Every finding on record at Scotland Manor Health and Rehabilitation Center

Based on observation, record review, and interviews with the resident, staff, and Medical Director, the facility failed to follow up with an audiologist's (a medical professional that specializes in the diagnosis, evaluation and treatment of hearing disorders) recommendation for ear wax removal for 1 of 1 resident reviewed for hearing difficulties (Resident #21).The findings included:Resident #21 was admitted to the facility on [DATE] with diagnoses which included stroke. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #21 had moderate cognitive impairment. Resident #21 was coded for minimal hearing difficulty and no hearing aid.The care plan, last reviewed on 10/30/25, revealed Resident #21 had a communication problem related to hearing deficit with interventions which included repeating as necessary, face the resident while speaking, and speaking clearly and slower than normal. The Audiology (scientific study of hearing and balance) visit summary dated 12/12/24 revealed Resident #21 was seen for new verbal communication difficulties such as need to have commands repeated, not turning when spoken to, and having difficulty understanding speech. The visit summary further noted Resident #21 reported bilateral (both sides) ear pain and tinnitus (ringing, buzzing, or hissing in ears with no external source). The Audiology clinical findings included that the degree of hearing loss could not be established in the right and left ear due to too much ear wax present to conduct the test. The Audiologist noted that Resident #21 was evaluated at the bedside and was noted to have excessive hardened ear wax in both ears that was unable to be removed by curette (a surgical instrument used for scraping). The Audiologist recommendations for the attending physician and nurse was to contact Resident #21's physician for wax removal protocol for both ears.The Audiology visit summary dated 11/07/25 revealed Resident #21 was seen by the Audiologist for reported bilateral tinnitus and ear pain. The clinical findings noted that the degree of hearing loss and discrimination (ability to understand speech) was unable to be established for both ears related to the amount of ear wax present. The Audiologist's additional comments noted that for the last two visits Resident #21's was noted to have hardened wax bilaterally that was unable to be removed with a curette, and the ear wax was still present at current visit. The Audiologist's recommendations for the attending physician and nursing staff were to contact Resident #21's physician for ear wax removal protocol. Resident #21's physician orders were reviewed and revealed the Audiologist's recommendations for ear wax removal on 12/12/24 and 11/07/25 were not implemented.An interview and observation of Resident #21 was conducted on 11/17/25 at 10:10 am. Resident #21 reported difficulty hearing, and he reported he did not have a hearing aid. This surveyor had to get close to Resident #21's left ear and speak slowly and at a slightly higher tone for the resident to be able to hear questions. Resident #21 stated he would like to have hearing aids if they were needed but he had not been able to get the test done. Resident #21 stated a doctor recently saw him but was not able to do anything about the hearing problem because he had too much ear wax in his ears. Resident #21 stated he did not recall if he had received any treatment for the ear wax. An interview was conducted with Nurse #3 on 11/19/25 at 12:45 pm who was assigned to Resident #21. Nurse #3 stated Resident #21 did not have hearing aids and she stated she felt he could hear okay, sometimes better than others. She stated that she did not recall Resident #21 report ear pain or ringing in ears. Nurse #3 stated that typically the Audiology recommendations were reviewed by someone in nursing management, not the medication cart nurse assigned to the resident. Nurse #3 stated she received direction to enter an order for Resident #21's ear wax treatment today (11/19/25) by the Director of Nursing (DON). An interview was conducted with the Social Worker on 11/20/25 at 11:21 am who revealed she was the person responsible to set up Audiology appointments. She stated she did receive the referral for Resident #21 to be seen by the Audiologist and she had the resident placed on the list to be seen. The Social Worker confirmed she was on the list to receive the visit summary email from the Audiologist along with the Director of Nursing, but she stated she only confirmed the appointment had been completed as scheduled and did not review for any nursing recommendations. A telephone interview was conducted on 11/20/25 at 12:34 pm with the Medical Director who was the physician for Resident #21. The Medical Director stated that she saw Resident #21 in January 2025, and he did not report any ear pain or ringing in ears at that time. The Medical Director stated had the facility notified her of the Audiology recommendations from the two visits she would have ordered Resident #21's ear wax removal treatment. The Medical Director stated she was at the facility every Friday and was available by phone if anything was needed for a resident before her in-person visit to the facility. During interviews with the DON on 11/19/25 at 1:31 pm and 11/20/25 at 11:40 am she confirmed that she did receive the Audiology visit notes from the provider, but she was unable to recall if she received them directly from the Audiologist or if they were forwarded from someone at the facility. The DON stated the 12/12/24 Audiology visit recommendations for Resident #21's ear wax removal should have been handled by the previous Assistant Director of Nursing when the recommendations were received, but she stated she did not follow up to make sure the provider was notified. The DON confirmed that she did receive the recommendations from the 11/07/25 Audiology visit for Resident #21's ear wax removal but she had not contacted the provider to get the order until 11/19/25. The DON stated the Audiology recommendation for Resident #21's ear wax removal should have been reviewed with the provider when they were received. An attempt to conduct a telephone interview with the previous Assistant Director of Nursing on 11/20/25 at 9:59 am was unsuccessful.During an interview on 11/19/25 at 1:44 pm with the Regional Director of Clinical Services she revealed the physician should have been provided with the Audiologist recommendations for Resident #21's ear wax removal when the visit summary was received.The previous Administrator was interviewed on 11/20/25 at 11:50 am and revealed the Director of Nursing or the previous Assistant Director of Nursing were responsible to ensure the Audiology recommendations for Resident #21's ear wax removal were reviewed with the provider to determine if orders were needed. The Administrator was interviewed on 11/20/25 at 11:52 am and revealed the DON was responsible to ensure the recommendations were reviewed with the provider for Resident #21 when they were received.

Based on observation, record review, and staff interviews, the facility failed to follow physician orders to change oxygen supplies, which included the nasal cannula, for 1 of 1 resident reviewed for respiratory care (Resident #21). The findings included:Resident #21 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD). The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #21 had moderate cognitive impairment. Resident #21 was coded for supplemental oxygen use. The care plan last reviewed on 10/30/25, revealed Resident #21 was at risk for shortness of breath related to COPD with interventions which included to administer oxygen as ordered.Resident #21 had a physician order dated 10/08/25 to change oxygen supplies (nasal canula tubing, humidifier bottles) every 7 days when oxygen is in use. Every night shift, every Wednesday for oxygen cannula. Review of the Medication Administration Record (MAR) for November 2025 revealed Resident #21's oxygen nasal cannula tubing was documented as changed on 11/05/25 and 11/12/25 by Nurse #4.An observation was conducted on 11/17/25 at 10:10 am of Resident #21. Resident #21 was observed in bed with oxygen at 2 liters via nasal cannula in place. The oxygen cannula tubing had a white piece of tape on the tubing with the date of 10/31/25 handwritten in black ink. An interview was conducted with Nurse #2 on 11/17/25 at 10:20 am who confirmed the date on Resident #21's oxygen nasal cannula was 10/31/25. Nurse #2 stated she believed the oxygen nasal cannula was ordered to be changed weekly during the night shift.A telephone interview was conducted on 11/18/25 at 2:38 pm with Nurse #4 who confirmed he was assigned to Resident #21 on 11/05/25 and 11/12/25 during the 11:00 pm to 7:00 am shift when the nasal cannula was ordered to be changed. Nurse #4 stated he normally changed the oxygen nasal cannula at the end of the shift before he left the facility, but it must have slipped his mind. Nurse #4 stated he must have signed the physician order as completed before he put the new oxygen supplies in place for Resident #21.During an interview with the Director of Nursing (DON) on 11/19/25 at 1:25 pm she revealed oxygen supplies were changed weekly during the night shift and typically would be changed by the night nurse assigned to the resident. The DON stated Nurse #4 was responsible for changing Resident #21's oxygen supplies on 11/05/25 and 11/12/25. An interview was conducted with the Administrator on 11/20/25 at 12:00 pm who revealed the nurse assigned to Resident #21 at the time the oxygen supplies were to be changed was responsible to ensure the physician order was completed.

