Every finding on record at St. Joseph's Nursing Home

Based on observation and interviews with facility staff, it was determined that the facility failed to manage expired food items. This deficiency was observed in the facility's kitchen during the recertification survey.The findings include:On 1/21/26 at 7:45 AM, the surveyor conducted an initial tour of the kitchen with Staff #24 (Cook). The facility's refrigerator contained opened food items with marked expiration dates that had passed. The surveyor noted the following expired items:-One opened bag of bagels (5 remaining) with an expiration date of 9/13/25.-One bag of raisin cinnamon bread with an expiration date of 12/03/25.-One bag of pumpernickel bread (20% remaining) with an expiration date of 11/28/25.-One bag of white bread with an expiration date of 1/13/26.-One bag of Hawaiian bread with an expiration date of 12/18/25.During a subsequent observation of the basement walk-in freezer at 8:00 AM on 1/21/26, the surveyor identified two foil-wrapped packs of ribs dated 11/22/25 and two 5-pound packs of low chicken dated 6/28/25. Staff #24 stated, Those items were for the sisters; I don't know how long they can be kept or used. When the surveyor asked how staff distinguished between food intended for the sisters and food for the residents, Staff #24 stated he did not know.On 1/21/26 at 8:45 AM, the surveyor interviewed Staff #25 (Certified Dietary Manager/Certified Food Protection Professional). She explained that all food items are marked with expiration dates and that staff are instructed to use freshly delivered bread first. According to Staff #25, when bread nears its expiration date, staff move it to the freezer. She noted that the bread items found in the refrigerator had been moved there from the freezer for use. However, when asked how long bread remains viable in the refrigerator after being moved from the freezer, Staff #25 stated she did not know.On 1/22/26 at approximately 10:00 AM, Staff #25 provided a policy titled HACCP: Bread from the Freezer. The policy required that:-Store-bought bread must be placed in the freezer before the labeled expiration date.-Bread removed from the freezer must be labeled with the date of removal.-Once defrosted, bread must be used within 3 days or discarded.-Quality guidelines: 3 months for best quality (USDA recommendation) and up to 6 months for store-bought bread if well-wrapped.While the surveyor reviewed the policy, Staff #25 admitted that she had researched and created the policy only after the surveyor brought the expired bread to her attention. The surveyor shared their concerns regarding food safety and oversight, which Staff #25 validated.

Based on review of pertinent documentation and interviews with facility staff, it was determined that the facility failed to have a system in place to ensure that the Resident Council was provided with responses, actions, and rationale taken regarding their concerns and to demonstrate the facility's response and rationale for such concerns. The Findings include: The Resident Council is a group of residents that meets regularly on the behalf of all residents in the facility to discuss concerns about facility policies and procedures affecting residents' care, treatment, and quality of life. Facility staff are required to consider resident and family group views and act upon grievances and recommendations. This may include developing or changing policies affecting resident care and life. Facility staff should discuss their decisions with the residents and/or family group and document their response and rationale in writing. The facility must be able to demonstrate their response and rationale. On 1/22/26 at 9:23 AM in an interview with the Director of Nursing (DON) she provided 1 sheet of lined paper titled, Resident Council News. No date was observed. When asked if she knew when the minutes were from, she stated no. She also provided 7 sheets of paper that she stated she had typed up after receiving the minutes on scrap pieces of paper. When asked how long the Resident Council had been holding meetings, she stated about August of last year (2025). On 1/22/26 at 9:28 AM review of the documentation revealed from 1 of the 7 typed papers, Thank you, Thank you, Thank you!! Lots of ideas from the Resident Council for the ideas, suggestions, and concerns slipped into our little pink bag on this bulletin board in these past months. Please feel free to continue making suggestions! Our next meeting is on Tuesday, October 21st, so we will discuss any new issues you may want to bring to our attention. The review of all 7 papers failed to reveal any of the concerns slipped into our pink bag. Additionally, the review failed to reveal any documentation of the facility's response to such concerns.On 1/22/26 at 9:46 AM in an interview with the DON she showed the survey team an organizational folder that on the left side had a list of the original Resident Council members. On the right hand side, she pointed to a paper that had Dates of Meetings with the first one documented as 1) 3/29/25. She pointed out and stated this was the first Resident Council meeting. Additionally, she provided 2 more handwritten Resident Council meetings minutes.On 1/22/26 at 12:27 PM in an interview with DON when asked what her understanding of the purpose/function of the Resident Council was, she stated, I think they [residents] feel empowered by having a say. It gives them a voice here. It might be as easy as they don't want pea soup or that they want a picnic. They had a summer picnic on the 4th of July. They wanted different food instead of just cheese balls. They wanted their parties later in the day. This is what we want to improve, and this is what we feel is good. They felt tickled about making care packages to welcome new residents. They've made an impact and it means a lot to them. They really like the bulletin board and have a suggestion box. During the interview when asked if there was documentation of issues/concerns residents and/or families shared and the facility's response to those issues, she stated, That would be something we need to do in the future. It certainly is worked on and is certainly done; it's just not in writing. The surveyor shared this was a concern and the DON acknowledged understanding of the concerns.

