Every finding on record at Snyder Nursing Home

Based on staff interviews, clinical record reviews, and facility document review, the facility staff failed to develop comprehensive care plans that included the residents code status for all current residents of the facility.The findings included:During the clinical record reviews, the survey team was unable to identify any information regarding the resident's current code status on the comprehensive care plans.On 10/27/2025 at 5:10 p.m., during an interview with Registered Nurse (RN) #2 this staff stated they did not include the residents code status on their comprehensive care plan. On 10/28/2025 at 8:20 a.m., RN #2 approached the surveyor, and stated she had updated the residents care plans to include their current code status. On 10/28/25 at 2:30 p.m., during a meeting with the Director of Nursing (DON) and Administrator the issue with the resident's code status not being care planned was reviewed. On 10/28/25 at 4:40 p.m., the DON provided the survey team with a copy of their policy with the subject Comprehensive Care Plan. This policy read in part, .Each resident will have a person-centered comprehensive care plan developed within 7 days of the completion of the comprehensive assessment and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review and facility document review the facility staff failed to provide evidence that Advance Care planning information was provided to residents/resident representatives upon admission and reviewed periodically. The findings included:During clinical record reviews, each clinical record reviewed was found to contain a form entitled, Advance Directives/Medical Treatment Decisions Acknowledge of Receipt which read in part, Resident Understanding Acknowledgement-Advance Directive/Medical Treatment Decision. This is to acknowledge that I have been informed in writing in a language that I understand of my rights and all rules and regulations to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate and to issue advance directions to be followed should I become decisionally incapable. I understand it is my responsibility to provide to the facility copies of all pertinent documentation which verify advance directives formulated and/or issued by me for placement in my medical record. None of the forms reviewed were signed by the resident or their representative.Surveyors spoke with the director or nursing (DON) on 10/27/25 at 4:50 pm regarding advance care planning. DON stated that the Advance Directives/Medical Treatment Decisions Acknowledge of Receipt form located in each residents' clinical record is just a worksheet for me and when a resident is admitted to the facility, she goes over their code status with them. DON stated she does not have residents/representatives sign the form to acknowledge receipt of the information.Surveyor requested and was provided with a facility policy entitled Advance Directives (Self Determination Rights for Residents) which read in part, Purpose: To promote resident rights. Upon admission each resident will be advised of and given the opportunity to execute Advanced Directives if they so desire. Procedure: 1. Upon admission, the resident or resident's legal representative will be notified of their right to implement advance directive if he or she chooses to do so. 2. If the resident is incapacitated and unable to receive information about his or her right to formulate an advanced, the information may be provided to the resident's legal representative.The concern of the facility staff failing to provide evidence that advance care planning was provided to each resident/representative was discussed with the administrator and DON on 10/29/25 at 11:00 am.No further information was provided prior to exit.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to maintain a complete and/or accurate clinical record for (1) of (16) sampled residents, Resident #3. The findings included:For Resident #3 the facility staff failed to accurately document the resident's fluid intake on the TAR (treatment administration record) as indicated by a medical provider order for fluid restriction. Resident #3's diagnosis list indicated diagnoses that included but were not limited to Chronic Atrial Fibrillation, Hypothyroidism, Chronic Kidney Disease-Stage 4, Chronic Obstructive Pulmonary Disease, Chronic Diastolic (Congestive) Heart Failure, and Cognitive Communication Deficit. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 10/7/25, assigned the resident a brief interview for mental status (BIMS) summary score of 13 out of 15 for cognitive abilities, indicating the resident was cognitively intact. A medical provider orders with a start date of 9/15/25 read in part, .1500 mL (milliliters) fluid restriction (a 1500 mL fluid restriction is a medical order that limits total daily liquid intake to 1500 milliliters-approximately 50.7 ounces). A review of the September and October 2025 MARs (medication administration records) did not disclose any indication of monitoring Resident #3's fluid restriction. A review of a Quarterly Nutritional Assessment dated 10/7/25 read in part, .1500 mL Fluid Restriction.Edema.Therapeutic diet r/t (related to) CHF (congestive heart failure).on fluid restriction & daily weights [with] extra Lasix per orders. On 10/28/25 at 5:15 PM, the director of nursing (DON) informed surveyor the registered dietician had provided nursing with a break-down of how the fluids were to be consumed and provided surveyor with a copy of the hand-written break-down instructions dated 9/15/25 which read in part, .1500 cc FR (fluid restriction).no water pitcher in room.She (Resident #3) gets 1260 cc fluids on meal trays.she can have 4 oz (ounces) water or other liquid with med (medication) pass x 3 (three times daily).Copy placed in MAR. The DON informed surveyor the fluid restriction is on the TAR not the MAR and nursing staff was honoring the fluid restriction for Resident #3, but they were not documenting it on the TAR. The DON provided surveyor with a copy of the September and October 2025 TARs and one entry was indicated on 9/16/25 for 1500 mL fluid restriction. No other entries were documented on either TAR. On 10/29/25 at 8:18 AM, the DON informed surveyor she updated the October TAR for monitoring of Resident #3's fluid intake and provided surveyor with a copy. A review of the October TAR showed an entry for 10/29/25 for fluid restriction. The DON also provided surveyor with a copy of an Accurate Intake and Output Record, that the DON stated would be utilized to monitor the amount of fluid Resident #3 intakes daily. This concern was discussed at the pre-exit meeting with the administrator and director of nursing on 10/29/25 at 10:35 AM. No further information was provided to the survey team prior to exit on 10/29/25.

Based on observation, staff interview, and clinical record review, the facility staff failed to ensure the highest practicable well-being for 2 of 16 current residents of the facility. Resident #39 and #2.The findings included:1. Resident #39 was observed with a chair alarm in place. The clinical record did not include a current provider order for a chair alarm. Resident #39's diagnoses included adult failure to thrive and muscle weakness. Section C (cognitive patterns) of Resident #39's annual minimum data set assessment (MDS) with an assessment reference date (ARD) of 10/03/25 was coded 1/1/2 to indicate Resident #39 had problems with long- and short-term memory and was moderately impaired in cognitive skills for daily decision making. Section GG0120 (mobility devices) was checked to indicate this resident used a wheelchair. Section P (restraints and alarms) was coded to indicate the resident used a bed alarm daily. Resident #39's comprehensive care plan included the focus area at risk for falls. Interventions included bed alarm. There was no intervention for a chair alarm. Resident #39's current provider orders included an order for a bed alarm and low bed with mat. It did not include an order for a chair alarm. On 10/28/2025 at 10:50 a.m., Resident #39 was observed up in their wheelchair in the dining room. Resident #39 was observed to have a chair alarm in place. The surveyor notified the Director of Nursing (DON) who accompanied the surveyor to the dining room and observed the chair alarm in place. The surveyor stated they did not see a provider order for the chair alarm in Resident #39's clinical record. The DON stated they would review Resident #39's clinical record. On 10/28/25 at 11:50 a.m., the DON confirmed that Resident #39 did not have a current order for a chair alarm and the alarm was being removed. On 10/28/25 at 2:30 p.m., during a meeting with the Administrator and DON the issue with Resident #39 having a chair alarm in place without a current provider order was reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. For Resident #2 the facility staff failed to follow a medical provider order to discontinue a bed alarm. Resident #2's diagnosis list indicated diagnoses that included, but were not limited to, Type 2 Diabetes Mellitus, Mild Cognitive Impairment, Macular Degeneration, Weakness, Lack of Coordination, and Lymphedema. The resident's admission minimum data set (MDS) with an assessment reference date (ARD) of 10/22/25 assigned the resident a brief interview for mental status (BIMS) summary score of 13 out of 15 for cognitive abilities, indicating Resident #2 was cognitively intact. On 10/27/25 at 3:36 PM, this surveyor observed Resident #2's bed to have a bed alarm in place. On 10/28/25 at 9:34 AM, this surveyor observed and interviewed Resident #2 in her room and observed a bed alarm in place on the resident's bed. Surveyor asked resident what happens when the bed alarm sounds, and the resident informed surveyor that she turns it off. A medical provider order dated 10/20/25 read in part, .D/C (discontinue) bed alarm. On 10/29/25 at 8:48 AM this surveyor spoke with the director of nursing about Resident #2's bed alarm being discontinued, the director of nursing agreed the bed alarm had been discontinued. She stated Resident #2 had been out to the hospital and the care plan had been updated with the new order for the bed alarm to be discontinued. The DON informed surveyor the bed alarm had been removed from Resident #2's bed this morning. This concern was discussed at the pre-exit meeting with the administrator and director of nursing on 10/29/25 at 10:35 AM. Surveyor requested and received a facility policy titled, Transcribing Orders that read in part, .Purpose: To accurately transcribe and follow new orders.5. Accurately place new order.ensuring proper.treatment.etc. No further information was provided to the survey team prior to exit on 10/29/25.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide a valid basis for a declination of readmission of the resident after a hospitalization with return anticipated and the facility staff failed to develop and implement an appropriate discharge process to the resident and/or resident representative for (1) one of (2) closed record reviews, Resident #45. The findings included:For Resident #45 the facility staff declined readmission following a hospital stay with a paid bed hold due to the resident electing hospice services. readmission was declined despite the facility offering individualized hospice service contracts. Resident #45's diagnosis list indicated diagnoses that included, but were not limited to, Multiple Sclerosis, Paraplegia, Osteoarthritis, Repeated Falls, Weakness, Depression, TIA (Transient Ischemic Attack), Cerebral Infarction, History of Disease of Digestive Tract, Anxiety Disorder, and Congestive Heart Failure. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 10/12/23, assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 for cognitive abilities, indicating the resident was cognitively intact. A review of the clinical record disclosed Resident #45 was discharged to the hospital on [DATE]. A review of a discharge MDS dated [DATE] was coded in Section A (Identification Information) A0310-F. as 11 (Discharge assessment-return anticipated). A communication fax from the hospital dated 12/18/23 contained a fax cover sheet with hand-written notes from the hospital case manager which read in part, .per our conversations the patient and the family wish to return with bipap and [name of hospice omitted].Please coordinate w/family & [hospice] regarding next steps in contract, expectations, etc. Hospital notes within the fax mentioned above read in part, .(page 5).Pending [nursing home name omitted] acceptance Monday, and organization of hospice contract by family and [nursing home].(page 9).Patient and family would like to pursue hospice.at discharge, and is currently awaiting acceptance back to.nursing home with plans for discharge 12/18 (2023).Would like to pursue hospice outpatient at discharge.Will discuss discharge planning with family.Per facility and CM (case manager), [nursing home] cannot accept patient pt (patient) till Monday .afternoon discussion with son.pt and CM.plan moving forward to include coordination between [nursing home] and [hospice] regarding responsibilities of hospice going forward. 12/20/23 12:30 PM.Nurse's Note.Son.in to pick up res's belongings. On 10/28/25 at 1:15 PM, surveyor interviewed the facility administrator and he informed surveyor that Resident #45 was not readmitted to the facility and informed surveyor the facility does not have a universal hospice contract and the facility does hospice contracts on an individual basis. The administrator agreed the resident had paid a bed hold. The administrator informed this surveyor the discharge planner at the hospital informed him the doctor had made the resident hospice and the resident had an order for hospice and that's when the issues started, as he did not have a hospice contract. Surveyor inquired why Resident #45 was not permitted to readmit back to the facility, as she had paid a bed hold and the administrator informed surveyor the resident could not readmit because she had an order for hospice. Surveyor inquired if a discharge notice was given after the resident was not permitted to readmit to the facility and the administrator informed surveyor a discharge notice was given when the resident was transferred to the hospital. This concern was discussed at the pre-exit meeting with the administrator and director of nursing on 10/29/25 at 10:35 AM. Surveyor requested and received a facility policy titled Discharge Planning which read in part, .Nursing Home will ensure that all residents receive appropriate discharge planning, preparation.upon discharge.At a minimum, documentation supporting the.discharge will include.The basis for the transfer.Specific needs that cannot be met. No further information was provided to the survey team prior to exit on 10/29/25.