Based on observation, record review, and staff interviews, the facility failed to ensure a medical record was accurate regarding oxygen nasal cannula changes. This was for 1 of 23 sampled residents whose medical records were reviewed (Resident #21). The findings included:Resident #21 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD). A physician order dated 10/08/25 to change oxygen supplies every 7 days when oxygen is in use. Initial and date supplies. Every night shift, every Wednesday for oxygen cannula. Review of the Medication Administration Record (MAR) for November 2025 revealed Resident #21's oxygen was used every shift as ordered by the physician. Further review of the MAR revealed Resident #21's oxygen nasal cannula tubing was documented as changed on 11/05/25 and 11/12/25 by Nurse #4.An observation was conducted on 11/17/25 at 10:10 am of Resident #21. Resident #21 was observed in bed with oxygen at 2 liters via nasal cannula in place. The oxygen cannula tubing had a white piece of tape on the tubing with the date of 10/31/25 handwritten in black ink.A telephone interview was conducted on 11/18/25 at 2:38 pm with Nurse #4 who confirmed he was assigned to Resident #21 on 11/05/25 and 11/12/25 during the 11:00 pm-7:00 am shift when the nasal cannula was ordered to be changed. Nurse #4 stated he normally documented the nasal cannula tubing was changed sometime during the shift but not necessarily at the time it was changed. Nurse #4 stated he changed the oxygen tubing at the end of the shift, but it must have slipped his mind on 11/05/25 and 11/12/25. During an interview with the Director of Nursing (DON) on 11/19/25 at 1:25 pm she revealed Nurse #4 should not have documented that Resident #21's oxygen tubing was changed if he did not change it. An interview was conducted with the Administrator on 11/20/25 at 12:00 pm who revealed the nurse that was assigned to Resident #21 should not have documented the oxygen tubing was changed if not completed as ordered.

Based on record review, and staff and Dialysis Charge Nurse interviews, the facility failed to maintain ongoing communication with the dialysis treatment center for 1 of 1 resident reviewed for dialysis (Resident #18). The findings included: Resident #18 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease (ESRD) and dependence on dialysis (treatment to filter wastes and water from the blood). Resident #18 had an active physician order dated 2/22/21 for dialysis on Monday, Wednesday, and Friday. Review of Resident #18's care plan last reviewed 7/09/24 revealed the need for dialysis related to renal failure with an intervention to communicate with the dialysis center by the dialysis communication form. Review of Resident #18's dialysis communication forms, located in the dialysis communication notebook at the nursing station, dated 8/01/24 through 9/09/24 revealed 8 of the 17 dialysis communications forms were not completed by the facility staff prior to dialysis for Resident #18. The reviewed dialysis communication forms did not have the following information noted from the facility: medications administered prior to dialysis, arteriovenous (catheter access area for delivery of hemodialysis) access site type, dialysis access type observation including signs or symptoms of infection, access site assessment including bruit (a whooshing sound heard at the fistula site with a stethoscope) and thrill (vibration caused by blood flow felt with fingers), resident pain, and time of transfer to dialysis center. A telephone interview was conducted on 9/10/24 at 1:46 pm with Medication Aide #1, who was assigned to Resident #18 on the dates the dialysis communication forms were not completed, revealed the only information she entered prior to Resident #18 leaving for dialysis were the vital signs (blood pressure, pulse, temperature, and respiratory rate), resident name, resident room number, the date, and the name of the physician. Medication Aide #1 stated she was not aware of any other information that was needed on the dialysis communication form for Resident #18 prior to the dialysis appointment. An attempt to conduct a telephone interview on 9/11/24 at 1:33 pm with Nurse #2, who was the nurse assigned to oversee Medication Aide #1 on the dates the dialysis communication forms were not completed, was unsuccessful. A telephone interview was conducted on 9/11/24 at 8:57 am with the Dialysis Charge Nurse who revealed the dialysis communication forms were sent with the resident from the facility. The Dialysis Charge Nurse stated the facility was to complete their portion of the form before the resident left the facility with information that included vital signs, any medications that were administered, any issues or concerns with the dialysis access site, and if any pain was reported. The Dialysis Charge Nurse stated the dialysis communication form was reviewed by staff at the dialysis center in the event there was a concern that needed to be addressed prior to starting treatment. The Dialysis Charge Nurse stated if any concerns were identified when Resident #18 arrived at the dialysis center a call would be placed to the facility for any additional information that was needed. An interview was conducted with the Director of Nursing (DON) on 9/10/24 at 1:08 pm who revealed the facility was responsible to complete the dialysis communication form prior to the resident being sent to dialysis center. The DON stated Medication Aide #1 was able to complete the non-assessment portions but was unable to complete the assessment portion of the form because Medication Aide #1 was not a licensed nurse. The DON stated Nurse #2, who was assigned to Medication Aide #1 should have completed the assessment portion of Resident #18's dialysis communication forms and made sure the forms were completed prior to dialysis. The DON stated she conducted random audits of the dialysis communication forms to ensure they were being completed, but she stated she just missed Resident #18's incomplete dialysis communication forms. During an interview on 9/11/24 at 10:33 am the Administrator reported the dialysis communication forms for Resident #18 should have been completed prior to his dialysis appointments. The Administrator stated the DON was responsible to ensure the dialysis communication forms for Resident #18 were completed.

Based on observation, record review, and staff interviews, the facility failed to implement their infection prevention program policies and procedures when Nurse Aide (NA) #1 failed to perform hand hygiene after performing bathing and incontinence care for 1 of 2 residents observed for incontinence care (Resident #26). The findings included: The facility policy titled Infection Control, no date noted, revealed the purpose of the policy was to provide guidelines for the prevention of infection control in the facility. The policy stated in part that gloves were worn by all staff when providing care such as suctioning, bathing, care of perineal area, and wound care to prevent cross-contamination of infectious waste to hands. The facility policy titled Handwashing/Hand Hygiene dated 11/02/21 revealed hand hygiene was the primary means to prevent the spread of infections and that all staff shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. The policy further stated that hand hygiene was to be performed before moving from a contaminated body site to a clean body site during resident care. A continuous observation on 9/09/24 at 1:25 pm through 1:34 pm revealed NA #1 prepared to provide bathing and incontinence care to Resident #26. NA #1 performed hand hygiene and donned clean gloves and prepared a wash basin and wash cloth and proceeded to clean Resident #26's front side of her body including the perineal area (pelvic area located between the legs), placed Resident #26's gown on, without removing her gloves and performing hand hygiene, and assisted Resident #26 to turn onto her left side. NA #1 then removed the urine soiled incontinence brief from under Resident #26 and continued to wash Resident #26's back side and in between her buttocks. NA #1 removed the urine soiled bed pad from under Resident #26 and, without removing her gloves and performing hand hygiene, placed a new incontinence brief and clean sheet under Resident #26. NA #1 removed her gloves, performed hand hygiene and exited the Resident #26's room with the soiled linen and trash bags. An interview was conducted with NA #1 on 9/09/24 at 1:55 pm who revealed she did not change her gloves during the incontinence care and bathing that was performed for Resident #26. NA #1 stated she always used the same gloves for entire process of bathing and incontinence care without putting on new gloves. NA #1 stated she did not know she had to take off the gloves before putting on the clean sheet and clothes for Resident #26. During an interview on 9/10/24 at 1:04 pm with the Infection Preventionist she revealed gloves were to be removed and hand hygiene performed before moving from dirty to clean tasks during resident care. The Infection Preventionist stated NA #1 should have removed her gloves and performed hand hygiene before putting on the clean brief and linens for Resident #26. An interview was conducted on 9/11/24 at 1:12 pm with the Administrator who revealed NA #1 should have removed her gloves and performed hand hygiene before touching the clean brief and linens during Resident #26's bathing and incontinence care.