Based on a review of medical records and interviews with facility staff, it was determined that the facility failed to notify the physician regarding the status of a resident's indwelling Foley catheter. Specifically, staff failed to obtain physician orders for the replacement of dislodged catheters and failed to document these re-insertions in the medical record. This evident one resident (Resident #7) of one resident reviewed for urinary catheter care during this recertification survey.The findings include:A Foley catheter is an indwelling urinary catheter (IDC) that drains urine from the bladder into a collection bag.During a review of Resident #7's medical records from November 2025 to January 2026 on 1/22/26 at 1:08 PM, it revealed that progress notes indicated the catheter was found dislodged or came out on six separate occasions: 11/13/25, 11/20/25, 11/26/25, 12/04/25, 12/16/25, and 1/15/26. While notes indicated the catheter was re-inserted each time, there was no evidence that the physician was notified or that an order was obtained for re-insertion.Further review of the Treatment Administration Record (TAR) on 1/22/26 at 2:00 PM it revealed that TAR contained an order 'to change the 16 French/10cc balloon catheter every 30 days for hygiene and infection control.' Although the monthly changes were initialed on 11/10/25, 12/10/25, and 1/15/26, there were no TAR entries or supporting clinical records for the five additional re-insertions that occurred between November and December.On 1/23/26 at 10:35 AM, the Director of Nursing (DON) stated that a provider's order is required for the re-insertion or change of a Foley catheter. She further stated that these events must be documented in both the progress notes and the TAR. Upon reviewing Resident #7's records with the surveyor, the DON validated that the re-insertions were not documented in the TAR and that there was no evidence of physician notification or obtained orders.

Based on interviews with facility staff and review of medical records and facility policy, it was determined that the facility failed to address pharmacy recommendations in a timely manner. This was evident for 2 (Resident #2 and Resident #11) of 5 residents reviewed for unnecessary medications during the facility's recertification survey. The findings include: The Medication Regimen Review (MRR) is a review of the medication regimen (plan) of each resident with the goal of promoting positive outcomes and minimizing adverse (negative) consequences and potential risks associated with medications. The MRR must be completed at least once a month by a licensed pharmacist and includes a review of the medical record to identify, report, and resolve medication-related problems, errors, and/or other irregularities. Irregularity refers to use of medication that is inconsistent with accepted standards of practice for providing pharmaceutical services, not supported by medical evidence, and/or that impedes or interferes with achieving the intended outcomes. An irregularity also includes, but is not limited to, use of medications without adequate indication, without adequate monitoring, in excessive doses, and/or in the presence of adverse consequences. 1) On 1/23/26 at 11:43 AM in an interview with the Director of Nursing (DON) when asked about the facility's MRR process, she stated the pharmacist completed the review and emailed the report. During the interview when asked who received the report, she stated, As far as I know, only me. When asked the process for the physician responding to the recommendations, she stated, I'll either fax it to the physician or if it's urgent I will call them. I also print a copy of any recommendations that need to be addressed. Occasionally, I've had physicians who won't fill them out. Additionally, she stated she put the recommendations that need to be addressed in the rolling cart in the charting room. She stated that it had any documentation that needed to be addressed by the physicians and they knew that. Furthermore, she stated it was the expectation for the physician to make a decision and check either agree, disagree, or other. If they disagreed with the recommendation, she stated there should be a documented rationale with the reason. The DON stated, Do they always, no but it is expected. During the interview she stated that the expectation was for them to sign and date the recommendation and put the completed form put back in the folder. Finally, the charge nurse was responsible for creating, discontinuing or revising orders. On 1/23/26 at 1:53 PM review of Resident #2's MRR's revealed: -9/30/2025 09:58 Pharmacy monthly review Late Entry: Note Text: Medication regimen review completed. Recommendation(s) to MD. (The recommendation was as follows: Please complete this order by adding a dose per application.generally 2gm (grams) for upper body and 4gm for lower body. Diclofenac Sodium External Gel 1 % (Diclofenac Sodium (Topical)). Apply to left wrist topically every 8 hours as needed for wrist pain.) -12/31/2025 10:00 Pharmacy monthly review Late Entry: Note Text: Medication regimen review completed. Recommendation(s) to MD. (The recommendation was as follows: Please complete this order by adding a dose per application.generally 2gm for upper body and 4gm for lower body. Diclofenac Sodium External Gel 1 % (Diclofenac Sodium (Topical)). Apply to left wrist topically every 8 hours as needed for wrist pain.) On 1/23/26 at 2:13 PM review of the 9/30/25 recommendation and 12/31/25 recommendation revealed they were the exact same recommendation; however, there was no documentation that the physician had addressed the 9/30/25 recommendation. The documentation from 12/31/25 revealed in the Physician/Prescriber Response section that the provider had checked agree and written in the comments section 2 gm to affected area (wrist) Q8h (every 8 hours) PRN (as needed). The documentation was signed and dated 1/13/26. Underneath the signature and date was handwritten, Fixed in PCC on 1/14/26. On 1/23/26 at 2:20 PM review of Resident #2's medical record revealed the Diclofenac Sodium External Gel 1 % order with a revision date of 1/14/26 with the following revision: Diclofenac Sodium External Gel 1 % (Diclofenac Sodium (Topical)). Apply to left wrist topically every 8 hours as needed for wrist pain. Apply 2gm. On 1/23/26 at 3:01 PM review of the facility's Medication Regimen Review Policy revealed, For non-urgent recommendations, the Facility and Attending Physician must address the recommendation(s) in a timely manner that meets the needs of the resident- but no later than their next routine visit to assess the resident- and the Attending Physician should document in the medical record: a. What irregularity has been reviewed, b. What action has been taken to address the issue, c. The pharmacy recommendation itself can be used as a tool to document in the medical record, or a notation may make in the medical record/EHR (electronic health record). 2) On 1/23/26 at 10:05 AM, the surveyor reviewed the MRR for Resident #11. Records showed that on 12/31/25, the pharmacist recommended a correction to an order for Tylenol oral capsule 325 mg (milligrams), 2 capsules by mouth at bedtime. The pharmacist's note asked: Is the resident receiving capsules or tablets? Please correct the order if the resident is actually receiving tablets. The MRR for Resident #11 contained a handwritten response stating, capsules per order, but it lacked both a date and a signature. On 1/23/26 at 11:45 AM, the surveyor and Registered Nurse (RN #26) inspected Resident #11's medication package in the medication cart. The package contained Tylenol 325 mg tablets, despite the order for capsules. RN #26 stated, The order is for capsules. Why did the pharmacy deliver tablets instead? During an interview at 11:51 AM, the Director of Nursing (DON) explained that after providers review and sign the MRR, charge nurses (primarily Staff #28) are responsible for following and addressing the orders. At 12:06 PM, the DON claimed that Staff #23 (RN) had just shown her Resident #11's Tylenol capsules. However, when the DON and the surveyor re-verified the medication cart, they confirmed the package still contained tablets. Ten minutes later, the DON presented a package of Tylenol 500mg capsules. Upon verification, the surveyor and DON noted these 500mg capsules were for a separate PRN (as needed) order, not the bedtime order in question. The surveyor expressed concerns that the pharmacist's recommendation was not appropriately addressed or resolved. The DON validated this finding.