Based on staff interview and clinical record review, the facility staff failed to follow the providers orders for 1 of 14 residents, Resident #20. The findings included: For Resident #20, the facility staff failed to administer the medication Metoprolol per the providers orders. Resident #20's diagnoses included, but were not limited to hypertension, atrial fibrillation, and congestive heart failure. Section C (cognitive patterns) of Resident #20's quarterly MDS assessment with an assessment reference date (ARD) of 07/12/23 included a brief interview for mental status (BIMS) score of 14 out of a possible 15 points. Resident #20's clinical record included an order for Metoprolol 50 mg take 1 tablet by mouth every day for hypertension hold if systolic is less than 90 AND diastolic less than 60. A review of Resident #20's medication administration records for August 2023 revealed that Licensed Practical Nurse (LPN) #1 held Resident #20's Metoprolol for a blood pressure of 106/68 on 08/20/23 for the administration time of 8:00 a.m. Resident #20's comprehensive care plan included the focus area has hypertension. Interventions included, but were not limited to, give anti-hypertensive medications as ordered. On 08/21/23 3:05 p.m., the Director of Nursing (DON) was made aware of the issue regarding Resident #20's medication Metoprolol. On 08/23/23 10:00 a.m., during a meeting with the Administrator and DON the DON stated they would have the provider review Resident #20's blood pressure medication orders. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observation, resident interview, staff interview, interviews with local health department staff, clinical record review, and facility document review, the facility staff failed to maintain an infection prevention program for preventing and controlling infection and communicable diseases during an identified outbreak of COVID-19. Facility staff failed to follow facility policy and procedure and CDC (Centers for Disease Control and Prevention) guidance related to cohorting COVID-19 positive and untested , asymptomatic residents together when vacant rooms were available creating the likelihood of the resident being exposed to and contracting COVID-19 for 1 of 29 current residents residing in the facility, Resident #18. Facility staff failed to follow CMS (Centers for Medicare and Medicaid Services) and CDC guidance related to performing COVID-19 testing for exposed residents and staff following residents testing positive for COVID-19 on [DATE] and [DATE]. At the time of the survey, two (2) residents were positive for COVID-19. The findings included: 1. For Resident #18, the facility staff failed to test the resident for COVID-19 or move the resident to a vacant room following the roommate testing positive for COVID-19 on [DATE]. Resident #18's diagnosis list indicated diagnoses which included, but not limited to, Multiple Sclerosis, Essential Hypertension, paraplegia, and Hyperparathyroidism. The resident's current physician's orders included the active diagnosis of congestive heart failure. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of [DATE] assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. On [DATE] at approximately 3:00 PM, surveyor observed signage present outside of Resident #18's room indicating contact and droplet transmission-based precautions were in place. Resident #18 shared a semi-private room with Resident #22. Surveyor donned necessary personal protective equipment (PPE) and entered the residents' room. Upon entrance, surveyor observed the privacy curtain drawn approximately halfway across the room, Resident #18's left side of the bed was against the wall and Resident #22's right side of the bed was against the wall, the residents were greater than six feet apart with the privacy curtain drawn between them. Each resident was in bed and neither resident was wearing a facial covering. Resident #18 was lying in bed and receiving oxygen via nasal cannula at 2 liters per minute. Resident #18 stated they were usually in the dining room but could not because of their roommate. A review of Resident #18's clinical record revealed a physician's order dated [DATE] for contact and droplet precautions related to roommate testing positive for COVID-19. Surveyor reviewed Resident #18's clinical record and was unable to locate documentation of the resident being tested for COVID-19 following exposure to the positive roommate. Resident #18 had no documented signs or symptoms of COVID-19. Resident #18 received COVID-19 vaccinations on [DATE], [DATE], and [DATE]. According to the roommate's (Resident #22) clinical record, they tested positive for COVID-19 on [DATE] at 9:30 AM. On [DATE] at 3:45 PM, surveyor observed five (5) vacant resident rooms available for use and one (1) vacant resident room being used for storage. Surveyor requested and received facility room census reports for [DATE] and [DATE]. A review of the room census reports revealed the five (5) identified vacant rooms were also vacant on [DATE] and [DATE]. Upon entrance on [DATE], the census in this 45-bed facility was 29. On [DATE] at 3:55 PM, the director of nursing (DON) provided the facility policy entitled Coronavirus Disease-COVID-19 - Resident Cohorting with an effective date of [DATE] which read in part . 1. During the pandemic, residents may be cohorted in a room utilizing the following guidelines: a. All resident [sic] who are COVID-19 positive (symptomatic or asymptomatic) may only be cohorted with residents who are also positive . The administrator and DON verified this was a current policy. On [DATE] at 11:06 AM, surveyor spoke with the DON who stated the facility medical director did not want residents moved due to COVID-19 and the possibility of spreading it to other areas in the facility. Surveyor asked the DON if Resident #18 was offered a room move and the DON stated no. DON stated staff were monitoring Resident #18's vital signs every shift to monitor for signs or symptoms of COVID-19. On [DATE] at 1:36 PM, surveyor spoke with the facility medical director (MD) who stated they instructed the staff not to move either resident due to possibility of exposing additional residents in other areas. MD further stated that the exposure was already there, and it was reasonable to keep the residents where they were. On [DATE] at 3:00 PM, surveyor spoke with Resident #18 who stated they were on isolation because their roommate had COVID, and staff had not talked to them about changing rooms. Resident #18 also stated they had not been tested for COVID-19. On [DATE] at 4:00 PM, the survey team met with the administrator and DON and discussed the concern of Resident #18 not being tested for COVID-19 and remaining in the room with a COVID-19 positive roommate despite having multiple vacant rooms available. The administrator acknowledged the facility had vacant rooms available. Surveyor shared and discussed current CDC guidance. The following information was provided: CDC COVID-19 Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated [DATE] documents in part, .The ICP [infection prevention and control] recommendations described below (e.g., patient placement, recommended PPE [personal protective equipment]) also apply to patients with symptoms of COVID-19 (even before results of diagnostic testing) and asymptomatic patients who have met the criteria for empiric Transmission-Based Precautions based on close contact with someone with SARS-CoV-2 infection. However, these patients should not be cohorted with patients with confirmed SARS-CoV-2 infection unless they are confirmed to have SARS-CoV-2 infection through testing .Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room .If cohorting, only patients with the same respiratory pathogen should be housed in the same room .If limited single rooms are available, or if numerous residents are simultaneously identified to have known SARS-CoV-2 exposures or symptoms concerning for COVID-19, residents should remain in their current location . On [DATE] at 10:03 AM, surveyor spoke with the local health department epidemiologist who stated they were unaware of the current COVID-19 activity in the facility and had not spoken to any facility staff. Surveyor informed the epidemiologist of the concern of Resident #18 remaining in the room with a COVID-19 positive roommate without being tested for COVID-19. Epidemiologist stated they always recommended the current guidelines. The epidemiologist then referred surveyor to the case investigator working with area facilities. On [DATE] at 10:09 AM, the administrator stated the medical director instructed them to leave the residents where they were and only to test residents if they were symptomatic and the facility did as they were directed. The administrator stated they saw this as a standing order. The administrator stated they were appreciative of the survey team identifying the issue and would be looking at the concerns. On [DATE] at 10:35 AM, surveyor spoke with the case investigator (CI) with the local health department who stated they were also unaware of the COVID-19 activity in the facility. Surveyor informed the CI of the concern regarding Resident #18; CI stated it was negligent for Resident #18 to remain in the room with a COVID-19 positive roommate when empty rooms were available. CI stated their recommendation would be to separate COVID-19 positive and negative roommates and do point prevalence testing. On [DATE] at 10:55 AM, the survey team met with the administrator and DON and provided contact information for the local health department case investigator for additional guidance. No further information regarding this concern was presented to the survey team prior to the exit conference on [DATE]. 2. Facility staff failed to follow CMS (Centers for Medicare and Medicaid Services) and CDC (Centers for Disease Control) guidance related to performing COVID-19 testing for exposed residents and staff following residents testing positive for COVID-19 on [DATE] and [DATE]. Upon facility entrance on [DATE], the survey team was informed of one (1) active case of COVID-19 stating Resident #22 had tested positive for COVID-19 on [DATE]. According to Resident #22's clinical record, they tested positive for COVID-19 on [DATE] at 9:30 AM. On [DATE] at approximately 3:00 pm, surveyor observed signage present outside of Resident #22's room indicating contact and droplet transmission-based precautions were in place. Resident #22 currently shared a semi-private room with Resident #18. Surveyor reviewed Resident #18's clinical record and was unable to locate documentation of the resident being tested for COVID-19 following exposure to the positive roommate. Resident #18's physician's orders included a current order for a rapid COVID test as needed. Resident #18 had no documented signs or symptoms of COVID-19. On [DATE] at approximately 8:30 am, the survey team was informed an additional resident, Resident #3, had tested positive for COVID-19 on the evening of [DATE]. On the previous day, surveyor observed Resident #3 outside on the patio with a minimum of ten (10) additional residents and attended a resident council meeting with a surveyor outdoors on the patio. Surveyor had also observed Resident #3 having lunch in the facility dining room with other residents and the resident remained in the dining room following lunch. On [DATE] at 9:37 AM, surveyor spoke with the director of nursing (DON) and requested the facility testing policy. At 10:55 AM, the DON provided surveyor with pages 1 and 6 of the CMS QSO-,d+[DATE]-ALL memo dated [DATE] and stated this was the facility testing policy. The [DATE] CMS QSO-,d+[DATE]-ALL memo read in part, .Requirements for COVID-19 Testing On [DATE], CMS issued an IFC (CMS-3401-IFC) requiring LTC [Long Term Care] facilities to perform routine testing of residents and staff for the COVID-19 infection. As noted in the IFC, this testing regulation will expire with the end of the PHE [public health emergency]. Note: CMS issued the testing requirements early in the COVID-19 PHE to ensure facilities were conducting the volume and frequency of tests needed to identify COVID-19 cases and prevent transmission, such as surveillance testing of nursing home staff. Throughout the PHE, CDC and CMS have updated the testing guidance, including most recently, removing the recommendation for surveillance testing of staff. However, COVID-19 testing is still an important action and is a nationally recognized standard to help identify and prevent the spread of COVID-19. Therefore, while this specific regulatory requirement will end with the PHE, CMS still expects facilities to conduct COVID-19 testing in accordance with accepted national standards, such as CDC recommendations . On [DATE] at 11:06 AM, the DON stated they monitor all residents for signs and symptoms of COVID-19 but were only doing vital signs every shift for COVID-19 monitoring on the two positive residents, Resident #22 and #3, and the exposed roommate, Resident #18. On [DATE] at 11:17 AM, surveyor spoke with the administrator who stated they were testing residents and staff based on signs and symptoms only. The administrator stated when a resident tested positive for COVID-19, notices were hung, the COVID information hotline was updated, a report was sent to the local health department, supplies were monitored, and the medical director was notified. On [DATE] at 1:36 PM, surveyor spoke with the medical director (MD) regarding the facility only testing for COVID-19 based on signs and symptoms and not following exposure, the MD stated they thought the facility was testing everyone, but they had no strong feelings either way about testing. MD stated it was reasonable to test Resident #22's exposed roommate. On [DATE] at 3:00 PM, surveyor spoke with Resident #18 who stated they had not been tested for COVID-19. On [DATE] at 4:00 pm, the survey team met with the administrator and DON and discussed the concern of the facility only testing symptomatic residents and staff and not performing testing following exposure to COVID-19. The administrator and DON stated their facility medical director instructed them to only test symptomatic residents. The administrator stated COVID-19 testing kits were issued to facility staff to take home and test when symptomatic. Surveyor shared and discussed current CMS and CDC guidance. The following information was provided: CMS QSO-,d+[DATE]-NH memo dated [DATE], expired [DATE] documents in part .Effective [DATE], this memo is no longer in effect. Testing for COVID-19 should be conducted by following accepted national standards, such as CDC recommendations . CDC COVID-19 Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated [DATE] documents in part, .Responding to a newly identified SARS-CoV-2 infected HCP [healthcare personnel] or resident - When performing an outbreak response to a known case, facilities should always defer to the recommendations of the jurisdiction's public health authority. - A single new case of SARS-CoV-2 infection in any HCP or resident should be evaluated to determine if others in the facility could have been exposed. - The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. - Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5 . On [DATE] at 8:30 AM, the DON stated they had not tested or offered to test Resident #18. On [DATE] at approximately 8:45 AM, the DON stated they tested the three (3) residents who Resident #3 shared a table in the dining room on [DATE]. The DON provided copies of COVID-19 test results for Resident #25, #26, and #27 obtained on [DATE], all results were negative. On [DATE] at 10:03 AM, surveyor spoke with the local health department epidemiologist who stated they were unaware of the current COVID-19 activity in the facility and had not spoken to any facility staff. Surveyor informed the epidemiologist of the concern of the facility not conducting testing on exposed residents or staff. Epidemiologist stated they always recommended the current guidelines. The epidemiologist then referred surveyor to the case investigator working with area facilities. The epidemiologist confirmed that a single positive COVID-19 case was considered an outbreak. On [DATE] at 10:09 AM, the administrator stated the medical director instructed them to only to test residents if they were symptomatic and the facility did as they were directed. The administrator stated they saw this as a standing order. The administrator stated they were appreciative of the survey team identifying the issue and would be looking at the concerns. On [DATE] at 10:31 AM, the administrator and DON confirmed they were only testing symptomatic staff members and to their knowledge, no staff have been tested for COVID-19 this week. On [DATE] at 10:35 AM, surveyor spoke with the case investigator (CI) with the local health department who stated they were also unaware of the COVID-19 activity at the facility. Surveyor informed the CI of the concern regarding the facility not conducting testing on exposed residents or staff, CI stated their recommendation would be to do point prevalence testing. On [DATE] at 10:55 AM, the survey team met with the administrator and DON and provided contact information for the local health department case investigator for additional guidance. No further information regarding this concern was presented to the survey team prior to the exit conference on [DATE].