Based on observations and staff interviews, the facility failed to 1) label and date opened items in 2 kitchen refrigerators (refrigerator #1 located in the stock room, and refrigerator #2 located near the tray line counter) and the kitchen wall freezer located in the stock room and 2) failed to remove expired items from the residents' refrigerator, failed to label and date food items in the residents' refrigerator, and keep 1 of 1 freezer used for residents' personal food items, free from ice build-up. The findings included: 1. During an observation of the kitchen on [DATE] at 10:14 am with the cook the following items were observed: a. The kitchen refrigerator #1, located in the stock room, was observed to have the following: 2 one-gallon containers of mayonnaise open and without a date, a container of tartar sauce open and without a date, a half empty jar of maraschino cherries open and without a date, and an open container of ranch dressing without a date. b. The kitchen wall freezer, located in the stock room, was observed to have 1 large clear plastic bag of frozen pizza slices with multiple holes in the bag and tied at the top without a date, and a clear zipper storage bag of pork chops (as determined by the Cook) without a label or date. c. The kitchen refrigerator #2, located near the tray line counter, was observed to have the following: ,d+[DATE] box of blueberry muffins partially covered with plastic wrap that was not dated, and 2 large meal serving trays with peanut butter and jelly sandwiches in individual bags without a date. An interview was conducted on [DATE] at 10:16 am with the Cook who revealed all staff were educated to place a date on anything open in the refrigerators or freezers, but she was unable to state why the open items were not dated. The Cook stated she thought the peanut butter and jelly sandwiches were made the day prior but since there was not a date on them, she would remove them from the refrigerator. During an interview on [DATE] at 2:55 pm the Dietary Consultant revealed all open items, premade sandwiches, and unused items placed in freezer were required to have a date they were made or placed for storage. She stated she had provided education in the past to all staff regarding labeling and dating all open items in the refrigerator or freezers and she would re-educate all staff immediately. An interview was conducted with the Dietary Manager on [DATE] at 11:30 am who revealed she was new to the facility but stated any item that was opened was required to be labeled with the date of opening, leftovers must be labeled and dated before going into the refrigerator or freezer, and the premade sandwiches were to be dated when they were made. During an interview on [DATE] at 10:19 am the Administrator revealed it was the Dietary Managers responsibility to ensure items in the kitchen refrigerator and kitchen freezer were labeled and dated as required. 2. During an observation on [DATE] at 2:05 pm of the residents' refrigerator/freezer, which was in the break room and used for residents' personal food items, with the Director of Nursing (DON) and Administrator #2 the following was observed: a. The freezer compartment was opened and observed to have freezer frost throughout the entire freezer which was unable to be penetrated by DON's hand or the surveyor's pen. No visualization of the interior of the freezer was possible due to the freezer frost buildup which filled the entire freezer compartment. b. The refrigerator compartment was opened and observed to have the following: 2 individual cartons of white milk unopened with expiration date of [DATE], 1 half-gallon bottle of orange juice open and not dated, 1 plastic bag with grapes without a resident name or date, 1 food plate covered with aluminum foil with date of [DATE], 1 white paper bag of homemade cookies with date of [DATE], 1 plastic bag with plate inside of leftover food dated [DATE], and 2 plastic bags with open food items without a resident name or date. An interview was completed on [DATE] at 2:10 pm with Administrator #2 in the presence of the DON who revealed all open food items in the residents' refrigerator were to be dated and labeled with the residents' name and were to be removed after 3 days. Administrator #2 stated the dietary department was responsible to monitor and remove expired foods from the residents' personal refrigerator. During an interview on [DATE] at 9:02 am the DON stated the cart nurse had the key to the residents' refrigerator/freezer, but any staff member was able to put the residents' items in the refrigerator. She stated staff were educated to label with resident name and date when items were placed in the refrigerator/freezer, but she was unable to state why this did not occur. The DON stated the dietary department was required to clean the refrigerator. During an interview on [DATE] at 11:32 am the Dietary Consultant revealed she was not notified of the responsibility to manage the resident refrigerator/freezer. She stated she covered the facility as an interim Dietary Manager and had not cleaned out the resident refrigerator/freezer or monitored the residents' refrigerator during her time at the facility. During an interview on [DATE] at 11:34 am the Dietary Manager revealed she was new to the facility but reported she was not notified she was responsible for the monitoring of the resident refrigerator/freezer. The Dietary Manager stated she had not monitored the resident refrigerator/freezer during her time at the facility. An interview was conducted on [DATE] at 11:38 am with the Maintenance Director who revealed he had not been instructed that he was responsible to defrost the resident freezer. He stated he was instructed to put a lock on both the refrigerator and freezer before but had not been informed he was responsible for monitoring or defrosting the freezer. An interview was conducted on [DATE] at 10:08 am with the Administrator who revealed she failed to notify the correct department of the requirement to monitor the resident refrigerator/freezer. She stated the Maintenance Director was responsible for defrosting the freezer when needed and the dietary department was responsible for disposal of the expired food items. The Administrator was unable to state when the resident refrigerator/freezer was last checked.

Based on observations and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put in place following the recertification survey conducted on [DATE]. This was for a recited deficiency on the current recertification and complaint survey in the area of food procurement, store, prepare, and serve in a sanitary manner. The continued failure during two surveys shows a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag is cross referenced to: F812: Based on observations and staff interviews, the facility failed to 1) label and date opened items in 2 kitchen refrigerators (refrigerator #1 located in the stock room, and refrigerator #2 located near the tray line counter) and the kitchen wall freezer located in the stock room and 2) failed to remove expired items from the residents' refrigerator, failed to label and date food items in the residents' refrigerator, and keep 1 of 1 freezer used for residents' personal food items, free from ice build-up. An interview was completed on [DATE] at 12:04 pm with the Administrator. The Administrator indicated the QAA committee met monthly to discuss the facility's ongoing performance improvement plans. The Administrator indicated there were no current monitoring plans in place for the area the food procurement, store, prepare, and serve in a sanitary manner. The Administrator indicated it was her expectation the facility continued to follow the QAA process and monitor those issues within the facility so they would not receive a recited deficiency.

Based on record review and staff interviews, the facility failed to complete a significant change assessment for a resident's admission to hospice services for 1 of 1 resident reviewed for hospice services. (Resident #151). The findings included: Resident #151 was admitted to the facility on [DATE] with diagnoses which included stroke, depressive disorder, and anxiety. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #151 had moderately impaired cognition and was not on hospice services. Review of the Hospice Admission record revealed Resident #151 was admitted to hospice services on 4/26/23 with a diagnosis of stroke. Review of the Minimum Data Set (MDS) assessments revealed no significant change assessment was completed for Resident #151's admission to hospice services. An interview was conducted on 5/23/23 at 2:42 pm with the MDS Nurse who revealed she was new in the position, and she was not aware of Resident #151's admission to hospice services. She stated she was not notified by nursing of the hospice admission for Resident #151. The MDS Nurse stated a significant change assessment was required for Resident #151's hospice admission but it was an oversight on her part. During an interview on 5/24/23 at 12:30 pm the Social Worker revealed Resident #151's hospice admission was discussed in the morning meeting for all management staff, the clinical morning meeting, and was documented on the 24-hour report. The Social Worker stated that when there was a change in the payor source it was discussed in the next morning meeting and if the change affected the plan of care, it would be further discussed in the clinical morning meeting as well as written on the 24-hour report. An interview was conducted on 5/25/23 at 8:52 am with the Director of Nursing (DON) who revealed all admissions, including hospice admissions, were discussed in the morning meeting. She stated Resident #151's admission would have been discussed during the morning meeting and the clinical meeting after signing onto hospice services. The DON stated the MDS Nurse was responsible to complete and submit an MDS significant change assessment for Resident #151's hospice admission. An interview with the Administrator was conducted on 5/25/23 at 10:12 am who revealed hospice admissions were discussed in the morning meeting and the MDS Nurse participated in the meetings. She stated the MDS Nurse was responsible for the completion of the MDS significant change assessment for Resident #151's admission to hospice service.