Based on review of medical records and interviews with facility staff, it was determined that the facility failed to ensure medications were ordered with an adequate indication for use. This was evident for 1 (Resident #8) out of 5 residents reviewed for unnecessary medications during the facility's recertification survey.The findings include: Adequate Indication for use refers to the identified, documented clinical rationale for administering a medication that is based upon an assessment of the resident's condition and therapeutic goals, and after any safer treatments have been deemed clinically contraindicated.On 1/23/26 at 10:54 AM review of Resident #8's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including, but not limited to, unspecified dementia, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Further review revealed the resident was ordered:-Candesartan Cilexetil Oral Tablet 16 MG (milligrams) Give 1 tablet by mouth one time a day. -Furosemide Oral Tablet 20 MG (Furosemide) Give 1 tablet by mouth one time a day. -Novolog Pen Fill Subcutaneous Solution Cartridge 100 UNIT/ML (Insulin Aspart) Inject 20 unit subcutaneously before meals.-Timolol Maleate Ophthalmic Solution 0.5 % Instill 1 drop in both eyes in the morning.-Lumigan Ophthalmic Solution 0.01 % (Bimatoprost). Instill 1 drop in both eyes at bedtime. Review of Resident #8's above orders failed to reveal an adequate indication for any of the medication orders.On 1/23/26 at 12:17 PM in an interview with the Director of Nursing (DON) when asked if medications should have an indication, she stated yes. The surveyor shared the concern that 5 out of 8 medications for Resident #8 did not have an indication. The DON stated, Oh, that's not good. and verbalized and acknowledged understanding of the concern.

Based on review of facility records and interview with facility staff, it was determined the facility staff failed to ensure the required committee members consistently attended monthly Quality Assurance and Performance Improvement (QAPI) meetings.The findings include:On 1/28/26 at 1:09 PM review of the facility's QAPI monthly attendance records for 1/2025 to 12/2025 revealed the following:-The Medical Director failed to attend 5 of 12 meetings (May 2025, August 2025, September 2025, November 2025, December 2025).-The Nursing Home Administrator failed to attend 1 of 12 meetings (May 2025).On 1/28/26 at 1:36 PM in an interview with the Infection Preventionist/Staff Educator/QAPI Secretary (IP/SE/QAPIS #1) when asked how long she had participated in QAPI meetings, she stated she had been in the QAPI Secretary role for about 2 years. During the interview the 2025 QAPI attendance sheets were reviewed by IP/SE/QAPIS #1, and she reviewed, verified and confirmed the surveyor's findings. The surveyor shared this was a concern and she acknowledged understanding of the concern.

