) 16, 2019 included a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The assessment also revealed the resident had received an antidepressant for seven days during the look back period. Further review of the (MONTH) 2019 MAR indicated [REDACTED]. However, review of the clinical record revealed no documentation that a consent was obtained from the resident prior to administration of the [MEDICATION NAME] and/or [MEDICATION NAME] from (MONTH) 10 through 16, 2019, nor was there documentation that the resident was informed of the risks and benefits of receiving an antidepressant medication, prior to being administered. Continued review of the clinical record revealed a verbal consent for [MEDICATION NAME] was obtained on (MONTH) 17, 2019. However, the consent did not include the reason for the administration of [MEDICATION NAME] or list the risks and benefits of the medication. The form included the following statement: I have been fully informed about the use of the prescribed psychoactive medication(s) listed below and the benefits, risks, and possible negative outcomes of their use. Per the consent, verbal authorization was given by the resident's family member. Regarding [MEDICATION NAME]: A physician's orders [REDACTED]. Review of the (MONTH) 2019 MAR indicated [REDACTED]. However, review of the clinical record revealed no documentation that a consent was obtained from the resident/resident representative prior to administration of the [MEDICATION NAME] from (MONTH) 19 through 23, 2019, nor was there documentation that the resident was informed of the risks and benefits of receiving the medication prior to being administered. Further review of the clinical record revealed a form dated (MONTH) 24, 2019, where consent for [MEDICATION NAME] was marked, I DO NOT APPROVE the use of this medication. The form did not include the reason for the administration of [MEDICATION NAME] or list the risks and benefits of the medication. The form included, I have been fully informed about the use of the prescribed psychoactive medication(s) listed below and the benefits, risks, and possible negative outcomes of their use. The form was signed by the resident's family member. An interview was conducted on (MONTH) 31, 2019 at 12:36 p.m., with a resource nurse (staff #92). She stated the admission nurse would be responsible for obtaining consent from the resident for admission orders [REDACTED]. She said the process of obtaining consent would include educating the resident and/or family about the new medication, the reason for its use and the side effects. She said the nurse would then have the resident sign the consent form. She said the nurse would need to wait for consent, before administering the medication. An interview was conducted on (MONTH) 31, 2019 at 12:45 p.m., with the Director of Nursing (DON/staff #15). She said if a [MEDICAL CONDITION] medication was ordered for a resident, the nurse would be expected to obtain consent before administration. She said if a resident had taken the medication at home or at the hospital prior to arriving at the facility, the nurse would still need to obtain consent. She said the consent process included explaining the risks, benefits and side effects and allowing the resident to agree or disagree. She said if the resident agreed, they would sign the consent and if they disagreed, the nurse would notify the provider and possibly request to change or discontinue the medication. Review of the facility's [MEDICAL CONDITION] medication documentation and management flow sheet revealed the steps for a new order for a [MEDICAL CONDITION] medication, which included to ensure the order was written with complete parameters and to obtain consent. The flow sheet instructed to document in the record if verbal consent was obtained and to obtain written consent as much as possible. The facility's [MEDICAL CONDITION] medication use policy revealed the facility should involve the resident or the resident's representative in the discussion of the potential non-drug and medication interventions to address the management of behaviors, and the involvement should be documented in the resident's medical record. The policy further included that staff should inform the resident and/or representative of the initiation, reason for use, and the risks associated with the use of [MEDICAL CONDITION] medications.