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to review and revise the comprehensive person-centered plan of care for 3 of 14 residents in the survey sample, Residents #10, #18, and #22. The findings included: 1. For Resident #10, the facility staff failed to revise the comprehensive person-centered care plan following the development of an unstageable pressure injury. Resident #10's diagnosis list indicated diagnoses, which included, but not limited to Alzheimer's Disease, Hemiplegia and Hemiparesis following Cerebral Infarction, Type 2 Diabetes Mellitus, and Chronic Congestive Heart Failure. The most recent annual minimum data set (MDS) with an assessment reference date (ARD) of 5/16/23 assigned the resident a brief interview for mental status (BIMS) summary score of 8 out of 15 indicating the resident was moderately cognitively impaired. A review of Resident #10's clinical record revealed a report entitled Weekly Pressure Ulcer Progress Report indicating a 1 cm x 1 cm unstageable wound was identified to the resident's left heel on 8/08/23. A physician's order was obtained on 8/08/23 to apply Betadine to the left heel wound twice a day until healed. Surveyor reviewed Resident #10's comprehensive person-centered care plan and was unable to locate documentation of a pressure wound to the resident's left heel. The plan of care included a focus area stating the resident had the potential for pressure ulcers due to frequent bowel and bladder incontinence and requiring assistance with bed mobility. On 8/22/23 at 4:00 PM, the survey team met with the administrator and director of nursing (DON) and discussed the concern of staff failing to revise Resident #10's care plan following development of an unstageable pressure injury. On 8/22/23 at 8:27 AM, the DON informed the surveyor they had now revised Resident #10's care plan and provided a copy of the revised care plan which included the unstageable pressure area. Surveyor requested and received the facility policy entitled Comprehensive Care Plan with the revision date of 10/01/17 which read in part .6. The comprehensive care plan will be reviewed and revised by IDT [interdisciplinary team] composed of individuals who have knowledge of the resident and his/her needs . No further information regarding this concern was presented to the survey team prior to the exit conference on 8/23/23. 2. For Resident #18, the facility staff failed to review and revised the comprehensive person-centered care plan following COVID-19 exposure and placement on transmission-based precautions (TBPs). Resident #18's diagnosis list indicated diagnoses, which included, but not limited to Multiple Sclerosis, Essential Hypertension, Hyperparathyroidism, and Paraplegia. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 7/12/23 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. On 8/21/23 at approximately 3:00 PM, surveyor observed signage present outside of Resident #18's room indicating contact and droplet precautions were in place. Resident #18's clinical record revealed a physician's order dated 8/20/23 for contact and droplet precautions related to roommate being positive for COVID-19. Surveyor reviewed Resident #18's comprehensive person-centered care plan and was unable to locate documentation of the resident's COVID-19 exposure and subsequent placement on transmission based-precautions. Surveyor requested and received the facility policy entitled Comprehensive Care Plan with the revision date of 10/01/17 which read in part .6. The comprehensive care plan will be reviewed and revised by IDT [interdisciplinary team] composed of individuals who have knowledge of the resident and his/her needs . On 8/23/23 at approximately 10:15 AM, the survey team met with the administrator and director of nursing and discussed the concern of staff failing to revise Resident #18's care plan to reflect their exposure to COVID-19 and subsequent transmission-based precautions. No further information regarding this concern was presented to the survey team prior to the exit conference on 8/23/23. 3. For Resident #22, the facility staff failed to revise the comprehensive person-centered care plan after the resident tested positive for COVID-19 and was placed on transmission-based precautions. Resident #22's diagnosis list indicated diagnoses, which included, but not limited to Hemiplegia and Hemiparesis following Cerebral Infarction, Essential Hypertension, Dementia, and Type 2 Diabetes Mellitus. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 7/12/23 assigned the resident a brief interview for mental status (BIMS) summary score of 1 out of 15 indicating the resident was severely cognitively impaired. On 8/21/23 at approximately 3:00 PM, surveyor observed signage present outside of Resident #22's room indicating contact and droplet precautions were in place. A review of Resident #22's clinical record revealed a nursing progress note dated 8/19/23 at 9:30 AM stating the resident had tested positive for COVID-19. A physician's order dated 8/19/23 was received to place Resident #22 on contact and droplet precautions. Surveyor reviewed Resident #22's comprehensive person-centered care plan and was unable to locate documentation of the resident's COVID-19 diagnosis and subsequent placement on transmission based-precautions. On 8/22/23 at 4:00 PM, the survey team met with the administrator and director of nursing (DON) and discussed the concern of staff failing to revise Resident #22's care plan following testing positive for COVID-19 and placement on transmission-based precautions. On 8/23/23 at 8:27 AM, the DON informed the surveyor they had now revised Resident #22's care plan and provided a copy of the revised care plan which included the diagnosis of COVID-19 and the intervention of contact and droplet precautions. Surveyor requested and received the facility policy entitled Comprehensive Care Plan with the revision date of 10/01/17 which read in part .6. The comprehensive care plan will be reviewed and revised by IDT [interdisciplinary team] composed of individuals who have knowledge of the resident and his/her needs . No further information regarding this concern was presented to the survey team prior to the exit conference on 8/23/23.