Based on observation, interview, and medical record review, it was determined that the facility failed to ensure maintaining an effective infection control program by failing to order contact precautions in a timely manner. This deficiency was identified for one resident (Resident #19) out of three reviewed for infection control during the annual recertification survey.The findings include:During the tour of the facility on 1/21/26 at 10:18 AM, the surveyor observed the contact precaution signage posted on the wall of Resident #19's room entrance.On 1/22/26 at 10:38 AM, the surveyor reviewed the records of three randomly residents currently receiving antibiotics. The review revealed that Resident #19 was diagnosed with Shingles (Herpes Zoster) by the attending provider on 1/19/26. Shingles is a painful, blistering rash caused by the reactivation of the varicella-zoster virus; per the Centers for Disease Control and Prevention (CDC), contact precautions are required to prevent the spread of the virus. However, no order for contact precautions was placed for Resident #19 until 1/20/26.During an interview on 1/22/26 at 2:00 PM, the Infection Preventionist (IP #1) stated that contact precautions are required for any resident diagnosed with Shingles and that the precaution order should be implemented simultaneously with the diagnosis. The surveyor shared concerns regarding the delay in Resident #19's contact precaution order, and IP #1 validated the finding.

Based on medical record reviews and staff interviews, it was determined that the facility failed to ensure that an employee's COVID-19 vaccination status was monitored and documented. This finding was evident for one of five staff members (Staff #17) whose immunization records were reviewed during the recertification survey.The findings include:The COVID-19 vaccine is intended to provide acquired immunity against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes coronavirus disease.On 1/22/26 at 11:38 AM, the surveyor reviewed the health files of five randomly selected employees. The review revealed that Staff #17 (Dietary Aide), who was hired in October 2024, lacked documentation to support their COVID-19 vaccination status.During an interview on 1/22/26 at 1:45 PM, the Infection Preventionist (IP #1) explained that upon hire, the facility collects copies of vaccination records and reviews the immunization status of all new employees. She stated that these records should include Flu, MMR, Hepatitis B, Tdap, Varicella, Tuberculosis (TB), and COVID-19. Upon a joint review of Staff #17's health records with the surveyor, it was confirmed that the file did not contain COVID-19 vaccination status. IP #1 validated the finding.

Based on review of medical records and interview with facility staff, it was determined that the facility failed to notify the provider of blood in a resident's stool and urine and weakness leading to the resident needing to be fed their meals. This was evident for 1 (Resident #5) of 16 residents reviewed during the facility's recertification survey.The findings include:On 1/22/26 at 10:54 AM review of Resident #5's medical record revealed:-12/14/2025 6:43 AM Resident was assisted with toileting this morning. He/she was observed by GNA (Geriatric Nursing Assistant) to be straining, and he/she had some BM (bowel movement) mixed with a moderate amount of blood in the toilet.-12/14/2025 11:42 AM Around 7:30 AM private aide reported that resident had a moderate amount of blood on his/her depends, also resident, also blood was observed in the toilet after bowel movement.-12/14/2025 11:56 AM Before lunch nurse aid reported that resident needs more help with transferring (is weaker) and probably he/she will need to use mechanical lift (next time when toileting).-12/14/2025 6:58 PM Resident is displaying change in condition. He/she was observed during dinner and was not able to feed him/herself or raise his/her eating utensils to his/her mouth. Resident also is letting his/her right arm hang down on the side of his/her wheelchair and when prompt to raise his/her arm up he/she becomes confused on what to do. Resident received full assistance with eating this evening. Resident is noted to have blood in his/her stool when using the bathroom, he/she is also becoming more tired than usual.-12/15/2025 6:50 AM Resident alert and verbal. He/she had a BM this morning mixed with a moderate amount of blood. Resident appears very weak.-12/15/2025 12:14 PM Resident was very weak this morning. Needed to be fed unable to feed him/herself due to his/her right-sided weakness but seems to have improved as the day went on. Still smiling and responsive.-12/15/2025 2:02 PM Resident verbal, alert. Resident was assisted by GNA with activities of daily living. Resident is not able to feed him/herself, so he/she was fed for both breakfast and lunch by staff members. When fed 100% of meal eaten. When taken to the bathroom, only stain of blood noticed on the depends (incontinence brief) and a few drops of blood noticed in the toilet. Resident has difficulties to stand up, need assistance of two people or need for mechanical lift.-12/15/2025 9:03 PM Care-staff also reported he/she had a trickle amount of blood in his/her urine while on the toilette this evening.-12/16/2025 2:14 PM Aide came in to stay with [resident's name] today. Care was given and he/she was fed. He/she is still weak and not moving his/her arms to assist with taking his/her medications. All vital signs were WNL (within normal limits). His/her sister was called today to make her aware of the changes in resident. Mr./Ms. [resident's name] is still bleeding in stool. He/she was in the activity room today and also in the dining room.-12/16/2025 8:04 PM Resident is still noted to have small amounts of blood with stool when using the bathroom this evening, he/she denies having any pain or discomfort at this time and states that he/she feels tired.-12/17/2025 12:33 PM CBC (complete blood count) results received with low HGB (hemoglobin) (8.3) and low HCT (hematocrit) (26.8). Of note, H&H marginally increased from last CBC on 10/22/25. Daughter/POA notified of results. She stated she plans to return to visit her [family member] this afternoon and will make a decision regarding his/her care. Doctor (D #29) notified of results via fax and confirmed receipt of fax with his office.-12/18/2025 15:40 Lower right arm shows signs of swelling. DON (Director of Nursing) delivered sling to keep arm elevated. Nurse Practitioner (NP #13) examined resident today. No new orders at this time.Resident #5's care plan was reviewed on 1/21/26 at 1:51 PM. The review revealed a care plan for hematological status. The goal was documented as I will remain free of complications related to altered hematological status through the review date (Target Date: 04/18/2026). The following interventions documented in the care plan to reach the above goal were : Monitor for blood in stool. Monitor/document/report PRN following s/sx (signs and symptoms) of anemia: Pallor; Fatigue; Dizziness; Syncope; Headache; Palpitations; Weakness; Feeling of cold; Low Hgb/hct (hemoglobin/hematocrit); SOB (shortness of breath) on exertion; Sore tongue; Chest pain; Tinnitus; Headache; Changes in mental status.On 1/28/26 at 12:27 PM in an interview with the Director of Nursing (DON) when asked the expectation if a resident was noted to have a change in condition such as blood in their stool, urine, incontinence brief, and/or the toilet, she stated, To report it to the charge nurse who usually calls the doctor right away. During the interview when asked the time frame she would expect the provider to be notified, she stated, In that shift, the provider would be notified. The surveyor shared the concern that there was no evidence in the medical record the provider was notified after Resident #5 was noted to have blood in their stool, urine, toilet and incontinence brief or after the resident was noted with weakness that progressed resulting in the resident being unable to feed themself. The DON stated, I gotcha and acknowledged understanding of the concern.