Based on clinical record review, staff interviews, and the Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS- , the facility failed to ensure the resident's representative signature on the NOMNC form was dated the day the form was signed for one of two sampled residents (#145). The deficient practice could result in NOMNC forms not being accurate. Findings include: Resident #145 was admitted on [DATE], with [DIAGNOSES REDACTED]. The resident was discharged on (MONTH) 8, 2019. Review of the admission Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident had intact cognition. Review of the resident's face sheet revealed the resident was his own primary responsible party. Review of a weekly Interdisciplinary Team Meeting (IDT) summary and note dated 9/19/19 at 3:32 p.m., revealed the resident's tentative safe transition date was 9/22/19. The participants listed did not include the resident or the resident's family member. The note included the resident's family member was notified via phone on 9/19/19. The note also included the NOMNC was issued. The note revealed the resident and the resident's family member expressed understanding of and was in agreement with the plan of care. The NOMNC meeting summary and notes dated 9/20/19 at 11:46 a.m., revealed the participants included the resident and the resident's family members x 2. The note included the resident's family member was presented with the NOMNC form and stated that they had also received the information via phone last night (9/19/19). The note also included that the NOMNC form was signed and that the family member was informed that the NOMNC form will be dated 9/19/19 since they were notified via phone on that date regarding the discharge date . A review of the NOMNC CMS- form revealed the Medicare skilled services would end (MONTH) 21, 2019. The NOMNC form included the family member was notified via phone on 9/19/19 at 2:24 p.m. The form also included the family member's signature with the date 9/19/19. Further review of the clinical record revealed no evidence the resident and/or his family member was given a copy the NOMNC form prior to 9/20/19. An interview was conducted with a case manager (staff #149) on 10/30/19 at 08:33 AM. Staff #149 stated that the resident or the resident's representative should be provided a copy of the NOMNC form at least 48 hours prior to the date the Medicare skilled services will end. She stated that the resident's family member was very upset about the discharge and refused to sign the NOMNC form at first. Staff #149 also stated that she was not the case manager for that resident at the time and that the resident's actual case manager was currently out of the country. She stated that she could not comment to the date the NOMNC form was signed. An interview was conducted with the administrator (staff #123) on 10/30/19 at 11:38 AM. The administrator stated that she believes the NOMNC form was presented to the resident's family member on 9/20/19. The administrator also stated that the NOMNC form may have been backdated to 9/19/19 by the case manager because that is when the family member was notified of the NOMNC via phone. The administrator stated that if the form was backdated, she would not consider that to be an acceptable practice. The Form Instructions for the NOMNC CMS- revealed the resident or the resident's representative must sign the signature line and must fill in the date that he or she signed the document.

Based on clinical record reviews, staff interviews and policy review, the facility failed to ensure two of five sampled residents (#298 and #2) were administered medication as ordered by the physician. The deficient practice of not receiving medications as ordered could result in possible adverse effects. Findings include: -Resident #298 was admitted on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. Review of the (MONTH) 2019 medication administration record (MAR) revealed that [MEDICATION NAME] 650 mg had been given four times for a pain level of 5. During an interview with a Licensed Practical Nurse (LPN/staff #92) on 10/31/19 at 10:00 a.m., the MAR for resident #298 was reviewed. Staff #92 stated the [MEDICATION NAME] should not have been given for a pain level of 5 and that the nurse should have called the doctor. Staff #92 reviewed the clinical record and found no documentation that the physician was notified. In an interview with the acting Director of Nursing/Assistant Director of Nursing (staff #15) on 10/31/19 at 10:55 a.m., staff #15 stated that she assesses the location of pain and uses the pain scale to determine their pain level, offers interventions such as repositioning, ice and gives medication within the parameters, which are set by the physician. At this time, staff #15 reviewed the physician orders [REDACTED]. -Resident #2 was admitted to the facility on (MONTH) 20, 2019, with [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment dated (MONTH) 27, 2019, included a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. A physician's orders [REDACTED]. Review of the (MONTH) 2019 MAR revealed that [MEDICATION NAME] was not given to the resident on (MONTH) 22, 2019, with a SBP of 104 and a pulse rate of 73. The MAR also showed documentation that the medication was given to the resident on (MONTH) 27, with a pulse rate of less than 60. An interview was conducted on (MONTH) 31, 2019 at 10:55 a.m. with the Acting Director of Nursing (DON/staff #15), who reviewed the physician's orders [REDACTED]. She stated that the medication should have been given to the resident on (MONTH) 22, as his SBP and pulse were within range. She said that there was not a checkmark, which would indicate that the medication had been given. Regarding (MONTH) 27 when the medication was given for a pulse less than 60, she stated that the medication should not have been given and this was an error. Review of the facility's Administration Medications policy revised in (MONTH) 2012, revealed that medications shall be administered in a safe and timely manner and as prescribed. Medications must be administered in accordance with the orders and the vital signs must be checked if necessary, prior to administering medications.

Based on observations, staff interviews and policy and procedures, the facility failed to ensure drinks stored in 1 of 2 nourishment refrigerators were not expired. Expired foods or drinks could pose a health hazard to residents. Findings include: On (MONTH) 29, 2019 at 11:32 a.m., an observation was conducted of the nutrition refrigerator in the front hall that is used to store residents food. The refrigerator contained a small row of apple juice cups and three of the cups were were marked do not use after (MONTH) 10, 2019. An interview was conducted with the food service manager (staff #161) on (MONTH) 31, 2019 at 12:01 p.m. Staff #161 stated that she checks both of the nourishment refrigerators daily each morning. She stated that she must have overlooked checking the expiration dates for the apple juice cups. She said expired juice cups should be disposed on or before their expiration dates. An interview was conducted with the Administrator (staff #123) on (MONTH) 31. 2019 at 12:38 p.m., who stated that it was her expectation that the nourishment refrigerators do not contain expired food or drink items at all times. A facility policy regarding the safe storage of food included that food service staff must discard any perishable foods on or before the use by date.