Based on staff interview and review of facility documents, the facility staff failed to conduct COVID-19 testing for asymptomatic staff based on the county positivity rate for 30 of 60 staff members. The findings included: The facility staff failed to conduct routine COVID-19 testing for asymptomatic staff members based on the county positivity rate for staff members that have not previously tested positive. At the time of the survey, there were no residents or staff positive for COVID-19. Testing totals in the facility indicated a cumulative total of 24 COVID-19 positive residents with three (3) deaths and a cumulative total of 30 positive staff members. On 2/09/21 at 2:15pm during the Entrance Conference with the survey team, the administrator stated the facility is testing staff based on signs and symptoms only. Survey team requested the current county COVID-19 positivity rate, administrator stated the current rate for the City of (name omitted) is 6.7% and the facility considers themselves to be in the low range for testing. Administrator stated they are using the VDH (Virginia Department of Health) website to monitor positivity rates. Administrator further stated that on 1/06/21, all staff that had never tested positive for COVID-19 were tested using PCR testing and all results were negative. Administrator reported the facility has been testing staff members based on signs and symptoms only since the first COVID-19 vaccine was administered, which was on 1/11/21, based on guidance from the local health department and the facility medical director. Surveyor requested the county positivity rates since 11/01/20. Administrator provided the following information for the City of (name omitted): 1/09/21 - 1/22/21 8.5% and 1/23/21 - 2/05/21 6.6%. Administrator stated the rates on the VDH website only went back to this timeframe. CMS QSO-20-38-NH: August 26, 2020 documents in part, Routine testing should be based on the extent of the virus in the community, therefore facilities should use their county positivity rate in the prior week as the trigger for staff testing frequency and The facility should begin testing all staff at the frequency prescribed in the Routine Testing table based on the county positivity rate reported in the past week. Testing requirements for a county positivity rate of 5% - 10% is a minimum testing frequency of once a week. Surveyor requested and received the facility policy entitled, COVID-19 Testing Plan which states in part: Policy: The facility will ensure compliance with federal and state guidance of performing resident and staff testing for [CONDITION(S)] respiratory illness, including COVID-19. Subsequent / Follow Up Testing 3) Following initial testing, the facility will test staff and residents, excluding those who have had positive test history at the frequency that is recommended by the local health department and based upon the prevalence of the virus in the geographical community. Specific Test Procedures 1) d) Asymptomatic Staff: test asymptomatic staff prior to employment, after return from travel to a high-risk location, upon suspicion of exposure and as required by CDC and CMS guidance. On 2/10/21 at 9:08am, survey team spoke via phone with (name omitted), epidemiology nurse with the local health department, who stated it was their understanding that if the facility is still screening staff it is okay that only new employees should be tested . Epidemiology nurse stated the facility's outbreak is over, every resident had COVID-19 and has received vaccinations. They stated they would review the CMS guidelines and their last conversation with the facility administrator and return the call to the survey team. Epidemiology nurse contacted the survey team at 9:53am and stated they looked at the CMS memo and facility should be testing once a week. They stated they do not remember talking to the facility about going by positivity rates for testing. On 2/10/21 at 9:58am, survey team spoke with administrator and DON (director of nursing) concerning the facility not testing asymptomatic staff based on the county positivity rates. Administrator stated staff are screened daily for signs and symptoms of COVID-19, their temperatures are checked and the 30 staff members that have remained negative are tested monthly. Administrator stated the facility has an ample supply of rapid COVID tests available for use. Survey team referred the facility to the CMS QSO-20-38-NH 8/26/20 memo for guidance for routine testing of staff. Administrator stated We are going to start testing according to locality positivity rate and we'll start testing today. On 2/11/21 at 8:52am, surveyor asked for the results of the staff COVID-19 tests performed yesterday. Administrator stated no one has tested positive. Surveyor spoke with the DON at 9:10am who stated 23 staff members have been tested . No further information regarding this issue was presented to the surveyor prior to the exit conference on 2/11/21.

Based on clinical record review, staff interview, and facility document review, the facility staff failed to ensure residents with pressure ulcers receive necessary treatment to promote healing as evidenced by failure to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings included: For Resident #8, the facility staff failed to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #8's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS (minimum data set) with an ARD (assessment reference date) of 12/15/20 coded the resident as being severely impaired in cognitive skills for daily decision making with short term and long term memory loss in section C, Cognitive Patterns. Resident #8 was coded as being totally dependent on staff for bed mobility, transfers, toilet use, and personal hygiene. A nurse's progress note dated 2/07/21 at 7:00am, states Found with Stage II open area to L (left) buttock - old site re-opened - See Wound sheet. Subsequent nurse's note on 2/07/21 at 11:00am states POA (power of attorney), DON (director of nursing), MD informed of open site L buttock N.O. (new order) noted. Weekly Pressure Ulcer Progress Report entry dated 2/07/21 states in part, area to the left buttock is a reoccurred stage II measuring 1cm x 0.3cm with 0 depth with causes identified as diabetes, continuous urinary incontinence, and Alzheimer's. A signed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .O. (telephone order) Dr. (name omitted). Resident #8 has a current care plan focus dated 2/07/21 for open area L buttock - tx (treatment) per order with an intervention for tx as ordered. Surveyor reviewed Resident #8's February 2021 TAR (treatment administration record) and was unable to locate the treatment order for the area to the left buttock. On 2/10/21 at approximately 3:05pm, surveyor spoke with LPN (licensed practical nurse) #1 and asked if they could located the order on the TAR. LPN #1 stated I don't see it either and likely I forgot to write it in. In the presence of the surveyor, LPN #1 transcribed the order Clean open site L buttock with NS [MEDICATION(S)] Cream bid and prn to site qd til healed to the February 2021 TAR and initialed TAR for 1/08/21 7-3 and 1/10/21 7-3. LPN #1 stated they did the treatment at those times. The treatment was only signed as being completed once on 2/08/21 and was not signed as being completed on 2/09/21. On 2/10/21 at approximately 3:10pm, surveyor asked LPN #1 to view Resident #8's tube of [MEDICATION(S)] Cream. LPN #1 pulled Resident #8's tube of [MEDICATION(S)] Cream from the treatment cart and removed the cap from the tube. The tube had been previously opened and there was a pressure indention on the outside of the tube. On 2/10/21 at approximately 3:15pm, surveyor notified the DON that Resident #8's treatment order to the left buttock from 2/07/21 was not transcribed to the TAR until today. On 2/11/21 at 9:55am, surveyor notified the administrator and DON of Resident #8's treatment to the left buttock not being completed as ordered. No further information regarding this issue was presented to the survey team prior to the exit conference on 2/11/21.

Based on observation, staff interview, and facility document review, the facility staff failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety. The findings included: The facility staff failed to ensure that food items were secured and labeled properly, failed to ensure that expired food items were discarded, and failed to ensure that dietary staff members hair was appropriately secured in the food service area. On [DATE] at 10:45 am, an initial tour of kitchen was conducted with the facility dietary manager. The surveyor observed the following items upon inspection of the walk in freezer; a plastic bag of mixed vegetables that had been opened with no documented open date on the bag, a plastic bag of corn dog nuggets that had been opened with no documented open date on the bag, sausage links opened on [DATE] that were not securely closed, riblets with no documented open date on the bag. The dietary manager was asked by the surveyor if the items mentioned above should have been dated. The dietary manager stated, They probably should have. The surveyor observed a frozen red ring in a plastic bag that was not labeled and dated. The dietary manager identified the frozen red ring as a punch ring for the Resident Christmas party. The surveyor asked the dietary services manager if the punch ring should have been labeled and dated. The dietary manager stated, It probably should have, but I know when it's going out. The surveyor observed a large container with frozen substance that was not labeled or dated. The dietary manager identified the frozen substance in the container as vegetable soup. The surveyor asked the dietary manager if the vegetable soup should be labeled and dated. The dietary manager stated, Yes, and removed the vegetable soup from the freezer. On [DATE] at 10:55 am, the surveyor inspected the walk in cooler. Upon inspection of the walk in cooler, the surveyor observed 3 large items wrapped in tan wrapping that was not labeled or dated. The dietary manager identified these items as cheese balls that she had just made for the Resident Christmas party. The dietary manager was asked if these items should have been labeled and dated. The dietary manager stated, Yes. The surveyor also observed a bag of lettuce with 3 heads of lettuce that was open and was not securely contained. The surveyor also observed that there was no open date documented on the bag of lettuce. On [DATE] at 11:01 am, the surveyor inspected the dry storage area. Upon inspection of the dry storage area, the surveyor observed the following items: Biscuit and gravy mix that had been opened with no open date documented on the package, prewashed pinto beans 20 lb. (pound) box that was open to air. The dietary manager stated, I don't have any way to seal that box that is how they come. The surveyor also observed a 20 lb. box of split peas that was open to air, a 50 lb. bag of Panko bread crumbs that had been opened with no open date documented on the package, and a box of baking soda open on top shelf in dry storage with a use by date of [DATE] printed on the box. The dietary manager stated, We use that for odors. The dietary manager discarded the box of baking soda. The dietary manager also observed a 48 oz. (ounce) container of vegetable shortening with no documented date opened and a use by date of [DATE] printed on the bottom of the container. The surveyor observed a 25 lb. box of Thick & Easy that was opened with no opened dated documented on the package. The surveyor observed 2 plastic storage containers on the top shelf in the dry storage room. The dietary manager stated that the items inside the container was used for activities by the activities department and that the dietary staff did not monitor those items. The surveyor reviewed the items inside the plastic containers and observed the following items: Waffle cones best if used by [DATE] documented on the package Graham Cracker piecrust 6oz Best by [DATE] documented on the package Waffle cones 5 oz. box best by (MONTH) 13 (YEAR) documented on the package Kraft Jet Puff Marshmallow [DATE] documented on the package Sugar cones unopened 5 oz. box best by ,[DATE]/`18 documented on the package Vanilla candy coating best by [DATE] documented on the package Light corn syrup unopened best by [DATE] documented on the package Light corn syrup unopened best by [DATE] documented on the package Grissine [MEDICATION NAME] 4.41 oz. opened no opened date [DATE] documented on the package Focaccia opened best by 18 (MONTH) (YEAR) documented on the package On [DATE] at 11:24 am, the surveyor inspected the spices located on the spice rack in the kitchen. Upon inspection of the spice rack in the kitchen, the surveyor observed a container of bay leaves with no opened date or dispensed date. The surveyor asked the dietary manager how she would know if the bay leaves were still good to use. The dietary manager stated, I use my judgement as a nutritional professional. The surveyor observed a 16 oz. container of all spice with no open or dispensed date. The surveyor asked the dietary manager how she knows if the all spice is still good to use. The dietary manager stated, As long as you can still smell it it's good. The surveyor observed a small glass jar of Lemon peel 1.5 oz. with a best by date of [DATE] printed on the container. The surveyor observed a bottle of lemon juice with a best by date of [DATE] printed on the bottle, and Gluten free chocolate chip cookies that were unopened with a best by date of [DATE] printed on the package. On [DATE] at 11:45 am, while checking tray line temperatures, the surveyor observed dietary aide # 1 as she checked the tray line temperatures. The surveyor observed that dietary aide # 1's hair was pulled back into a bun and the bun was not secured under the hairnet. The surveyor also observed dietary aide # 2 in the food service area. The surveyor observed that dietary aide # 2's hair in the front was not secured underneath her hairnet. On [DATE] at 12:02 pm, the surveyor observed a gallon of milk in the reach in cooler with a use by date of ,[DATE] printed on the container and a ½-gallon of buttermilk with a use by date of ,[DATE] printed on the container. On [DATE] at 2:47 pm, the surveyor inspected the unit refrigerator. Upon inspection of the unit refrigerator, the surveyor observed an opened carton of milk with a use by date of ,[DATE] printed on the container. The facility policy on Infection Control Dietary Services contained documentation that included but was not limited to, . IV Personal Hygiene a. Proper attire for food handlers should include a hair covering (hair net or caps) VI Proper Food Handling I. Leftovers must be labeled, dated, covered. On [DATE] at 5:30 pm, the administrator and director of nursing was made aware of the findings as stated above. No further information regarding this issue was provided to the survey team prior to the exit conference on [DATE].