Based on observations and staff interview, it was determined that the facility failed to store foods in a manner that protects them from contamination and in a manner to prevent spoilage. This was evident during the initial kitchen tour. The findings include: On [DATE] at 8:35 AM, an initial kitchen tour was conducted with Staff #1. An observation was made in the large walk-in refrigerator of the kitchen. A box of 6 yogurts with expiration date of [DATE] were present. An open and undated package of bacon was seen sitting on an open rack above open containers of produce. These findings were verified by Staff #1. After surveyor intervention, Staff #1 discarded the box of 6 expired yogurts and the open and undated package of bacon. On [DATE] at 9:18 AM, an interview was conducted with the Certified Dietary Manager (Staff #8). When asked who handles the storage of perishable foods in the refrigerator, Staff #8 stated that she handles all the storing of the food products in the kitchen. When asked what their expectation was for how to check for product's expiration dates, Staff #8 stated that she checks the expiration dates everyday and ensures to place the newer products behind the older products on the shelves.

Based on observation, medical record review and staff interview it was determined the facility failed to ensure that a staff member did not make negative remarks about Residents #23 and #32 in front of them. This was evident for 2 of 5 residents present in the Day Room when the remarks were made. The findings include: On 10/22/19 at 12:05 PM, 5 residents were observed sitting in the Day Room. Two residents were sitting at tables being fed by Geriatric Nursing Aides (GNA)s #2 and #3. GNA #1 was standing in the middle of the room next to a resident but with her back to the surveyor. She was overheard saying, (He/she) has spit at me 3 times and I'm not going to feed (him/her) anymore. A tray on the table next to this resident had the name of Resident #32 on it. The surveyor then left the room to make observations in the main dining room. At 12:25 PM on 10/22/19 when the surveyor returned to the day room, GNA 3# was sitting at a table feeding a resident and GNAs #1 and #2 were sitting together at a different table and each feeding a resident. GNA #1 had her back to the surveyor and was overheard saying, (He/she) makes up more excuses than anyone I know. (He/she's) a picky eater and just pushes things around on the plate. When GNA #1 got up and left the room, GNA#3 was asked who the resident was that GNA #1 was feeding. She (GNA#3)stated it was Resident #23. When the residents had finished eating, Resident #23 was interviewed. The resident was asked if he/she liked the lunch and after talking for a little while, stated he/she liked food but was a picky eater. When asked if staff were nice to him/her, she mumbled for a little bit and then said, yes. It was unclear if she (#23) really understood the questions. Resident #32 had already left the area so was not interviewed at this time. At 12:50 PM on 10/22/19, the Director of Nursing (DON) was notified of the remarks made by GNA #1 in front of the residents so that she could initiate an investigation. On 10/22/19 at 10:15 AM the medical record of Resident #23 was reviewed. The resident has a [DIAGNOSES REDACTED]. According to https://www.verywellhealth.com/bims-identifying-dementia- : BIMS stands for Brief Interview for Mental Status. The BIMS test is used to get a quick snapshot of how well you are functioning cognitively at the moment. It is a required screening tool used in nursing homes to assess cognition . To reach a final tally, add up the total points from all three tests. The numeric value can be interpreted as follows: 13 to 15 points: intact cognition 8 to 12 points: moderately impaired cognition 0-7 points: severely impaired cognition Resident #32, also, has a [DIAGNOSES REDACTED]. On 10/22/19 at about 11:00 AM Resident #32 was interviewed but did not respond appropriately to any questions. On 10/22/19 the surveyor asked to interview GNAs #2 and #3. GNA #3 was not available. At 2:20 PM GNA #2 was interviewed and asked what she heard GNA #1 say about Residents #32 and #23 at lunch when the incident occurred. She stated she heard GNA #1 say that Resident #32 had spit 3 times and she wasn't going to feed him/her anymore. She stated she heard GNA #1 say that Resident #23 was a picky eater and just likes sweets.