Based on record review, observations, and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessments for 4 of 24 sampled residents whose MDS were reviewed (Resident #3, Resident #18, Resident #23, and Resident #31). The findings included: 1. Resident # 3 was admitted to the facility on [DATE]. A physician order dated 8/31/23 for fentanyl patch (opioid medication for pain) 72 hour 50 micrograms/hour (mcg/hr). Apply 1 patch every 72 hours for pain remove per schedule. Review of the Medication Administration Record (MAR) for April 2023 revealed the fentanyl patch was administered as ordered. The Minimum Data Set (MDS) annual assessment dated [DATE] revealed Resident #3 was not coded for opioid medication. During an interview on 5/24/23 at 12:48 pm the MDS Nurse revealed she was new to the position and was still learning and it was an oversight of the medication when she completed the annual assessment for Resident #3. An interview was conducted on 5/25/23 at 8:56 am with the Director of Nursing (DON) who revealed the MDS was responsible to accurately complete Resident #3's MDS assessments. An interview with the Administrator on 5/25/23 at 10:12 am revealed the MDS Nurse was responsible to accurately code Resident #3's MDS assessments. 2. Resident #18 was admitted to the facility on [DATE] with a diagnosis which included dementia. a. A physician order dated 12/11/20 to check wander guard placement every day shift and night shift for wander guard placement. The quarterly wandering assessment completed on 1/17/23 revealed Resident #18 was a high risk to wander. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #18 was not coded for wander/elopement alarm. An interview on 5/23/23 at 2:39 pm with the MDS Nurse revealed she was new to the position and was not notified by nursing staff that Resident #18 had a wander guard in place. She stated it was an oversight. An interview was conducted with the Director of Nursing (DON) on 5/25/23 at 9:05 am who revealed the MDS Nurse was responsible to accurately complete Resident #18's MDS assessments. An interview with the Administrator on 5/25/23 at 10:12 am revealed the MDS Nurse was responsible for Resident #18's MDS assessments to be completed correctly. b. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #18 was coded for use of anticoagulant (used to prevent clotting) and antipsychotic (used to treat psychotic disorders) medications. Review of the physician orders for April 2023 revealed Resident #18 did not have an order for an anticoagulant or an antipsychotic medication. During an interview on 5/23/23 at 2:39 pm the MDS Nurse revealed she completed the medication section of the MDS assessment from Resident #18's physician orders. The MDS Nurse confirmed Resident #18 did not have an order for an anticoagulant or antipsychotic medications. The MDS Nurse stated it was an oversight and she incorrectly coded Resident #18 for an anticoagulant and antipsychotic medications. An interview was conducted with the Director of Nursing (DON) on 5/25/23 at 9:05 am who revealed the MDS Nurse was responsible to accurately complete Resident #18's MDS assessments. An interview with the Administrator on 5/25/23 at 10:12 am revealed the MDS Nurse was responsible to accurately complete the MDS assessments. The Administrator stated the MDS Nurse had multiple consultants available to her if she had any questions about how to complete the assessments correctly. 3. Resident # 23 was admitted to the facility on [DATE]. The Minimum Data Set (MDS) annual assessment dated [DATE] revealed Resident #23 was coded for an anticoagulant (used to prevent blood clotting) medication. Review of the physician orders for the month of March 2023 revealed Resident #23 did not have an order for an anticoagulant medication. During an interview on 5/23/23 at 2:39 pm the MDS Nurse confirmed Resident #23 did not have an order for an anticoagulant medication during the period the MDS assessment was completed. The MDS Nurse stated she incorrectly coded Resident #23 for an anticoagulant medication. An interview was conducted with the Director of Nursing (DON) on 5/25/23 at 9:05 am who revealed the MDS Nurse was responsible to accurately complete the MDS assessments for Resident #23. An interview with the Administrator on 5/25/23 at 10:12 am revealed the MDS Nurse was responsible to accurately complete the MDS assessments and she had multiple consultants available if she had any questions regarding Resident #23's medications. 4. Resident #31 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #31 was coded for a stage 3 pressure ulcer which was not present upon admission. Review of Resident #31's physician orders revealed there were no orders for treatment of a stage 3 pressure ulcer. Resident #31 had a care plan which was last reviewed 5/19/23 for potential for pressure ulcer development related to decreased mobility and incontinence. During an interview on 5/23/23 at 2:40 pm the MDS Nurse stated she thought she saw a note in Resident #31's record regarding a stage 3 pressure ulcer so she coded him for a pressure ulcer. The MDS Nurse stated she was not provided with a list of residents from the nursing department of those residents that have pressure ulcers, so she reviewed the progress notes. During an interview on 5/23/23 at 1:43 pm Nurse #1 revealed Resident #31 did not have a pressure ulcer and did not have an order for pressure ulcer treatment. An interview was conducted on 5/23/23 at 3:05 pm with the Director of Nursing (DON) who revealed Resident #31 did not have a stage 3 pressure ulcer. An observation on 5/24/23 of personal care revealed Resident #31 did not have a pressure ulcer. During an interview on 5/25/23 at 10:16 am the Administrator revealed the MDS Nurse was able to reach out to nursing staff or her consultant when she had questions about completing an MDS assessment. The Administrator stated the MDS Nurse was required to ensure the assessments were completed accurately.

Based on staff interviews and record reviews, the facility failed to obtain a Level II Preadmission Screening and Resident Review (PASRR) after the initial approval for nursing home placement expired for 3 of 3 residents reviewed for PASRR (Resident #16, Resident #36, and Resident #35). The findings included: 1. Resident #16 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (a disorder in the brain caused by a chemical imbalance in the blood). The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 had moderately impaired cognition. The MDS further revealed the Resident required extensive assistance from 2 staff members to complete activities of daily living and exhibited no behaviors during the assessment period. A review of the PASRR Level II Determination Notification document dated [DATE] revealed nursing facility placement was appropriate for a limited stay of no more than 30 days. The notification further explained if the resident was expected to extend beyond that 30-day period ([DATE]) further approval and screening must be obtained within 5 days of the PASRR expiration date. No additional PASRR Level II Determination Notifications were found the medical record. An interview was completed on [DATE] at 10:44am with the Social Worker. The Social Worker stated she was new to the position and did not understand the PASRR process. She revealed she was not aware PASRR level II's were at times issued with an expiration date. An interview was completed [DATE] 10:22am with the Administrator. She indicated the Social Worker was responsible for ensuring the PASRR's were reviewed and updated as needed. The Administrator stated the Social Worker or Admissions were expected to discuss during the facility's clinical meeting but was unable to recall if PASRR's were discussed. An interview was completed on [DATE] at 10:51am with the Director of Nursing (DON). The DON verified the PASRR level II had expired for Residents #16. She indicated it was the Social Worker's responsibility to review and update PASSR's. The DON stated the Social Worker was new to the position and did not understand the PASSR level 2 process. 2. Resident #36 was admitted to the facility on [DATE] with diagnoses that included adjustment disorder with anxiety and depression. The annual MDS dated [DATE] revealed Resident #36 was cognitively intact. A review of the PASRR Level II Determination Notification document dated [DATE] revealed nursing facility placement was appropriate for a limited stay of no more than 30 days. The notification further explained if the resident was expected to extend beyond that 30-day period ([DATE]) further approval and screening must be obtained within 5 days of the PASRR expiration date. No additional PASRR Level II Determination Notifications were found the medical record. An interview was completed on [DATE] at 10:44am with the Social Worker. The Social Worker stated she was new to the position and did not understand the PASRR process. She revealed she was not aware PASRR level II's were at times issued with an expiration date. An interview was completed [DATE] 10:22am with the Administrator. She indicated the Social Worker was responsible for ensuring the PASRR's were reviewed and updated as needed. The Administrator stated the Social Worker or Admissions were expected to discuss during the facility's clinical meeting but was unable to recall if PASRR's were discussed. An interview was completed on [DATE] at 10:51am with the Director of Nursing (DON). The DON verified the PASRR level II had expired for Residents #36. She indicated it was the Social Worker's responsibility to review and update PASSR's. The DON stated the Social Worker was new to the position and did not understand the PASSR level 2 process. 45045 3. Resident # 35 was admitted to the facility on [DATE] with diagnoses which included bipolar II disorder and borderline personality disorder. The PASRR Level II Determination Notification dated [DATE] revealed Resident #35's nursing facility placement was appropriate for a 60-day period. The PASRR Level II expiration date was [DATE]. No additional PASRR Level II Determination Notification was found in the medical record. During an interview on [DATE] at 4:45 pm the Director of Nursing (DON) and the [NAME] President of Clinical Services revealed the PASRR Level II re-evaluation for Resident #35 had not been sent. An interview was conducted on [DATE] at 10:03 am with the DON who revealed the Social Worker was responsible to monitor the PASRR's and send the required information for re-evaluation when it was needed. The DON was unable to state why the PASRR Level II re-evaluation for Resident #35 was not completed. During an interview on [DATE] at 10:44 am the Social Worker revealed she did not understand the PASRR process and did not realize Resident #35's PASRR Level II had expired and she was required to be re-evaluated. An interview with the Administrator on [DATE] at 10:22 am revealed the Social Worker was to ensure Resident #35's PASRR Level II was re-evaluated as required.