Based on staff interview, facility document review, and clinical record review, the facility staff failed to ensure 8 of 15 residents were free of an unnecessary medication (Resident #20, Resident #15, Resident #29, Resident #35, Resident #33, Resident #5, Resident #8, Resident #38). The findings included: 1. The facility staff failed to document when Resident #20 exhibited behaviors to support the use of the antidepressant [MEDICATION NAME] and failed to ensure the current comprehensive care plan included targeted behaviors for the use of [MEDICATION NAME] (an antidepressant). Resident #20 was admitted to the facility [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #20's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of [DATE] assessed the resident with a BIMS (brief interview for mental status) as ,[DATE]. Resident #20 was identified to have inattention daily. Resident #20 was not assessed with [REDACTED]. Section N Medications and specifically N0410 Medications documented Resident #20 had received an antidepressant 7 days during the look back period [DATE]-[DATE]. Resident #20's current comprehensive care plan initiated [DATE] had a focus area that read Resident #20 receives routine antidepressant med (medication) w/potential (with) for adverse effects. Interventions: Meds as ordered, notify provider of behavioral symptoms and/or adverse effects, observe for and record adverse effects, observe for and record behavioral symptoms, and pharmacist to review meds monthly & (and) as needed. The care plan did not identify any specific targeted behaviors or non-pharmacological interventions to use. Resident #20's (MONTH) (YEAR) physician orders [REDACTED].#20 currently received [MEDICATION NAME] 100 mg qd (everyday) for depression. The surveyor reviewed the monthly psychoactive medication flow records from (MONTH) (YEAR) through (MONTH) (YEAR) for [MEDICATION NAME]. Targeted behaviors identified were tearfulness, decrease interest in activities and persistent sadness. Side effects circled to monitor were disorientation, confusion, lethargy, increased agitation, and sedation/drowsiness. The monthly behaviors sheets from (MONTH) (YEAR) through (MONTH) (YEAR) did not identify any issues with tearfulness, decrease interest in activities, persistent sadness, disorientation, confusion, lethargy, increased agitation, or sedation/drowsiness. Each day was marked with a 0 and the nurse's initials. The surveyor reviewed the (MONTH) (YEAR) through the (MONTH) (YEAR) nurse's notes. The [DATE] nurse's note stated the resident was seen by her physician for s/s (signs/symptoms) of depression; however, there are no signs or symptoms of depression charted. Resident #20's [MEDICATION NAME] had been increased from 50 mg (milligrams) to 100 mg on [DATE] without any evidence to support the increase in [MEDICATION NAME]. Resident #20's physician had documented on the medication regimen review for (MONTH) (YEAR) has failed GDRs (gradual dose reductions) in the past with recurrence of depressive sx (symptoms). No further GDRs. The surveyor interviewed the activities director/social worker on [DATE] at 8:42 a.m. about Resident #20. The activity director/social worker stated that during the mood interview for the most recent MDS, the resident had been having trouble sleeping, expressed about being sad, lonely, and the resident's fixation on men. The activity director/social worker stated after the men leave, the resident goes back to focusing on her baby dolls. The surveyor asks the activity director/social worker where the information just provided was located as the surveyor was unable to locate any of this information in the clinical record. The activity director/social worker stated it wasn't charted-we just know it. The surveyor informed the administrator and the director of nursing of the above concern on [DATE] at 12:44 p.m. and requested the facility policy on [MEDICAL CONDITION] medications. The surveyor reviewed the facility policy titled [MEDICAL CONDITION] Medication Usage on [DATE]. The policy read in part, The facility will ensure [MEDICAL CONDITION] medications are used only when the medication is appropriate to treat a resident's specific, [DIAGNOSES REDACTED]. [MEDICAL CONDITION] medications will be prescribed at the lowest possible dosage for the shortest period and will be subject to gradual dose reduction and review. The staff will observe, document and report to the Attending Physician information regarding the behaviors, effectiveness of any intervention, and/or any side effects and consequences of [MEDICAL CONDITION] medications. No further information was provided prior to the exit conference on [DATE]. 2. The facility staff failed to document when Resident #15 exhibited behaviors to support the use of the antidepressant [MEDICATION NAME] and failed to ensure the current comprehensive care plan included targeted behaviors for the use of [MEDICATION NAME] (an antidepressant). The clinical record of Resident #15 was reviewed [DATE] through [DATE]. Resident #15 was admitted to the facility [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #15's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of [DATE] assessed the resident with a BIMS (brief interview for mental status) as ,[DATE]. There were no signs or symptoms of [MEDICAL CONDITION], behaviors affecting others or evidence of [MEDICAL CONDITION]. Section N Medications and specifically N0410 Medications documented Resident #15 received an antidepressant 7 days during the look back period [DATE]-[DATE]. Resident #15's current comprehensive care plan identified the focus area that read Resident #15 receives routine antidepressant therapy for [DIAGNOSES REDACTED]. Date initiated: [DATE]. Interventions: Administer meds (medications) as ordered, notify provider of behavioral symptoms, adverse effects and/or pharm (pharmacy) rec (recommendations), observe for behavioral symptoms and/or adverse effects, and pharmacist reviews meds monthly & (and) as needed. The current comprehensive care plan did not identify any specific targeted behaviors for the use of [MEDICATION NAME] or identify any non-pharmacological interventions. The (MONTH) (YEAR) physician's orders [REDACTED].#15 had orders that read [MEDICATION NAME] ([MEDICATION NAME]) 15 mg (milligrams) take 1 tablet by mouth at bedtime for depression and [MEDICATION NAME] 50 mg take 1 tablet daily for depression ([MEDICATION NAME]). The surveyor reviewed the monthly psychoactive medication flow records from (MONTH) (YEAR) through (MONTH) (YEAR) for [MEDICATION NAME] and [MEDICATION NAME]. Targeted behaviors identified were tearfulness, decrease interest in activities and persistent sadness. Side effects circled to monitor were dry mouth, [MEDICATION NAME] symptoms, sedation/drowsiness and increased falls/dizziness. The monthly behaviors sheets from (MONTH) (YEAR) through (MONTH) (YEAR) did not identify any issues with tearfulness, decrease interest in activities, persistent sadness, dry mouth, [MEDICATION NAME] symptoms, sedation/drowsiness and increased falls/dizziness. Each day was marked with a 0 and the nurse's initials. The surveyor reviewed the (MONTH) (YEAR) through the (MONTH) (YEAR) nurse's notes. The nurse's notes did not have any documentation of tearfulness, decrease interest in activities, or persistent sadness. The surveyor informed the director of nursing of the above concern with the prescribed medications ([MEDICATION NAME] and [MEDICATION NAME]) and the lack of documentation to support the use of both on [DATE] at 10:19 a.m. The DON stated Resident #15's depressive signs and symptoms would come back if a GDR (gradual dose reduction) was done and then the resident would require more meds. The most recent GDR for [MEDICATION NAME] was in (YEAR) and the last GDR for [MEDICATION NAME] was in (YEAR). The administrator and the director of nursing were informed of the above concern on [DATE] at 12:44 p.m. The surveyor requested the facility policy on the use of [MEDICAL CONDITION] medications. The surveyor reviewed the facility policy titled [MEDICAL CONDITION] Medication Usage on [DATE]. The policy read in part, The facility will ensure [MEDICAL CONDITION] medications are used only when the medication is appropriate to treat a resident's specific, [DIAGNOSES REDACTED]. [MEDICAL CONDITION] medications will be prescribed at the lowest possible dosage for the shortest period and will be subject to gradual dose reduction and review. The staff will observe, document and report to the Attending Physician information regarding the behaviors, effectiveness of any intervention, and/or any side effects and consequences of [MEDICAL CONDITION] medications. No further information was provided prior to the exit conference on [DATE]. 3. The facility staff failed to identify targeted behaviors for the use of [MEDICATION NAME] for Resident #29. The clinical record of Resident #29 was reviewed [DATE] through [DATE]. Resident #29 was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. Resident #29's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of [DATE] assessed the resident with a BIMS (brief interview for mental status) as ,[DATE]. There were no signs or symptoms of [MEDICAL CONDITION], behaviors affecting others, or evidence of [MEDICAL CONDITION]. Section N Medications and specifically N0410 Medications documented Resident #29 received an antidepressant 7 days during the look back period [DATE]-[DATE]. Resident #29's current comprehensive care plan had the focus area that read Resident #29 receives [MEDICATION NAME] routinely for depression w/potential (with) for adverse effects. Date initiated: [DATE]. Interventions: Meds as ordered, notify provider of behavioral symptoms and/or adverse effects, observe for and record adverse effects, observe for and record behavioral symptoms, and pharmacist to review meds monthly & (and) as needed. The care plan did not identify any specific behaviors or non-pharmacological interventions to use. The (MONTH) (YEAR) physician's orders [REDACTED].#29 had orders for [MEDICATION NAME] ([MEDICATION NAME]) 7.5 mg (milligrams) every day. A review of the Psychoactive Medication Monthly Flow Records for (MONTH) (YEAR) through (MONTH) (YEAR) identified the resident was tearful, had decreased interest in activities and had persistent sadness. Side effects to observe were disorientation and confusion, reduced social contact, increased agitation, [MEDICATION NAME] effects, and nausea. The monthly behaviors sheets from (MONTH) (YEAR) through (MONTH) (YEAR) did not identify any issues with tearfulness, decrease interest in activities, persistent sadness, disorientation and confusion, reduced social contact, increased agitation, [MEDICATION NAME] symptoms, and nausea. Each day was marked with a 0 and the nurse's initials. The surveyor reviewed the (MONTH) (YEAR) through the (MONTH) (YEAR) nurse's notes. The nurse's notes did not have any documentation of tearfulness, decrease interest in activities, or persistent sadness. The surveyor reviewed the nurse's notes from (MONTH) (YEAR) through (MONTH) (YEAR). One dated [DATE] at 4:30 p.m. stated the resident had vomited a small amount of food when out on leave with son. The nurse's note dated [DATE] at 5:30 p.m. stated the resident was still feeling nauseous and refused dinner. The nurse's note dated [DATE] at 8a.m. stated the resident continued to complain of (c/o) nausea, MD (medical doctor) was notified, and a urinalysis was obtained and the resident was started on medication for a urinary tract infection. The nurse's note dated [DATE] at 2:10 p.m. stated the resident c/o nausea early in the morning. The surveyor interviewed licensed practical nurse #1 on [DATE] 10:41a.m. The surveyor showed [MI]P.N. #1 the monitoring on the behavior sheets with 0 (zero) on all shifts-behavior not observed. [MI]P.N. #1 stated the resident often refuses food, tends to isolate herself in her room, but blossoms when family come and take her out. Weight has increased. The surveyor stated the targeted behaviors on the (MONTH) (YEAR) through (MONTH) (YEAR) are the same for all the residents. [MI]P.N. #1 stated she filled out the monthly forms and was told to put something to look at for the residents. [MI]P.N. #1 stated the monthly records are not person-centered. The surveyor informed the administrator and the director of nursing of the above concern on [DATE] at 12:44 p.m. and requested the facility policy on [MEDICAL CONDITION] medications. The surveyor reviewed the facility policy titled [MEDICAL CONDITION] Medication Usage on [DATE]. The policy read in part, The facility will ensure [MEDICAL CONDITION] medications are used only when the medication is appropriate to treat a resident's specific, [DIAGNOSES REDACTED]. [MEDICAL CONDITION] medications will be prescribed at the lowest possible dosage for the shortest period and will be subject to gradual dose reduction and review. The staff will observe, document and report to the Attending Physician information regarding the behaviors, effectiveness of any intervention, and/or any side effects and consequences of [MEDICAL CONDITION] medications. No further information was provided prior to the exit conference on [DATE]. 4. The facility staff failed to identify specific targeted behaviors for the use of [MEDICATION NAME] and [MEDICATION NAME] on the care plan for Resident #33. The clinical record of Resident #33 was reviewed [DATE] through [DATE]. Resident #33 was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. Resident #33's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of [DATE] assessed the resident with a BIMS (brief interview for mental status) as ,[DATE]. Resident #33 was not assessed with [REDACTED]. Section N Medications and specifically N0410 Medications Resident #33 had received antidepressant and antipsychotic medications 7 days during the look back period [DATE]-[DATE]. Resident #33's current comprehensive care plan identified the focus area that read Resident #33 receives [MEDICATION NAME] as ordered for depression & (and) [MEDICATION NAME] as ordered for [MEDICAL CONDITION] w/potential (with) for adverse effects. Date initiated: [DATE]. Interventions: Administer meds (medications) as ordered, notify provider of behavioral symptoms, adverse effects and/or pharm (pharmacy) rec (recommendations), observe for behavioral symptoms and/or adverse effects, and pharmacist reviews meds monthly & (and) as needed. The current comprehensive care plan did not identify any specific targeted behaviors for the use of [MEDICATION NAME] or [MEDICATION NAME] or identify any non-pharmacological interventions. The (MONTH) (YEAR) physician's orders [REDACTED].