Based on medical record review, observation and interview with staff it was determined that the facility failed to ensure that staff documented the removal of controlled medication at the time the medication was removed from the supply (Resident #22); and failed to ensure that two nurses completed the controlled medication count at the change of shift as evidenced by missing signatures in the controlled substance count book and observation of one nurse completing the count by herself. This was found to be evident on one of the two nursing units. The findings include: Review of the facility's Controlled Dangerous Substance Policy revealed the following: At the change of each nursing shift, all controlled substances are reconciled. The physical amount of drugs on hand is verified with the controlled drug substance inventory count down sheet. Count is verified and signed by two licensed nurses every shift. On 3/31/16 review of Resident #22's medical record revealed an order, in effect since 11/13/15, for Tramadol (a narcotic pain medication) to be administered four times a day. Review of the Medication Administration Record [REDACTED]. Review of the Controlled Medication Utilization Record for the resident's Tramadol revealed only two entries between 3/9 and 3/11, accounting for only two doses on 3/10/16. Review of the MAR indicated [REDACTED]. The amount of Tramadol remaining after the removal of the second dose of Tramadol on 3/10/16 was 14 tablets. Review of the Controlled Medication Utilization Record for the resident's Tramadol revealed five entries dated 3/11/16. The first entry, completed by staff nurse #4 had no time specified as to when the Tramadol was removed, documents that one tablet was given but the amount remaining went from 14 tablets to 12 tablets. The next entry was also completed by staff nurse #4 and documented the regularly scheduled 6 AM dose. The other 3 entries for 3/11/16 also documented the regularly scheduled doses. Further review of the Controlled Medication Utilization Record revealed two entries between the 3/11 entries and the 3/12 entries which were dated 3/10 and account for the 3rd and 4th doses administered 3/10/16. In addition to the Controlled Medication Utilization Record for each individual controlled substance the facility also kept a notebook with a running total of the resident's narcotics where the nurses sign off that that the count had been completed at the beginning and end of each shift. On 3/31/16 at approximately 3:00 PM review of the notebooks for controlled substances for Station 1 (there was one specifically for Tramadol and another for the other Narcotics) failed to reveal any signature for the off-going nurse for the Evening shift on 3/28/16 for the Narcotics; and failed to reveal any signature for the 3/25/16 evening shift either on-coming or off-going for the Tramadol. On 3/31/16 at 3:11 PM the surveyor reviewed with the Director of Nursing the missing signatures noted in the controlled count books as well as the Controlled Medication Utilization Record for Resident #22 with the non-sequential sign out dates. On 3/31/16 at 3:41 PM when asked about the process for counting the narcotics the nurse (Staff #2) reported that she gets the books, that she signs in for when she comes on then later that night she would sign off. The surveyor then observed the nurse conducting the controlled drug count by herself, no other staff nurse was present in the medication room at the time. The nurse was observed comparing the medication to the counts in the books only. When asked by the surveyor if she normally did the count by herself the nurse replied: to start the shift, yes. On 3/31/16 the Director of Nursing (DON) reported that when the narcotic count is conducted the staff should be looking at the Controlled Medication Utilization Record and the book to make sure they match. The DON also reported that it is her expectation that two nurse's will be counting together. On 3/31/16 at approximately 4:50 PM surveyor informed the DON of the observation of one nurse (staff #2) completing the controlled drug count by herself and that she was comparing the number of medications to the notebook, and there was no evidence of review of the Controlled Medication Utilization Record during the surveyor's observation.

Based on medical record review and interview with staff it was determined that the facility staff failed to implement an order to notify the physician if the resident's systolic blood pressure (top number) was above 140. This was evident for one out of five residents (Resident #22) selected for medication review. The findings include: On 3/31/16 review of Resident #22's medical record revealed that the resident was admitted to the facility several years ago with [DIAGNOSES REDACTED]. Further review of the medical record revealed the following hand written physician order, dated 12/19/15: d/c [MEDICATION NAME] ([MEDICAL CONDITION]), BP (check mark) weekly, call if SBP > 140. [MEDICATION NAME] is a medication used to treat high blood pressure. SBP is the systolic blood pressure which is the top number of a blood pressure reading. A nursing note, written by Staff #3 and dated 12/19/15 at 1:30 PM, stated: Resident examined by (name of physician)- orders are: d/c [MEDICATION NAME], Lab next week, and arterial doppler study. Further review of the medical record failed to reveal any documentation that the order to call the physician if the SBP was above 140 was acknowledged or implemented. Also no order was found prior to 12/19/15 to call the physician if the SBP was above 140. Review of the Medication Administration Record [REDACTED]. Review of the MARs from December 16, 2015 thru March 30, 2016 revealed at least 21 occasions when the resident's SBP was above 140. No documentation was found to indicate the physician was notified when the resident's blood pressure was above 140. On 3/31/16 at 12:26 PM the nurse (staff #1) reviewed the the 12/19/15 order and confirmed that it was to check the blood pressure weekly and to call the doctor if the systolic blood pressure was greater than 140. Surveyor expressed concern that the order had not been implemented. The nurse (Staff #1) responded that: It should of got picked up somewhere. The nurse then confirmed that the [MEDICATION NAME] had been discontinued as ordered. On 3/31/16 at 12:45 PM when asked about the process for implementing an order, the Director of Nursing reported that the written orders are faxed to the pharmacy either by the nurse or herself. Surveyor then reviewed with the Director of Nursing that the order to contact the physician regarding the elevated SBP could be found in the orders printed by the pharmacy.