Based on record review, staff interviews, and Pharmacy Consultant interview, the facility failed to ensure Physician orders for as needed (PRN) psychotropic medications were time limited in duration for 1 of 1 resident reviewed for hospice services (Resident #151). The findings included: Resident #151 was admitted to the facility on [DATE] with diagnoses which included stroke, anxiety, and major depressive disorder. Resident #151 was discharged to the hospital on 4/17/23 and returned to the facility on [DATE] and was placed on hospice services. A physician order dated 4/25/23 for lorazepam (a medication used to treat anxiety) 1 milligram (mg) every four hours as needed (PRN) for agitation without a stop date. Record review of the Medication Administration Record (MAR) for April 2023 and May 2023 revealed Resident #151 had not been administered the lorazepam PRN. An interview was conducted on 5/23/23 at 3:06 pm with the Nurse Unit Manager who revealed she entered the lorazepam PRN order for Resident #151. She stated the lorazepam PRN order required a stop date but stated the Physician Assistant or the Pharmacy Consultant would normally find the error and the order would be changed. The Nurse Unit Manager stated new orders were to be checked the next day by another nurse for accuracy, but she was unable to state how the lorazepam PRN order without a stop date was missed for Resident #151. During an interview on 5/25/23 at 8:49 am the Director of Nursing (DON) revealed Resident #151's lorazepam PRN order required a 14-day stop date unless otherwise directed for a longer stop date by the doctor, but it required a stop date. The DON stated new orders were checked in the morning meeting with nursing management and was unable to state how the lorazepam PRN order without a stop date was missed for Resident #151. An attempt to interview the Physician Assistant on 5/25/23 at 10:00 am was unsuccessful. An interview on 5/25/23 at 10:10 am with the Administrator revealed physician orders were reviewed in the clinical meetings and it as the nursing management teams responsibility to ensure the 14-day stop date was in place for Resident #151's lorazepam PRN order. A telephone interview with the Pharmacy Consultant was conducted on 5/25/23 at 10:28 am who revealed he had not completed the monthly medication review for the facility and had not yet reviewed the new orders for Resident #151. The Pharmacy Consultant stated his normal practice was when he completed the monthly review of medications, he notified the facility of the need for a stop date for as needed psychotropic medications if found. The Pharmacy Consultant stated Resident #151's lorazepam as needed medication was required to have a stop date. An attempt to interview the Medical Director on 5/25/23 at 10:48 am was unsuccessful.

Based on observations, policy review and staff interview the facility failed to prevent cross contamination by one of one staff who failed to wear a beard net during meal service. The findings included: A review of the Next Level Hospitality Services policy, under Staff Attire policy statement reads as: It is the center policy that all Dining Services employees wear approved attire for the performance of their duties. Action Steps: 1. The Dining services Director ensures that all staff members have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained. During the meal observation on 1/06/22 at 11:36 AM the dietary manager was observed taking the meal temperatures. The dietary manager wore a face mask and was observed to have an uncovered two-inch beard that protruded below his face mask. In an interview on 1/06/22 at 12:39 PM the dietary manager stated he usually kept his beard trimmed and was working extra hours to cover for staff out on medical leave. He revealed beard nets were available in the diet office and he would put one on. In an interview on 1/07/21 at 1:33 PM the Director of Nursing stated they would want the dietary manager to wear a beard net. The DON stated she would check to make sure beard nets were available for staff use.

Based on observation, record review and staff interviews, the facility failed to keep the urinary catheter drainage bag from touching the floor to reduce the risk of infection or injury for 1 of 3 residents (Resident #13) reviewed for urinary catheter care. The findings included: Resident #13 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #13 had severe cognitive impairment and was coded for an indwelling catheter. Resident #13's care plan last revised 12/22/21 revealed a focus area of urinary catheter with a goal that he would be free from catheter related trauma. The interventions for the goal included position urinary catheter bag and tubing below the level of the bladder. An observation of Resident #13's catheter on 1/4/22 at 12:50 PM revealed the resident was laying on the bed and the urinary catheter drainage bag was laying on the floor. An interview was conducted with NA# 7 on 1/4/22 at 12: 53 PM. The NA stated the urinary drainage bag was supposed to be hanging below the bladder and not touching the floor. NA #7 stated she was not aware of how the urinary catheter drainage bag ended up on the floor. NA # 7 retrieved gloves and hung the urinary drainage bag on the foot of the bed. An observation of Resident #13's urinary catheter bag on 1/6/22 at 9:35 AM revealed the resident was lying in bed with head of bed elevated. The urinary catheter drainage bag was hung at the foot of the bed and drainage bag was touching the floor. An observation of Resident #13's catheter bag on 1/6/2022 at 1:08 PM revealed the resident was lying in bed and the urinary drainage bag was hanging at the foot of the bed touching the floor. An interview was conducted with NA# 8 on 1/6/2022 at 1:10 PM. NA #8 stated that the urinary catheter bag should not have been touching the floor. NA #8 stated that it was difficult to place the bed in the lowest position and keep the catheter bag off the floor. An interview was conducted with the Director of Nursing (DON) on 1/6/22 at 1:20 PM. The DON stated the urinary catheter bag should not have been touching the floor. The DON stated that she would initiate education about urinary catheter bags touching the floor.

Based on record review and staff interview, the facility failed to refer a resident with a newly evident [DIAGNOSES REDACTED]. (Resident #32). Findings included: Review of Resident #32 ' s PASARR Level I Determination Notification letter dated 2/19/19 revealed the resident was assessed to be level I. There were no further PASARR referrals for Resident #32 in the medical record. Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent significant change Data Set (MDS) assessment dated [DATE] indicated Resident #32 ' s cognition had been severely impaired. Resident #32 was not currently considered by the State Level II PASARR process to have a serious mental and/or intellectual disability or a related condition. His [DIAGNOSES REDACTED]. He was administered antipsychotic medication and antidepressant medication on 7 of 7 days during the assessment period. Resident #32 ' s plan of care included the focus of antidepressant medication use related to the [DIAGNOSES REDACTED]. Review of Resident #32 ' s (MONTH) 2019 physician's order [REDACTED].#32 continued to receive antipsychotic medications and antidepressant medications. During an interview with the MDS nurse on 6/25/19 at 11:00 AM, she revealed she had not done a new PASARR screen for Resident #32. During an interview with the Administrator on 6/26/19 at 08:42 AM, the Administrator stated the PASARR screen dated (MONTH) 2019 was the last PASARR screen performed on Resident #32. She confirmed this was a PASARR Level I. The Administrator further stated Resident #32 had not been referred to have a new screening. She stated the added [DIAGNOSES REDACTED]. The Administrator indicated the staff was forwarding the new screening documents immediately and the facility would review all residents receiving antipsychotic medications.

Based on record review and staff interview, the facility failed to develop comprehensive plans of care in the area of hospice (Resident # 22). The findings included: Resident # 22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident # 22 as severely cognitively impaired and was a hospice patient at the facility. A review of Resident # 22's comprehensive plan of care indicated a care plan related to hospice services was not initiated on 5/8/2019. Review of the nurse note dated 6/20/2019 revealed the resident passed away at the facility and was under the care of hospice. An interview was conducted with the MDS Coordinator on 6/26/2019 at 1:29 PM. She confirmed Resident # 22 was admitted to hospice care and the services were ongoing. The MDS Coordinator indicated she will review all hospice residents admitted at the facility and make sure their care plans are completed. She reported a care plan related to hospice should have been initiated promptly following Resident # 22's admission to hospice. An interview was conducted with the Director of Nursing on 6/27/2019 at 11:12 AM. She indicated she expected hospice care plans to have been completed for Resident # 22. The Administrator stated in an interview on 6/27/2019 at 12:50 PM she expected hospice to be careplanned as soon as a resident becomes a hospice patient.

Based on record review and staff interview the facility's Quality Assessment and Assurance Committee (QAA) failed to maintain implemented procedures and monitor interventions that the committee previously put in place. This failure was related to non-compliance at the regulatory grouping of 483.21: Comprehensive Care Plans, on four consecutive annual recertification surveys, which was recited on the current 6/27/2019 annual recertification/complaint investigation survey. The facility's continued failure during the recertification surveys showed a pattern of the facility's inability to sustain an effective QAA program. The findings included: 1.This tag is cross referenced to: 483.21 Develop/Implement Comprehensive Care Plan: Based on record review and staff interviews, the facility failed to develop comprehensive care plan for hospice care 1 of 1 sampled resident. (Resident #22) During an interview with the Administrator on 06/27/19 at 12:22 PM, the Administrator stated she has recently hired a new Minimum Data Set (MDS) coordinator. The MDS Coordinator has been provided with education through our corporate VP of Clinical Reimbursement, regional and sister facilities to provide her with the education and support to assure the comprehensive care plans are being completed properly. The Administrator also stated there has been ongoing audits to assure the care plans are being completed thoroughly.