#33 had orders for [MEDICATION NAME] 40 mg (milligrams) take one tablet by mouth every day for depression, Quetiapine 25 mg tablet take one tablet by mouth every day for hallucinations/[MEDICAL CONDITION], and Quetiapine 25 mg tablet take 3 tablets by mouth at bedtime for hallucinations/[MEDICAL CONDITION]. The surveyor reviewed the monthly psychoactive medication flow records from (MONTH) (YEAR) through (MONTH) (YEAR) for [MEDICATION NAME] and Quetiapine. Targeted behaviors for [MEDICATION NAME] were tearfulness, decrease interest in activities and persistent sadness. Side effects circled to monitor were dry mouth, weight gain, and tremors. Targeted behaviors for Quetiapine were hallucinations and to monitor for the following side effects: muscle spasm, motor restlessness, involuntary movements, and increased agitation. The monthly behaviors sheets from (MONTH) (YEAR) through (MONTH) (YEAR) did not identify any issues with tearfulness, decrease interest in activities, persistent sadness, or hallucinations Each day was marked with a 0 and the nurse's initials. The surveyor reviewed the (MONTH) (YEAR) through the (MONTH) (YEAR) nurse's notes. The nurse's notes did not have any documentation of tearfulness, decrease interest in activities, persistent sadness or hallucinations. The surveyor informed the administrator and the director of nursing on [DATE] at 12:44 p.m. of the lack of documentation of behaviors that were identified as the targeted behaviors on the psychoactive medication flow records and the lack of targeted behaviors on the comprehensive care plan. In addition, the facility has failed to document the use of non-pharmacological interventions on the care plans. The surveyor requested the facility policy on the use of [MEDICAL CONDITION] medications. The surveyor reviewed the facility policy titled [MEDICAL CONDITION] Medication Usage on [DATE]. The policy read in part, The facility will ensure [MEDICAL CONDITION] medications are used only when the medication is appropriate to treat a resident's specific, [DIAGNOSES REDACTED]. [MEDICAL CONDITION] medications will be prescribed at the lowest possible dosage for the shortest period and will be subject to gradual dose reduction and review. The staff will observe, document and report to the Attending Physician information regarding the behaviors, effectiveness of any intervention, and/or any side effects and consequences of [MEDICAL CONDITION] medications. No further information was provided prior to the exit conference on [DATE]. 5. The facility staff failed to identify targeted behaviors for the use of [MEDICATION NAME] ([MEDICATION NAME]), [MEDICATION NAME] 75 mg ([MEDICATION NAME]), [MEDICATION NAME] 50 mg ([MEDICATION NAME]), and [MEDICATION NAME] 0.5 mg and failed to include targeted behaviors for the antidepressant use on the current comprehensive care plan for Resident #8. The clinical record of Resident #8 was reviewed [DATE] through [DATE]. Resident #8 was admitted to the facility [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #8's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of [DATE] assessed the resident with a BIMS (brief interview for mental status) as ,[DATE]. Resident #8 had no signs or symptoms of [MEDICAL CONDITION], no behaviors that affected others and no signs or symptoms of [MEDICAL CONDITION]. Section N Medications assessed the resident to receive an antipsychotic medication and an antidepressant 7 days in the look back period [DATE] through [DATE]. Resident #8's current comprehensive care plan identified a focus area that read the resident uses [MEDICAL CONDITION] medications-[MEDICATION NAME] for dementia w/[MEDICAL CONDITION] (with), & (and) [MEDICATION NAME], & [MEDICATION NAME] for depression, w/potential for adverse effects. Date initiated: [DATE] Revision on: [DATE]. Interventions: Administer [MEDICAL CONDITION] medications as ordered by physician. Monitor for side effects and effectiveness q shift (every shift). Monitor/document report PRN (as needed) any adverse reactions of [MEDICAL CONDITION] medications. Monitor/record occurrence for targeted behavior symptoms and document per facility protocol. Notify provider of behavioral symptoms, adverse effects, and/or pharm (pharmacy) rec (recommendations). Pharmacist to review meds (medications) monthly & as needed. Resident #8 also had the focus area that read the resident has a mood problem-has the following dx (diagnoses): Major Depressive D.O (disorder), Single Episode, Anxiety D.O., Psychotic D.O. with delusions due to known physiological condition, [MEDICAL CONDITION] with late onset. Interventions: Assist the resident in developing/provide the resident with a program of activities that is meaningful and of interest music, companionship. Encourage and provide opportunities for exercise, physical activity. Resident #8's (MONTH) (YEAR) physician's orders [REDACTED]. The surveyor reviewed the Psychoactive Medication Monthly Flow Records from (MONTH) (YEAR) through (MONTH) (YEAR). The Psychoactive Medication Monthly Flow Record for [MEDICATION NAME] identified delusions yet there was no documentation that Resident #8 had experienced delusions. All of the boxes had 0 in them. In Section II: Side Effects, all boxes had 0 in them as well. The Psychoactive Medication Monthly Flow Records for [MEDICATION NAME], and [MEDICATION NAME] all were documented with a 0 no behavior had occurred. The surveyor reviewed the (MONTH) (YEAR) through (MONTH) (YEAR) nurse's notes and found no documentation of targeted behaviors for the use of [MEDICATION NAME] or [MEDICATION NAME]. The surveyor interviewed licensed practical nurse #1 on [DATE] at 12:25 p.m. The surveyor asked what types of behaviors the resident exhibited. [MI]P.N. #1 stated she curses a lot. It's one of her outlets. Cursing was not identified as a targeted behavior on the monthly record monitoring or on the comprehensive care plan. The nurse's notes did not have any episodes of cursing documented. The surveyor informed the administrator and the director of nursing on [DATE] at 12:44 p.m. of the lack of documentation of behaviors that were identified as the targeted behaviors on the psychoactive medication flow records and the lack of targeted behaviors on the comprehensive care plan. In addition, the facility has failed to document the use of non-pharmacological interventions on the care plans. The surveyor requested the facility policy on the use of [MEDICAL CONDITION] medications. The surveyor reviewed the facility policy titled [MEDICAL CONDITION] Medication Usage on [DATE]. The policy read in part, The facility will ensure [MEDICAL CONDITION] medications are used only when the medication is appropriate to treat a resident's specific, [DIAGNOSES REDACTED]. [MEDICAL CONDITION] medications will be prescribed at the lowest possible dosage for the shortest period and will be subject to gradual dose reduction and review. The staff will observe, document and report to the Attending Physician information regarding the behaviors, effectiveness of any intervention, and/or any side effects and consequences of [MEDICAL CONDITION] medications. No further information was provided prior to the exit conference on [DATE]. 6. The facility staff failed to identify appropriate person centered target behaviors to support the use of [MEDICATION NAME] for Resident # 5. Resident # 5 was a [AGE] year-old-female who was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The clinical record for Resident # 5 was reviewed on [DATE] at 5:06 pm. The most recent MDS (minimum data set) assessment for Resident # 5 was a quarterly assessment with an ARD (assessment reference date) of [DATE]. Section C of the MDS assesses cognitive patterns. In Section C1000, the facility staff documented that Resident # 5's cognitive status was severely impaired. Section N of the MDS assesses medications. In Section N0410, the facility staff documented that Resident # 5 had received antipsychotic medication for 7 days during the lookback period for the [DATE] ARD. The plan of care for Resident # 5 was reviewed and revised on [DATE]. The facility staff documented a focus area for Resident # 5 as, The resident receives [MEDICATION NAME] as ordered for depression, [MEDICATION NAME] as ordered for anxiety & [MEDICATION NAME] as ordered for [MEDICAL CONDITION] w (with)/potential for adverse effects. Interventions included but were not limited to, Observe for behavioral symptoms q (every) shift & prn (as needed). Resident # 5 had current orders that included but was not limited to, Quetiapine 200 mg tablet Take 1 tablet by mouth twice a day for delusional [MEDICAL CONDITION] For [MEDICATION NAME]. This order was initiated by the physician on [DATE]. Upon further review of the current orders for Resident # 5, the surveyor observed that Resident # 5 did not have any current orders for medications to manage or treat dementia. On [DATE] at 9:15 am, the surveyor observed a pharmacy recommendation in Resident # 5's clinical record dated [DATE]. The pharmacy recommendation was documented as, This resident has had failed GDR (gradual dose reduction) attempts for [MEDICATION NAME] in the past. It has been discussed that no further GDR attempts be requested due to previous failed attempts. Please document if no further GDR attempts are indicated for [MEDICATION NAME] for this resident. The surveyor observed that the physician documented an (X) next to agree and handwrote, Her condition is fragile and likely to worsen with any further GDR attempts. On [DATE] at 9:20 am, the surveyor reviewed the Psychoactive Medication Monthly Flow Record for Resident # 5. The surveyor observed that the facility staff had circled delusions and paranoia as target behavioral symptoms for Quetiapine ([MEDICATION NAME]). The surveyor reviewed the Psychoactive Medication Monthly Flow Record for Resident # 5 from ,[DATE] through ,[DATE]. The surveyor observed that the facility staff had documented that Resident # 5 had no behaviors of delusions or physical aggression on day, evening, or night shift from ,[DATE] through ,[DATE], and no behaviors of delusions or paranoia on day evening or night shift from ,[DATE] through ,[DATE]. On [DATE] at 9:25 am, the surveyor interviewed the director of nursing. The surveyor asked the director of nursing what types of behaviors Resident # 5 displayed during delusional and paranoid episodes. The director of nursing stated that Resident # 5 would attempt to get up and believed that a baby was at home alone and would try to get home to the baby. The director of nursing also stated that Resident # 5 would cry out loudly at times and become agitated. On [DATE] at 9:34 am, the surveyor interviewed LPN # 1 (licensed practical nurse) The surveyor asked LPN # 1 what types of behaviors did Resident # 5 display during delusional and paranoid episodes. LPN # 1 stated that Resident # 5 resisted care. LPN # 1 stated, She will fight and she will hit. She thinks a baby is left at home all alone. She thinks all of her family has died . She will talk about her mom and dad and how her mother hates her, but most often talks about a baby boy being left. The surveyor asked LPN # 1 if Resident # 5 became combative often. LPN # 1 stated, Maybe every 2 weeks we will hear of her hitting out. Just in the last 2 weeks she got one of the CNAs (certified nursing assistant) pretty good. She did not break the skin but she did leave marks. The surveyor asked LPN # 1 if she felt that the behaviors that Resident # 5 displayed were due to [MEDICAL CONDITION] or if they were behaviors related to dementia. LPN # 1 stated, Dementia. The surveyor reviewed the Psychoactive Medication Monthly Flow Record along with LPN # 1. LPN # 1 agreed that combative behaviors was not listed as a target behavior to support the use of [MEDICATION NAME]. The surveyor reviewed the nurse's notes in Resident # 5's clinical record from ,[DATE] through ,[DATE]. The surveyor did not locate any documentation of combative, paranoid, or delusional episodes. The facility policy for [MEDICAL CONDITION] Medication Usage contained documentation that included but was not limited to; .Policy: The facility will ensure [MEDICAL CONDITION] medications are only used when the medication is appropriate to treat a resident's specific, diagnosed and documented condition and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication. For any resident who is receiving a [MEDICAL CONDITION] medication to treat a disorder other than expressions or indications of distress related to dementia (for example [MEDICAL CONDITIONS] mania, depression with psychotic features, or other medical condition other than dementia, which may cause [MEDICAL CONDITION]), the GDR may be considered clinically contraindicated for reasons that include but are not limited to: a) The continued use is in the accordance with relevant current standards of practice and the physician has documented the clinical rationale for why any attempted dose reduction would be likely to impair the resident's function or exacerbate an underlying medical or psychiatric disorder; or b) The resident's target symptoms returned or worsened after the most recent attempt at a GDR within the facility and the physician documented the clinical rationale for why an additional attempted dose reduction at the time would be likely to impair the resident's function or exacerbate an underlying medical or psychiatric disorder. Antipsychotic medications shall generally only be used for the following conditions/[DIAGNOSES REDACTED]. f) [MEDICAL CONDITION] in the absence of dementia . On [DATE] at 2:30 pm, the administrator and director of nursing was made aware of the findings as stated above. No further information regarding this issue was presented to the survey team prior to the exit conference on [DATE]. 7. The facility staff failed to identify person centered target behaviors for support the use of [MEDICATION NAME] for Resident # 35. Resident # 35 was a [AGE] year-old-female who was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The clinical record for Resident # 35 was reviewed on [DATE] at 4:37 pm. The most recent MDS (minimum data set) assessment for Resident # 35 was a quarterly assessment with an ARD (assessment reference date) of [DATE]. Section C of the MDS assesses cognitive patterns. In Section C1000, the facility staff documented that Resident # 35's cognitive status was moderately impaired. Section N of the MDS assesses medications. In Section N0410, the facility staff documented that Resident # 35 had received antipsychotic medications for 7 days during the look-back period for the [DATE] ARD. The current plan of care for Resident # 35 was reviewed and revised on [DATE]. The facility staff documented a focus area for