Based on medical record review and interview with staff it was determined that the facility staff failed to ensure that the information used to complete the Minimum Data Set (MDS) Quarterly assessment for Functional Status was accurate. This was evident for 2 out of 15 (#35 and #41) residents reviewed during stage 2 of the survey. The MDS is a federally-mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. The findings include: 1. On 1/27/15 at 11:30 AM Resident #35's MDS records were reviewed. This review revealed quarterly assessments that were completed on 10/08/14 and 1/08/15. Further review of the MDS' section G- Functional Status G0110 Activities of Daily Living (bed mobility, transfer, locomotion on unit, dressing, toilet use and personal hygiene) and G0120 Bathing revealed that the resident scored a 4 (Total Dependence), indicating that the resident did not participate in performing the task. Further review of the physician's medical history and admission examination dated 3/29/14 revealed the resident's functional status: requires assistance and ambulates with assistance. Review of the November monthly nursing summary revealed the resident requires help with personal care. During an interview with staff #4 she revealed that the resident was not totally dependent. Staff #4 acknowledged that the resident is able to stand with assistance and complete activities of daily living with assistance. She also revealed that the resident is able to self propel in the wheel chair. 2. Resident #41's MDS was reviewed on 1/27/15 at 1:30 PM. This review revealed that the resident's quarterly assessment MDS section G- Functional Status G0110 (E) locomotion on unit dated 08/14/14 and 11/14/14 revealed that the resident scored a 4 (Total Dependence), indicating that the resident did not participate in performing the task. During observation of the resident on 1/23/15 and 1/27/15, the resident was observed moving freely through out the unit. During an interview with the Director of Nursing on 1/18/15 at 2:30 PM she acknowledged that the resident was able to self-propel in the wheel chair and was not dependent on staff, but that the resident did not have any direction. All findings discussed with the Director of Nursing and the Nursing Home Administrator during the exit.

Based on medical record review and interview with staff it was determined that the facility staff would obtain a CBC with differential when the physician ordered only a CBC and obtained a laboratory test without a physician's orders [REDACTED].#12, 16, 43, and 21) reviewed during stage two of the survey. The findings include: 1. On 1/28/15 Resident 12's medical record was reviewed. This review revealed a current order, originally written 11/3/04, for a CBC (complete blood count) every 6 months. Further review of the medical record revealed a CBC with differential was obtained on 11/6/14. No order could be found for the CBC with differential for this date. Further review of Resident 12's medical record revealed a physician order, dated 6/18/14, for a CBC in the AM (morning). Further review revealed that a CBC with diff was obtained on 6/19/14. No order could be found for the CBC with differential for this date. 2. On 1/28/15 Resident #16's medical record was reviewed. This review revealed a current order, originally written in 2006, for a CBC (complete blood count) every 6 months due in January and July. Further review of the medical record revealed that a CBC with differential was obtained on 7/17/14 and 1/8/15. No order could be found for the CBC with differential for these dates. On 1/28/15 at 10:49 AM the nurse (staff #1) reported that they always get a CBC with diff. She stated that is what the doctor wants but he always writes CBC, and that this is what they have always done. Further review of Resident #16's medical record revealed that a CBC (with no differential) was obtained for this resident, as ordered, on 1/16/14. On 1/28/15 at 11:55 AM interview with another nurse (Staff #3) revealed if the doctor were to write an order for [REDACTED]. On 1/28/15 at 1:02 PM the Director of Nursing confirmed that there was no policy regarding which lab test to obtain when a CBC was ordered. On 1/28/15 at 3:07 PM, this surveyor reviewed with the administrator and the DON concern sregarding staff obtaining CBC with differential when only a CBC is ordered. 3. A review of Resident #43's clinical record on 1/27/15 revealed a current order, originally written on 8/20/14, for a Complete Blood Count (CBC) every 6 months. Further review of the medical record revealed a CBC with Differential was obtained on 8/14/14. No order could be found for the CBC with Differential for this date. The DON was interviewed on 1/28/15 at 3:20 PM and she agreed that the order was for a CBC not a CBC with Differential. 4. On 1/28/15 Resident #21's medical records and physician orders [REDACTED]. Further review of the medical records revealed that the resident had a CBC on 4/24/14 and in 6 months on 10/2/14, medical records also revealed that the resident had another CBC drawn on 10/9/14. During an interview with Staff # 1 she revealed that when the physician writes an order for [REDACTED].#1 for the physician's orders [REDACTED]. All findings were discussed with the Director of Nursing and the Administrator during exit.