Based on record review and staff interviews, the facility failed to complete a comprehensive Minimum Data Set (MDS) assessment for 2 of 5 residents reviewed for admission (Resident #17 and #199). Findings included: 1. Resident #17 had been readmitted to the facility post hospitalization on [DATE]. Her [DIAGNOSES REDACTED]. A Significant Change in Status (SCS) MDS assessment with an Assessment Reference Date (ARD, the last day of the MDS 7 day look back period) of 5/18/18 was scheduled. On 6/06/18 Resident #17's SCS MDS assessment was observed in the electronic medical record (EMR) as in progress and not completed. On 6/06/18 at 4:00 PM an interview was conducted with the MDS nurse. The nurse stated Resident #17 had returned from the hospital in a weakened condition and a SCS assessment had been scheduled. She stated Resident #17's SCS assessment should have been completed and closed by the 14th day after the ARD which was 6/01/18. The MDS nurse stated she had been on unscheduled leave with an illness and getting coverage for completing the assessments was difficult. On 6/06/18 at 4:15 PM an interview with the Director of Nursing (DON) was conducted. The DON stated it was her expectation that MDS assessments be completed on time. 2. Resident #199 had been admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Resident #199's Admission MDS assessment with an Assessment Reference Date (ARD, the last day of the MDS 7 day look back period) of 5/23/18 was scheduled. On 6/06/18 Resident #199's Admission MDS assessment was observed in the electronic medical record (EMR) as in progress and not completed. On 6/06/18 at 4:00 PM an interview was conducted with the MDS nurse. The nurse stated Resident #199 had been a new admission and the Admission MDS assessment had been scheduled for 5/23/18. The nurse stated the assessment had not been completed and closed by the 14th day after admission which was 5/29/18. The MDS nurse stated she had been on unscheduled leave with an illness and getting coverage for completing the assessments was difficult. On 6/06/18 at 4:15 PM an interview with the Director of Nursing (DON) was conducted. The DON stated it was her expectation that MDS assessments be completed on time.

Based on record review and staff interviews, the facility failed to develop comprehensive care plans in the areas of activities of daily living (ADLs), risk for falls, risk for skin break down, high risk medication use and medical conditions requiring monitoring for 1 of 18 residents reviewed (Resident #199). Findings included: Resident #199 had been admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Baseline care plans dated 5/17/18 were observed in Resident #199 ' s medical record. One nutrition comprehensive care plan initiated on 5/29/18 was also observed. Resident #199 ' s Admission MDS assessment with an Assessment Reference Date (ARD, the last day of the MDS 7 day look back period) of 5/23/18 was scheduled. The assessment was observed in the electronic medical record (EMR) as in progress and not completed. On 6/06/18 at 4:00 PM an interview was conducted with the MDS nurse. The nurse stated Resident #199 had been a new admission on 5/16/18. The nurse stated comprehensive care plans should be completed for new residents by the 21st day after admission which was 6/05/18. She also stated comprehensive care plans usually included ADLs, risk for falls, risk for skin break down, activities, medication use and monitoring. On 6/06/18 at 4:15 PM an interview with the Director of Nursing (DON) was conducted. The DON stated it was her expectation that comprehensive care plans be completed on time.

Based on observations and staff interviews, the facility failed to secure 1 of 2 medication carts (North Hall). Findings included: On 6/06/18 at 4:23 PM the North Hall medication cart was observed parked against the wall between rooms [ROOM NUMBERS]. The cart lock was observed in the unlocked position (a red dot is visible on the side of the lock when in the unlocked position). No staff were observed in the hallway and the door to room [ROOM NUMBER] was slightly open. A few moments later Nurse #1 was observed exiting room [ROOM NUMBER]. On 6/06/18 at 4:26 PM an interview was conducted with Nurse #1. The nurse stated she had accidently left the cart unlocked and it should have been locked when she walked away. On 6/07/18 at 9:18 AM an interview with the Director of Nursing (DON) was conducted. The DON stated it was her expectation that medication carts be locked when out of the eye sight of the nurse.

Based on observations, record review and staff interviews the facility's Quality Assessment and Assurance Committee (QAA) failed to maintain implemented procedures and monitor interventions that the committee previously put in place. This failure was related to non-compliance at the regulatory grouping of 483.21 (comprehensive care plans) on three consecutive annual recertification surveys, which was recited on the current 6/7/2018 annual recertification survey. This failure was also related to non-compliance at the regulatory grouping of 483.80 (infection control) on two consecutive annual recertification surveys which was recited on the current 6/7/2018 annual recertification survey. The facility's continued failure during the recertification surveys showed a pattern of the facility's inability to sustain an effective QAA program. The findings included: 1.This tag is cross referenced to: 483.21 Develop/Implement Comprehensive Care Plan: Based on record review and staff interviews, the facility failed to develop comprehensive care plans in the areas of activities of daily living (ADLs), risk for falls, risk for skin break down, high risk medication use and medical conditions requiring monitoring for 1 of 18 residents reviewed (Resident #199). 483.21 was originally cited during the (MONTH) (YEAR) recertification survey for failing to develop a care plan for a resident using an anti-depressant. 483.21 was also cited during the (MONTH) (YEAR) recertification survey for failing to develop a care plan for a resident with severe constipation and rectal impaction, and failing to develop a care plan for a resident receiving an anti-psychotic medication. During an interview on 6/7/2018 at 9:15 AM, the Administrator stated all the care plans were audited after the (YEAR) recertification survey to be sure they were up to date, and random audits had been completed since then by the Director of Nursing. The Administrator stated the Minimum Data Set (MDS) nurse had an unexpected hospitalization recently, but the care plans should have been completed timely. 2. This tag is cross referenced to: 483.80 Infection Prevention and Control: Based on observation, staff interviews, and record review the facility failed to disinfect glucometers per the manufacturer's recommendations after use for 2 of 2 residents (resident #17, and resident #45) observed for blood sugar checks. 483.80 was originally cited during the (MONTH) (YEAR) recertification survey for failing to wash hands during medication pass. During an interview on 6/7/2018 at 9:15 AM, the Administrator stated education was completed on hand washing after the (YEAR) recertification survey, and follow up on infection control in general was completed. The Administrator stated the facility did not have a Quality Improvement Plan in place for glucometer disinfection, but random audits had been completed by the Unit Manager.