Based on staff interview and clinical record review, the facility staff failed to ensure the DDNR (durable do not resuscitate order) was complete for 1 of 15 residents (Resident #18). The findings included: The facility staff failed to ensure Resident #18's DDNR was accurate. The clinical record of Resident #18 was reviewed 12/18/18 through 12/20/18. Resident #18 was admitted to the facility 7/25/18 with [DIAGNOSES REDACTED]. Resident #18's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 10/23/18 assessed the resident with a BIMS (brief interview for mental status) summary score of 01/15. Resident #18's clinical record contained a Durable Do Not Resuscitate Order (DDNR) dated 5/15/11. The DDNR was incomplete. Section 1 of the DDNR read in part, I further certify (must check 1 or 2): 1. The patient is CAPABLE of making an informed decision . 2. The patient is INCAPABLE of making an informed decision . The boxes beside #1 and #2 were blank. Section 2 read If you checked 2 above, check A, B, or C below: The three boxes below were blank. The surveyor informed the administrator and the director of nursing of the incomplete DDNR in the end of the day meeting on 12/18/18 at 5:13 p.m. No further information was provided prior to the exit conference on 12/20/18.

Based on staff interview and clinical record review, the facility staff failed to ensure an accurate clinical record for 1 of 15 Residents in the survey sample, Resident # 24. The findings included: The facility staff improperly documented insulin administration for Resident # 24. Resident # 24 was a [AGE] year-old-female who was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The clinical record for Resident # 24 was reviewed on 12/18/18 at 4:52 pm. The most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 11/6/18. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 24 had a BIMS (brief interview for mental status) score of 6 out of 15, which indicated that Resident # 24's cognitive status was severely impaired. Section N of the MDS assesses medications. In Section N0350, the facility staff documented that Resident # 24 had insulin injections for 7 days during the lookback period for the 11/6/18 ARD. The current plan of care for Resident # 24 was reviewed and revised on 11/13/18. The facility staff documented a focus area for Resident # 24 as, Resident # 24 has potential for hyper or hypoglycemic episodes secondary to diabetes. Interventions included but were not limited to, Meds as ordered. Resident # 24 had current orders that were signed by the physician on 11/28/18. Orders included but were not limited to, [MEDICATION NAME] 100U (units)/ML (milliliter) Inject 15 units sub-q (subcutaneously) three times daily with meals *Hold if BS (blood sugar) <110*. On 12/18/18 at 4:55 pm, the surveyor reviewed the facility accucheck flow sheet for Resident # 24. The surveyor observed that facility staff had documented a blood sugar of 97 for the 6:30 am blood sugar on 10/26/18 for Resident # 24. The surveyor reviewed the (MONTH) (YEAR) Medication Administration Record [REDACTED]. The surveyor reviewed the back of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. On 12/18/18 at 5:30 pm, the administrator and director of nursing was made aware of the findings as stated above. On 12/19/18 at 10:29 am, the director of nursing informed the surveyor that she had spoken to the nurse that was responsible for medication administration on 10/26/18. The director of nursing stated that the nurse stated that she did not give the medication. The director of nursing agreed that the documentation of [MEDICATION NAME] on 10/26/18 for Resident # 24 was inaccurate. No further information regarding this issue was presented to the survey team prior to the exit conference on 12/20/18.

Based on staff interview and clinical record review, the facility staff failed to ensure 1of 15 residents was free of a significant medication error (Resident #17). The findings included: The facility staff failed to administer insulin as ordered by the physician for Resident #17. Resident #17 was administered [MEDICATION NAME]on two occassions when the medication should have been held. The clinical record of Resident #17 was reviewed 12/18/18 through 12/20/18. Resident #17 was admitted to the facility 2/8/18 with [DIAGNOSES REDACTED]. Resident #17's quarterly minimum data set (MDS) with an assessment reference date (ARD) of 10/23/18 assessed the resident with a BIMS (brief interview for mental status) as 15/15. The surveyor reviewed the physician's orders [REDACTED]. Resident #17's blood sugar on 9/20/18 at 6:30 a.m. was recorded as 94. Resident #17 was administered [MEDICATION NAME] 3 units at 8:00 a.m. As per the physician order, [MEDICATION NAME] 3 units should have been held. Resident #17's blood sugar on 11/28/18 at 11:30 a.m. was recorded as 108. Resident #17 was administered [MEDICATION NAME] 3 units at 11:30 a.m. As per the physician order, [MEDICATION NAME] 3 units should have been held. Resident #17's current comprehensive care plan was reviewed. One focus area read Resident #17 has potential for elevated blood sugar due to (d/t) diabetes. Date initiated 2/21/2018. Interventions: Accuchecks as ordered. Administer meds (medications) as ordered. The surveyor interviewed licensed practical nurse #1 on 12/19/18 at 11:30 a.m. [MI]P.N. #1 reviewed the insulins administered and the physician orders [REDACTED]. The surveyor informed the administrator and the director of nursing of the above insulin concern during the end of the day meeting on 12/19/18 at 4:42 p.m. No further information was provided prior to the exit conference on 12/20/18.

Based on observation and staff interview, the facility staff failed to remove expired items in the facility medication room and failed to label and date food in the refrigerator. The findings included: The facility staff failed to remove expired medical items from the facility medication room and failed to label and date a bag of candy. The surveyor and registered nurse #1 checked the medication room on [DATE] at 1:55 p.m. The refrigerator contained an opened 40-ounce bag of Hershey kisses. There was no date or resident name on the bag. R.N. #1 stated the name and date should be on the bag when opened. The surveyor checked the cabinets with R.N. #1. One closed system Foley catheter tray had expired ,[DATE]. One IV (intravenous) Latex free start kit had expired [DATE]. One 22-gauge 0.9 x 25 mm (millimeter) syringe expired ,[DATE]. R.N. #1 stated the expired items should be removed and proceeded to do this. The surveyor informed the director of nursing of the above expired items found in the medication room on [DATE] at 5:13 p.m. The surveyor requested the facility policy for dating/removing expired items. The administrator stated the facility does not have a policy on labeling and dating medical items. When asked if he expected staff to remove items that had expired, he stated yes. No further information was provided prior to the exit conference on [DATE].