Based on medical record review and interview with staff it was determined that the facility failed 1. to document any information about a resident's immunization status for a resident admitted during the flu season (resident #28), 2. to document that the resident, or the legal representative, was provided education regarding the benefits and potential side effects of the influenza immunization prior to administration for four residents (#29, 31, 36, and 22). This was evident for five out of five residents reviewed for immunization status. The findings include: 1) On 1/27/15 review of Resident 28's medical record revealed that the resident had been admitted in December 2014. Further review of the medical record revealed an Immunization Record sheet in which the sections for influenza and pneumococcal were blank. No documentation could be found in the medical record to indicate if the resident had received, or been offered, the flu vaccine this season or not. On 1/27/15 at 2:03 PM when asked about this resident's immunization status the Director of Nursing (DON) reported that she had previously spoken with the doctor who reported that the resident got the flu vaccine this year and pneumococcal a few years ago. The DON went on to report difficulty with obtaining records from the previous facility. 2) On 1/27/15 review of Residents #29, #31, #36, and #22's medical records revealed that they all received their influenza immunization on 10/21/14. No documentation could be found to indicate that any discussion regarding the administration of the vaccine had occurred with the resident, or the responsible party, prior to the administration. Review of the facility's Immunizations: Influenza (Flu) Vaccination of Resident, Staff and Volunteer policy revealed the following statement: "Informed consent in the form of discussion regarding risks and benefits of vaccination will occur prior to vaccination." Further review of this policy failed to reveal where or how this consent would be documented. On 1/27/15 at 2:03 PM the Director of Nursing (DON) reported that documentation of the discussion regarding the immunization is when the doctor marks the order for the flu vaccine on the admission order sheet. Review of Resident #22's admission physician order [REDACTED]. Review of Residents #29, #31 and #36's medical records failed to reveal an order for [REDACTED]. On 1/27/15 at 3:39 PM the DON was informed that review of Resident 22's medical record revealed that the resident did not have an annual flu vaccine ordered, that no documentation of a discussion of the immunization could be found and that the resident had received the immunization in October. Surveyor then requested any evidence of education and or consent for Residents #29, #31 and #36. The DON reported that this information may be in the thinned records for these residents. On 1/28/15 at 9:48 AM, the DON reported that she was unable to find any evidence of consent for immunizations for Residents #29, #31 or #36. The DON also presented a new form to be used to document that education/consent occurred.

Based on medical record review and interview with the facility staff, it was determined that the facility staff failed to accurately assess the resident's functional status such as bathing, dressing and transfers (how resident moves between surfaces). This was evident for 1 out of 17 (#11) residents reviewed in the stage 2 sample. The findings include: Review of the Maryland monthly assessment records indicated that resident #11 was totally dependent (full staff performance every time) for bathing, dressing and transfers. Further review of the medical records revealed that the resident required physical assistance with bathing, grooming and transfers; this indicated that the resident is able to assist with care. During an interview with staff # 3 on 11/7/2013 at 1:00 p.m, she acknowledged that the resident is not dependent on staff for bathing, dressing or transfers. Interview with staff # 4 on 11/8/2013 confirmed that the resident requires assistance with bathing, dressing and transfers.

Based on medical record review and interview with staff, it was determined that the facility failed to ensure an effective system for conducting, reviewing, and following up on monthly pharmacy reviews. This was evident for 1 of 5 (#26) sampled residents selected for review. On 11/8/2013, review of the medical record for resident #26 revealed that monthly pharmacist reviews were conducted on 7/17/2013 and 8/26/2013, and that an irregularity was noted, with a recommendation made to the physician. Review of the medical record with the charge nurse (staff 5), failed to reveal any documentation to indicate that the physician had addressed the 7/17/13 recommendation made by the pharmacist. Further review of the medical record revealed that the physician had accepted the recommendation made by the pharmacist in August, but failed to write an order to address the recommendation. During an interview with the Director of Nursing on 11/8/2013, she acknowledged that it must have been an oversight by the physician.

Based on record review and interview, it was determined that facility staff failed to ensure that the resident environment remains as free of accident hazards as is possible. The findings include: On April 9, 2012, the surveyor, during review of the Material Safety Data Sheets (MSDS), determined that there were no sheets for the chemicals that the pest control operator (PCO) was using in the facility. There was a compact disc available from the PCO but that apparently contained all the chemicals that the PCO has in its inventory. There was also an old binder that contained MSDS's for chemicals that were used in the past. A newer binder had a list of what appeared to be chemicals currently used but was not complete since one of the recent reports from the PCO showed a pesticide named "Temprid SC" which was not on the list. MSDS's are intended to provide workers and emergency personnel with procedures for handling or working with that substance in a safe manner, and includes information such as physical data, storage, disposal, protective equipment, and spill-handling procedures and should be readily available if needed in an emergency.

Based on interview it was determined that facility staff failed to operate and provide services in compliance with all applicable Federal, State and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. The findings include: On April 9, 2012, the surveyor, in conversation with the co-administrator determined that the facility did not possess a license from the Maryland State Board of Cosmetology to operate a beauty salon. If the nursing home salon is sponsored by a licensed salon and the cosmetologist working in the nursing home salon is also employed by the sponsoring salon then the nursing home salon does not need a license issued by the Board of Cosmetology.