Based on interviews with staff and the primary care physician and record review, the facility failed to administer [MEDICATION NAME] (an anti-convulsant medication) and [MEDICATION NAME] (an anti-convulsant medication) per physician's orders [REDACTED].# 34) reviewed for medication usage. Findings included: Resident # 34 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan, dated 7/21/14, indicated Resident # 34 was at risk for [MEDICAL CONDITION]. The goals established included reaming free from injury during [MEDICAL CONDITION] activity and maintaining therapeutic levels of anti-convulsant medications. Interventions included giving medications as ordered and monitoring for effectiveness and side effects. The quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident was moderately cognitively impaired. [MEDICAL CONDITION] disorder was identified as a diagnosis. Review of a May 16, 2014 neurology consult indicated the resident was assessed with [REDACTED]." The neurologist ordered [MEDICATION NAME] 25 milligrams (mgs) twice daily for one week and then a maintenance dose of 50 mg twice a day. There was no stop date included in the order; only a statement that indicated the medication was for maintenance. The neurologist wrote on the consult to stop the [MEDICATION NAME] 200 mg at bedtime on 5/16/14, since the medication was not controlling the resident's [MEDICAL CONDITION] and to continue [MEDICATION NAME] (an anti-convulsant medication) 1000 mg every 12 hours. A telephone order received as an order from the neurologist, dated 5/16/14 and signed by the resident's primary care physician (PCP), indicated the [MEDICATION NAME] should be given stat (a medical term used to designate the medication should be given immediately) 25 mg twice a day for 1 week and then a maintenance dose of 50 mg twice a day. The physician's orders [REDACTED]. Review of the May 2014 Medication Administration Record (MAR), indicated the resident received [MEDICATION NAME] 200 mg every other day at bedtime and [MEDICATION NAME] 300 mg every other day at bedtime. The [MEDICATION NAME] 200 mg was last documented as given on May 14th and the [MEDICATION NAME] 300 mg was last documented on the MAR as given on May 15th. [MEDICATION NAME] 1750 mg was administered to the resident twice daily as ordered from 5/1/14 through 5/31/14. There was no entry on the MAR that indicated [MEDICATION NAME] was given in May. Review of the June 2014 MAR was reviewed and revealed an entry for [MEDICATION NAME] 100 mg every other day at bedtime for 3 weeks, then start [MEDICATION NAME] 200 mg every other day at bedtime for 3 weeks. The last day for the [MEDICATION NAME] was documented as 6/5/14. Notations on the MAR indicated [MEDICATION NAME] 25 mg was given twice a day starting on 6/6/14 and ended on 6/12/14. A hand written notation indicated [MEDICATION NAME] 50 mg would be started for 30 days. On 6/13/14, the [MEDICATION NAME] 50 mg was given twice daily until the end of the month. Review of the July 2014 MAR revealed an entry that indicated [MEDICATION NAME] 50 mg would be given twice daily for 30 days. Per documentation on the MAR, the resident received the medication twice daily until 7/13/14. A handwritten entry along side the entry wrote "STOP" after the last dose received on the 13th. The August 2014 physician's orders [REDACTED]. Nurse's notes for 8/14/14 at 7:30 PM nurse's notes indicated Resident # 34 was in the lobby and was observed having a [MEDICAL CONDITION]. The nurse documented the [MEDICAL CONDITION] lasted 4 minutes. The Nurse Practitioner (NP) and the Responsible Party were notified. An interview was held with the Director of Nursing (DON) on 9/11/14 at 11:56 AM. The DON stated any consultation forms received, when a resident returned from an appointment, were reviewed by the nurse working on the hall. The DON reviewed the 5/16/14 neurology consultation and the physician's telephone order and stated based on what she had read, the [MEDICATION NAME] for Resident # 34 had no stop date and should have been continued indefinitely to control the resident's [MEDICAL CONDITION]. The nurse reviewed all physician's telephone orders and could not find an order to discontinue the [MEDICATION NAME]. The DON added omitting the [MEDICATION NAME] would be considered a significant medication error since the resident had a [MEDICAL CONDITION] in August; which was after the [MEDICATION NAME] was discontinued. She added the resident had not returned to the neurologist that ordered the [MEDICATION NAME] since the medication had been discontinued. The DON identified the nurse that transcribed the order and the nurse that did the first chart check for the July 2014 orders as the same nurse. Nurse # 2 was interviewed on 9/11/14 at 3:07 PM. The nurse reviewed the telephone order from 5/16/14 and acknowledged she had been the nurse that transcribed the order. She also acknowledged she had been the nurse to write discontinue on the MAR beside the [MEDICATION NAME]. Nurse # 2 reviewed the 5/16/14 physician's telephone order for [MEDICATION NAME] and stated maintenance meant the resident would continue on the medication. She acknowledged there was no stop date. She stated end of month reconciliation was done by comparing the new MAR to the old MAR and then looking for any new orders. The nurse reviewed the order and then reviewed the MAR and stated she had made a transcription error. She added [MEDICATION NAME] was an anti-convulsant medication and could cause the resident to have [MEDICAL CONDITION]. The nurse stated Resident # 34 had a [MEDICAL CONDITION] on 8/14/14. An attempt to contact the prescribing neurologist was unsuccessful. Her office stated she was out of the office and would not be available for phone calls. An interview was held with the Medical Director on 9/12/14 at 11:20 AM. He stated he was very familiar with Resident # 34. The MD stated he referred Resident # 34 to the neurologist in May because of uncontrolled [MEDICAL CONDITION] despite receiving [MEDICATION NAME] and [MEDICATION NAME]. The MD added he wanted the neurologist to evaluate the resident to determine if any new medications were available to control the resident's [MEDICAL CONDITION]. The 5/16/14 order was read to the MD. He stated, from a physician's viewpoint, maintenance meant the medication would be needed to be taken forever in order to control [MEDICAL CONDITION]. Prior to discontinuing the [MEDICATION NAME], the MD stated he would have expected the nurse to review the order and notify either him or the neurologist; adding he had not been notified. The MD added that stopping an anti-convulsant medication without a taper could lower the [MEDICAL CONDITION] threshold and/or cause rebound [MEDICAL CONDITION].

Based on staff interview, interviews with the consultant pharmacist and the Medical Director and record review, the facility's consultant pharmacist failed to identify Vimpat (an anti-seizure medication) had not been administered per physician's orders [REDACTED].# 34) reviewed for medication usage. Findings included: Resident # 34 was admitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident was moderately cognitively impaired. Seizure disorder was identified as a diagnosis. Review of a May 16, 2014 neurology consult indicated the resident was assessed with [REDACTED]." The neurologist ordered Vimpat 25 milligrams (mgs) twice daily for one week and then a maintenance dose of 50 mg twice a day. There was no stop date included in the order; only a statement that indicated the medication was for maintenance. The neurologist wrote on the consult to stop the Dilantin 200 mg at bedtime on 5/16/14, since the medication was not controlling the resident's seizures and to continue Keppra (an anti-convulsant medication) 1000 mg every 12 hours. A telephone order, received as an order from the neurologist, dated 5/16/14 and signed by the resident's primary care physician (PCP), indicated the Vimpat should be given stat (a medical term used to designate the medication should be given immediately) 25 mg twice a day for 1 week and then a maintenance dose of 50 mg twice a day. The physician's orders [REDACTED]. Review of the May 2014 Medication Administration Record (MAR), indicated the resident received Dilantin 200 mg every other day at bedtime and Dilantin 300 mg every other day at bedtime. The Dilantin 200 mg was last documented as given on May 14th and the Dilantin 300 mg was last documented on the MAR as given on May 15th. Keppra 1750 mg was administered to the resident twice daily as ordered from 5/1/14 through 5/31/14. There was no indication on the MAR that Vimpat given during the month of May. The 6/17/14 Medication Regimen Review, completed by the consultant pharmacist, noted the Dilantin had been decreased, the Keppra continued and Vimpat 50 mg twice daily added. There was no notation that indicated the pharmacist had identified Resident # 34 had not received the Vimpat or received the Dilantin as the 5/16/14 physician's orders [REDACTED]. Review of the June 2014 MAR was reviewed and revealed an entry for Dilantin 100 mg every other day at bedtime for 3 weeks, then start Dilantin 200 mg every other day at bedtime for 3 weeks. The last day for the Dilantin was documented as 6/5/14. Notations on the MAR indicated Vimpat 25 mg was given twice a day starting on 6/6/14 and ended on 6/12/14. A hand written notation indicated Vimpat 50 mg would be started for 30 days. On 6/13/14, the Vimpat 50 mg was given twice daily until the end of the month. Review of the July 2014 MAR revealed an entry that indicated Vimpat 50 mg would be given twice daily for 30 days. Per documentation on the MAR, the resident received the medication twice daily until 7/13/14. A handwritten entry along side the entry wrote "STOP" after the last dose received on the 13th. The 7/15/14 Medication Regimen Review indicated there were no new medications. There was no documentation the pharmacist had noted or reported the discontinuation of the Vimpat on 7/13/14 and there was no indication the pharmacist had noted or reported the Dilantin had not been administered per the physician's orders [REDACTED]. The August 2014 physician's orders [REDACTED]. Nurse's notes for 8/14/14 at 7:30 PM nurse's notes indicated Resident # 34 was in the lobby and was observed in the middle of having a seizure. The nurse documented the seizure lasted 4 minutes. The Nurse Practitioner (NP) and the Responsible Party were notified. The pharmacist's 8/29/14 Medication Regimen Review noted the discontinuation of the Dilantin. There was no dated identified. There was no documentation regarding the discontinuation of the Vimpat. A telephone interview with the consultant pharmacist was held on 9/12/14 at 10:00 AM. The pharmacist stated she had worked with the facility for a month and had not been the pharmacist that reviewed the record for Resident # 34 during the months of June and July 2014. She was not familiar with the resident or his seizure diagnosis. She stated that any information she gave would be based on her personal practice and what she did during monthly medication reviews. She added during monthly chart reviews, she reviewed physician's orders [REDACTED]. The physician's telephone order, dated 5/16/14, for the Vimpat was read to the pharmacist. She stated maintenance meant to continue indefinately. During a medication review, if the medication had been discontinued, she would look for a discontinue order. If there was no discontinue order she would have questioned why the medication had been stopped. The pharmacist stated the question of stopping the medication, without a discontinuation order, should be documented in the monthly medication review notes.