Based on clinical record reviews, staff interviews, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure MDS (Minimum Data Set) assessments for two residents (#38 and #5) were accurate. Findings include: -Resident #38 was admitted on (MONTH) 3, (YEAR) with [DIAGNOSES REDACTED]. A review of the resident's care plan initiated on (MONTH) 3, (YEAR) revealed the resident's discharge plan was to return to previous community living. Review of the Discharge Plan/Patient Instructions/Summary of Service dated (MONTH) 21, (YEAR) revealed the resident had a planned discharge to the community. Review of a nursing progress note dated (MONTH) 21, (YEAR) revealed resident #38 was discharged to the community. Review of the resident's discharge MDS assessment dated (MONTH) 21, (YEAR) revealed the resident was discharged to an acute hospital. -Resident #5 was readmitted on (MONTH) 23, (YEAR) with [DIAGNOSES REDACTED]. A review of the resident's care plan initiated on (MONTH) 23, (YEAR) revealed the resident's discharge plan was to return to previous community living. Review of the Discharge Plan/Patient Instructions/Summary of Service dated (MONTH) 31, (YEAR) revealed the resident had a planned discharge to the community. Review of a physician's orders [REDACTED]. Review of a nursing progress note dated (MONTH) 2, (YEAR) revealed resident #5 was discharged home. Review of the resident's discharge MDS assessment dated (MONTH) 2, (YEAR) revealed the resident was discharged to an acute hospital. An interview was conducted with a MDS Registered Nurse (staff #100) on (MONTH) 13, (YEAR) at 3:57 p.m. Staff #100 stated that to accurately complete MDS assessments, clinical records are reviewed including physician, nursing, and CNA (certified nursing assistant) documentation, and physical and occupational therapy documentation from the last 7 days. Staff #100 stated that a discharge MDS assessment should include accurate information about where the resident was discharged to. An interview was conducted on (MONTH) 13, (YEAR) at 4:49 p.m. with the Director of nursing (staff #52) who stated that the expectation is for the MDS assessments to be accurate and complete. Staff #52 stated that the MDS nursing staff review all sources of documentation prior to completing a MDS assessment; then complete the MDS assessment based on the 7 day review. The RAI Manual for the MDS assessment instructs staff to review the medical record including transfer, admission and discharge plans and orders, and enter the correct code which corresponds to the location that the resident was admitted from and the discharge location. Further, Federal regulations require that the assessment accurately reflects the resident's status.

Based on clinical record review, staff interviews and facility documentation, the facility failed to provide care and services for one resident (#178) to maintain the highest practicable well-being, as evidenced by failing to ensure physician ordered medications were administered, resulting in a hospitalization within two days of admission. Findings include: Resident #178 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the hospital transfer documents received by the facility's Guest Services on July 27, 2012, for this resident revealed that admission orders [REDACTED]. The admission orders [REDACTED]. The second e-mail transmission contained prescriptions for four of the 12 medications, two for pain, an antibiotic and a medication for urinary hesitancy. In reviewing the admission orders [REDACTED]. Review of the admission orders [REDACTED]. Review of the resident's clinical record revealed a physician's telephone order dated July 30, 2012 at 1:15 p.m., to send the resident to the emergency room (ER) due to unstable vital signs. However, there were no documented vital signs in the clinical record at the time of transfer to the hospital. Review of the ER records dated July 30, 2012, documented that the resident presented to the ER in [MEDICAL CONDITION] with a rapid ventricular response. Vital signs on arrival were as follows; blood pressure 127/89, pulse of 160 beats per minute and oxygen saturation of 93 percent on two liters of oxygen. A cardiology consult was conducted and the resident was admitted to the hospital with [REDACTED]. On December 5, 2012 at 12:15 p.m., an interview was conducted with the Nursing Unit Manager (RN) and she explained that nursing was notified by Guest Services when they were to receive an admission and once the facility accepted the admit, the admission orders [REDACTED]. The nurse stated they would sit down with the physician if available or verify the admission orders [REDACTED] An interview was conducted on December 5, 2012 at 1:15 p.m. with the Guest Services Director and he related that when a resident was transferred from a hospital the information would come over in two separate e-mails and from experience he knew that the first e-mail contained the physician's admission orders [REDACTED]. He went on to add that July 27, 2012 was a Friday and the weekend staff member handled the e-mail transmissions and was not aware of how the hospitals transmits the physician's orders [REDACTED]. He added that all were now aware of the hospital transfer procedures. A policy and procedure was requested and received from the facility on how transfer documents are handled for admissions from other healthcare facilities, but the policy did not cover the facility's handling to insure that the documents received were complete.