Based on staff interview and clinical record review, the facility staff failed to ensure 1 of 16 residents (Resident #11) was free of an unnecessary medication. Resident #11's clinical record did not reveal that a GDR (gradual dose reduction) determination had been done for [MEDICATION NAME] (an antidepressant/[MEDICAL CONDITION]) since 12/16/15. The findings included: The facility's contracted pharmacist failed to ensure a GDR for [MEDICATION NAME] was completed for Resident #11. The last GDR for [MEDICATION NAME] was recommended in December 2015. The clinical record of Resident #11 was reviewed 12/5/17 through 12/7/17. Resident #11 was admitted to the facility 4/3/07 with [DIAGNOSES REDACTED]. Resident #11's quarterly minimum data set (MDS) with an assessment reference date (ARD) of 9/26/17 assessed the resident with a cognitive summary score of 9 out of 15 in Section C. The surveyor reviewed Resident #11's clinical record for unnecessary medication. Resident #11's physician's orders [REDACTED].#11 had been receiving [MEDICATION NAME] for depression and had been receiving since 1/22/15. The surveyor reviewed the Chronological Medication Regimen Review from 12/2016 through 12/2017 and identified that Resident #11 had not had a GDR for [MEDICATION NAME] since 2015. At the request of the surveyor, Registered Nurse #1 placed a call to the contracting pharmacy at 9:56 a.m. on 12/7/17. The surveyor spoke with contracting pharmacist #2 regarding [MEDICATION NAME] and GDR. Pharmacist #2 stated [MEDICATION NAME] was on the [MEDICAL CONDITION] list and a GDR should have been done. The consultant pharmacist #2 stated she didn't know why one wasn't done. The surveyor informed the DON on 12/07/17 10:05 a.m. regarding no GDR since [DATE] for [MEDICATION NAME] for Resident #11. The DON stated she would pull the thinned records. On 12/07/17 11:54 AM the surveyor spoke with consultant pharmacist #1 regarding [MEDICATION NAME] GDR. The consultant pharmacist #1 stated that the surveyor was correct. The consultant pharmacist stated that the pharmacist, DON and medical director meet and do chart reviews throughout the year. The consultant pharmacist stated these are usually discussed verbally. I'll have to check my laptop when I get to work and check if I wrote anything about the GDR and the discussion with the medical director. I may not have documented. On 12/07/17 12:45 p.m., the surveyor spoke with the DON regarding the GDR for [MEDICATION NAME]. The DON stated there was no documentation in the physician's visits that spoke about [MEDICATION NAME] or the GDR. No further information was provided to the surveyor prior to the exit conference on 12/7/17 regarding the pharmacy's failure to present to the attending physician or prescribing practitioner the need to attempt a GDR for Resident #11's [MEDICATION NAME].

Based on staff interview and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for 2 of 11 residents (Resident #7 and Resident #8). The findings included: 1. The facility staff failed to document the reason a urinalysis was obtained from the physician's standing orders for Resident #7. The clinical record of Resident #7 was reviewed 11/8/16 and 11/9/16. Resident #7 was admitted to the facility 9/8/2011 with [DIAGNOSES REDACTED]. Resident #7's annual minimum data set (MDS) assessment with an assessment reference date (ARD) of 4/12/16 assessed the resident with a brief interview for mental status score of 9 out of 15. The laboratory section of the clinical record had the results of a urinalysis obtained on 3/9/16. The surveyor was unable to locate a physician order [REDACTED].>The surveyor requested the assistance of the director of nursing on 11/9/16 at 10:00 a.m. After reviewing the clinical record, the DON stated the facility had standing orders and the nurse obtained the urine based on those and didn't need to write an order. The surveyor questioned why the urinalysis was obtained. The standing orders for urinalysis read Lab (routine) (unless otherwise indicated) 11. Urinalysis with reflex culture + sensitivities prn (whenever necessary) for any patient with fever and/or urinary symptoms. The DON and surveyor reviewed the nurse's notes from 3/8/16 and 3/9/16. The nurse's note dated 3/8/16 6:30 p.m. read Temperature 97.5, no complaints pain or otherwise, no unusual behaviors or hallucinations. 3/8/16 8:45 p.m. nurse's note read Urine obtained by I&O (in and out) cath (catheter) using sterile technique for U/A (urinalysis) with reflex culture. 3/9/16 3 a.m. nurse's note read T (temperature) 96.8, no complaints of urinary discomfort, waiting on UA C&S (culture and sensitivity) results. The surveyor questioned the director of nursing again regarding the reason for the urinalysis obtained 3/9/16. The DON was unable to locate any evidence why the staff obtained a urinalysis and culture and sensitivity. The facility staff failed to document any signs or symptoms why a urinalysis was obtained on Resident #7. Resident #7 did not have a fever or documentation of signs or symptoms of a urinary tract infection. The surveyor informed the administrator and the director of nursing of the above concern on 11/9/16 at 3:00 p.m. No further information was provided prior to the exit conference on 11/10/16. 2. The facility staff failed to document the reasons a urinalysis was obtained from the physician's orders [REDACTED]. The clinical record of Resident #8 was reviewed 11/10/16. Resident #8 was admitted to the facility 9/28/16 with [DIAGNOSES REDACTED]. The admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 10/6/16 assessed the resident with short term memory issues, long term memory problems, and severe impairment for daily decision making. The laboratory section of the clinical record had the results of a urinalysis obtained 10/26/16. The surveyor was unable to locate the physician order. The surveyor requested the assistance of licensed practical nurse #2 on 11/10/16 at 8:30 a.m. She reviewed the clinical record and stated she was unable to find a physician order. L.P.N. #2 stated the facility used standing physician orders. The surveyor asked L.P.N. #2 the reason for the urinalysis. L.P.N. #2 stated Resident #8 had had several falls since admission. The surveyor reviewed the nurse's note for 10/26/16. There was one nurse's note for 10/26/16 at 4 a.m. but no reason why the urinalysis had been obtained. The surveyor reviewed the 10/22/16, 10/23/16, and 10/25/16 nurse ' s notes and found no documentation why the urinalysis was obtained. The standing orders for urinalysis read Lab (routine) (unless otherwise indicated) 11. Urinalysis with reflex culture + sensitivities prn (whenever necessary) for any patient with fever and/or urinary symptoms. The surveyor asked L.P.N. #2 if falls were listed on the standing orders as a reason to obtain a urinalysis. L.P.N. #2 stated no. There was no documentation that Resident #8 had a fever or signs or symptoms of a urinary infection. The surveyor informed the administrator and the director of nursing of the above concern in lack of documentation for obtaining a urinalysis on Resident #8 on 11/10/16 at 10:40 a.m. The DON stated she knew why the urinalysis was obtained but stated she failed to document the reason. No further information was provided prior to the exit conference on 11/10/16.

Based on staff interview and clinical record review, the facility staff failed to ensure an accurate minimum data set (MDS) assessment for 1 of 11 residents (Resident #7). The findings included: The facility staff failed to ensure Section D Mood of the annual minimum data set (MDS) assessment was accurate for Resident #7. The staff assessment of resident mood was inaccurate with dash marks used to identify symptoms present and symptom frequency. The clinical record of Resident #7 was reviewed 11/8/16 and 11/9/16. Resident #7 was admitted to the facility 9/8/2011 with [DIAGNOSES REDACTED]. Resident #7's annual minimum data set (MDS) assessment with an assessment reference date (ARD) of 4/12/16 assessed the resident with a brief interview for mental status score of 9 out of 15. Section D Mood was reviewed. Section D0500 Staff Assessment of Resident Mood was noted to have dash marks for both symptom presence and symptom frequency for the following: A. Little interest or pleasure in doing things B. Feeling or appearing down, depressed, or hopeless D. Feeling tired or having little energy. F. Indicating that s/he feels bad about self, is a failure, or has let self or family down G. Trouble concentrating on things, such as reading the newspaper or watching television I. States life isn't worth living, wishes for death, or attempts to harm self J. Being short-tempered easily annoyed. The surveyor interviewed the minimum data set (MDS) registered nurse on 11/9/16 at 9:00 a.m. about Section D. The MDS RN stated social services was responsible for completing Section D. The surveyor interviewed the social worker/activities director on 11/9/16 at 9:10 a.m. The Social Worker reviewed Section D and stated she didn't interview any staff. The social worker stated she charted what she observed. She also stated she didn't remember using the dash marks. The social worker stated she could observe Resident #7 eating and could complete that part. The social worker stated Resident #7 was difficult to assess. The surveyor asked to see the interview/answers from the staff assessments. The social worker stated she didn't have any. The surveyor informed the director of nursing and the administrator of the inaccuracy of Section D on Resident #7's annual MDS during the end of the day meeting on 11/9/16 at 3:00 p.m. No further information was provided prior to the exit conference on 11/10/16.

Based on resident interview, staff interview and clinical record review it was determined the facility staff failed to facilitate voting privileges for 2 of 11 residents (Residents #8 and #9.) Findings: 1. Resident #8 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The clinical record was reviewed 11/13/15 at 10:00 AM. The latest MDS (minimum data set) dated 8/25/15 coded the resident with intact cognitive skills. The resident required the assistance of one nursing staff member to achieve the ADLs (activities of daily living.) On 12/18/14 the resident was evaluated as to her choice of activities while living at the facility. Clinical documentation indicated the resident was a registered voter and was interested in voting. The manner of the vote (absentee of going to the polls) was not designated in the record. On 11/12/15 at 1:30 PM the resident council group was interviewed. Resident #8 told the surveyor she had not been able to vote in the recent election because the facility ACT/SW (activities/social worker) had not registered her in time. On 11/12/15 at 2:15 PM the ACT/SW was interviewed. She acknowledged the resident had expressed a desire to vote, but she was not registered locally to do so. The ACT/SW said she didn't realize she was not registered to vote locally until it was too late to sign her up. The administrator and DON were informed on 11/12/15 at 4:00 PM. 2. Resident #9 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The clinical record was reviewed 11/13/15 at 10:30 AM. The latest MDS (minimum data set) dated 10/13/15 coded the resident with intact cognitive skills. The resident required the assistance of one nursing staff member to achieve the ADLs (activities of daily living.) On 1/6/15 the resident was evaluated as to her choice of activities while living at the facility. Clinical documentation indicated the resident was a registered voter and was interested in voting. The manner of the vote (absentee of going to the polls) was not designated in the record. On 11/12/15 at 1:30 PM the resident council group was interviewed. Resident #9 told the surveyor she had not been able to vote in the recent election because the facility ACT/SW (activities/social worker) had not registered her in time. The resident stated, I have always voted. This is the first time in my life I haven't been able to do that. On 11/12/15 at 2:15 PM the ACT/SW was interviewed. She said the resident had expressed a desire to vote, but she was not registered locally to do so. The ACT/SW said she didn't realize she was not registered to vote locally until it was too late to sign her up. That is something we need to work on.) The administrator and DON were informed on 11/12/15 at 4:00 PM.