Based on observation, record reviews and staff interviews, the facility failed to recognize or identify signs and symptoms of pain during a pressure ulcer dressing change for 1 of 4 residents reviewed for pressure ulcers, who was unable to verbalize pain (Resident # 27). The findings included: Resident # 27 was readmitted to the facility on [DATE]. Medical [DIAGNOSES REDACTED]. Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 27 's cognition was severely impaired. The assessment also indicated Resident # 27 was able to respond adequately to simple direct communication only sometimes. A review of Resident # 27 's care plan, most recently updated on 7/17/2013, revealed the problem of impaired skin integrity was addressed with interventions which included monitoring for signs of pain. The care plan also indicated the resident should receive pain medication as needed per physician 's order. A review of the Controlled Drug Record for the [MEDICATION NAME] 1ml (milliliters) (20 mg milligrams) with a dispense date of 6/18/13 for resident # 27 revealed the last dose of medication was signed out on 7/31/13 at 1:30 am. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. At 10:00 am on 8/7/2013, the Director of Nursing Services (DNS) and the Wound Care nurse were present in Resident # 27 's room. Prior to beginning the pressure ulcer dressing change, the Director of Nursing Services (DNS) asked the wound care nurse if the resident had been medicated for pain. The wound care nurse replied "I don 't know." During an observation of a pressure ulcer dressing change on 8/7/2013 that began at 10:00 am, Resident exhibited facial grimacing and bilateral shoulders/arms tensing as the wound care nurse cleansed a stage 3 pressure ulcer to the right hallux. During the dressing change the DNS asked the Wound Care nurse if she recognized any signs of pain in Resident # 27 's behavior. The Wound Care nurse said " Not no more than usual. She flinches like that sometimes even when she is in the room by herself. " At 10:15 am, as the wound care nurse proceeded to reposition the great toe and apply the dressing, the resident again exhibited facial grimacing, facial flushness, and bilateral shoulders/arms tensing. The DNS indicated she recognized the resident 's display of nonverbal signs of pain. The DNS upon exiting the room, instructed the hall nurse to come immediately and medicate the resident for pain at which time the dressing change was completed. During an interview on 8/7/2013 at 10:18 am, Nurse #1 indicated she was instructed to give pain medication immediately. In an interview on 8/7/13 at 10:38 am, Nurse # 1 indicated she medicated the resident with [MEDICATION NAME] 1 ml (20 mg) by mouth for pain level score of 10 on a non-verbal pain scale of 1-10 at 10:20 am. Nurse # 1 stated "She still had facial grimacing when I got in there, I rated it a 10." During an interview on 8/7/2013 at 10:40 am, the wound care nurse stated the resident was difficult to monitor for pain because she occasionally flinched like that even when she was in the room alone. She further stated "I will be more aware." During an interview on 8/7/2013 at 10:42 am, the Director of Nursing Services (DNS) indicated her expectation was for the wound care nurse to stop the treatment and go get the nurse so the resident can be administered pain medication immediately.

Based on observation, staff, resident and family interviews and record review, the facility failed to maintain the dignity of 1 of sampled residents (Resident # 54) who was observed with flies on her body and unable to brush them off. Findings include: Resident # 54 was admitted on [DATE] with cumulative [DIAGNOSES REDACTED]. An Annual Minimum Data Set (MDS), dated [DATE], indicated Resident # 54 had short and long term memory impairment and was severely impaired in cognitive skills for daily decision making. The MDS also indicated the resident was rarely or never able to understand others and had no speech. Resident # 54 was coded as totally dependent on staff for all activities of daily living. She was also identified as having functional limitation in range of motion unilaterally in her upper and lower extremities. On 8/22/11at 3:00 PM, an observation was made of flies crawling on Resident # 54's face and lips. The resident did not respond in any way. She was unable to brush the flies away. On 08/23/11 at 12:30 PM, an observation was made in the facility lobby. Each time the door was opened, flies came into the building. No fan, insect light or fly strip was seen in use to deter the flies from entering the building. Resident # 54's room was the first room on the left hall after entering the building An interview was held on 08/23/11 at 12:45 PM with Resident # 54's Responsible Party (RP) and 2 other family members. All family members agreed flies had been an issue for Resident # 54. One family member stated she had been in the facility one day recently and had to continually brush flies off the resident's face. The family member added during one of her visits, the Administrator came by with a visitor. She added she summoned the Administrator in the room to discuss the flies. The Administrator told her he would be back to talk with her later. The family member stated, "later has not come yet". Resident # 54's RP stated the resident was unable to do anything for herself and would not be able to brush flies off her face. The family members added they had been in the resident's room with fly swatters trying to kill the flies. The dinner meal was observed on 8/23/11 at 5:10 PM. Residents were observed brushing flies away from their food. One resident was observed with fly swatter in his lap. At 5:30 PM on 08/23/11, a nursing assistant (NA) was observed assisting with a resident's dinner. The NA told the resident that she, the NA, needed to sit there to keep the flies away. Review of the Grievance Log from 06/10 through 08/24/11 did not indicate any residents or family members had complained of insects in the building. Review of the resident council minutes for June, July and August did not indicate concerns about flies in the building. An observation was made on 8/24/11 at 10:27 AM. No flies were seen in the resident's room. There was no fly strip positioned over the resident's window valance. An interview was held with the Maintenance Director (MD) on 08/24/11 at 10:48 AM. Pest control logs were reviewed. The MD stated the company responsible for pest control visited monthly. He added the facility had a large fly control program which included 5 fly lights that were located on each hall, the dining area, the employee break room and the lobby. The MD added the fly light in the lobby had been reinstalled that morning. The Administrator had asked that the fly light in the lobby be replaced on Monday morning (8/22/11). The MD stated that with residents opening and closing doors so much, flies were allowed to enter the building. The MD stated there was one resident about a year ago that complained there were flies, but the room mate did not. If a resident complains about flies, then a glue strip for flies was placed over the window valance. The MD stated he had not noticed flies in any particular resident rooms. An interview was held with NA # 3 on 8/24/11 at 2:29 PM. NA # 3 stated in the last few weeks she had seen flies in the dining room and in resident's rooms and on the resident's bodies. The NA named a particular resident who had trouble with flies, but added this resident could brush the flies away. NA # 3, who worked with Resident # 54 on 8/24/11 stated Resident # 54 was unable to brush flies away if they should land on her body. The NA stated she had not received complaints from residents, families or staff about flies. The NA acknowledged she had not reported her observations of flies in the dining area or on residents to anyone. An interview was held with the Administrator on 08/24/11 at 2:49 PM. The Administrator stated the fly light was in the lobby, but had been taken down a couple of months ago in order to do work. He added since there had been no problem with flies, there had been no hurry to put the fly light back up. The Administrator stated he had noticed a problem with flies increased a couple of days ago. He added flies could cause illnesses by spread of bacteria because they are nasty. The Administrator stated he had received no complaints about flies from residents or families in the last year. He stated he could not recall Resident # 54's family speaking to him about flies. The Administrator stated flies on a resident's face and mouth was disgusting. The Administrator acknowledged Resident # 54 had no ability to brush flies away independently. At this point, the Administrator stated nothing had been done to keep flies off dependent residents and at this time, he doesn't know what could be done. An interview was held with the Director of Nursing Services (DNS) on 08/24/11 at 3:35 PM. The expectation would be for the staff to get the flies off the resident and then report it to her or the Maintenance Director. The DNS stated she had not seen flies on any resident. An observation was made on 08/24/11 at 5:30 PM in the dining room. Resident # 62 was observed continuously brushing flies away from his face. He stated the flies were a big bother. The resident had his fly swatter laying on the dining room table. He stated he had to keep swatting to keep the flies to keep them off his food. The resident stated flies were really bad in the building. The admission assessment for this resident, dated 07/19/11, indicated the resident was cognitively intact.