Every finding on record at Sun Harbor Healthcare

Based on observation, review of the clinical record, review of facility policy and procedures, resident and staff interviews, the facility failed to provide the necessary care and services to maintain personal hygiene for 4 (Resident #8, #17, #95, and #47) of 4 sampled residents who required assistance with activities of daily living (ADL's). The findings included: The facility policy Activities of Daily Living documented, The facility shall ensure a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living . A resident who is unable to carry out activities of daily living shall receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene . 1. Review of the clinical record revealed Resident #8 had an admitted [DATE] with diagnoses including anxiety, depression, hypothyroidism and adult failure to thrive. Review of the Admission Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) dated 6/14/24 documented resident #8 required partial to moderate assistance with personal hygiene. The MDS noted Resident #8's cognitive skills for daily decision making were intact. On 9/16/24 at 11:33 a.m., Resident #8 was observed sitting in her wheelchair at bedside. She had a black beard extending from the corners of her mouth and under her chin, approximately one inch growth. In an interview she said she did not like it, but no one had shaved her when she asked. Resident #8 said, I'm beginning to look like a circus performer. She said, My arm pits and legs need shaving as well. I told the certified nursing assistant (CNA) but she does not do it. On 9/17/24 at 11:43 a.m., Resident #8 was observed in her bed. She remained with a beard. The resident's legs were observed to be very hairy. Resident #8 said she told the nurse about the CNA not shaving her. Review of the progress notes showed no documentation the resident refused care including shaving. A review of the CNA documented the resident received personal hygiene care each shift from 9/1/24 through 9/17/24. On 9/17/24 at 3:58 p.m., in an interview Unit Manager Licensed Practical Nurse (LPN) Staff H said Resident #8 refuses to be shaved. She said when she works in the evenings she offers to shave her and she says no. Staff H was then observed asking Resident #8 if she wanted to be shaved. Resident #8 readily agreed and requested the facial hair and her legs shaved. On 9/18/24 at 9:03 a.m., Resident #8 was in bed and was observed with no facial hair. She said, The nurse shaved me last night. I feel better without that beard. I was feeling like the bearded lady at the circus. 2. Review of the clinical record revealed Resident #17 had an admitted [DATE] with diagnoses including type 2 diabetes, anxiety, left breast neoplasm and dementia. The Quarterly MDS dated [DATE] documented, Resident #17 was dependent on staff for all her care needs. The MDS noted Resident #17's cognitive skills for daily decision making were severely impaired. Review of the care plan initiated on 5/31/24 documented, Right hand splint as ordered, nursing to monitor skin integrity and circulation. Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. During random observations on 9/16/24 at 1:49 p.m., and 9/17/24 at 10:30 a.m., Resident #17 was observed in bed. Her right-hand fingernails extended over 1/2 inch in length past the tip of the fingers with a brown substance under the nails. The righ hand fifth fingernail extended approximately two inches in length from the tip of the finger. Resident #17 had bilateral hand contractures (fixed deformity) and kept her hands in a tight fist. Resident #17 was observed slightly opening her hands periodically. The left thumb fingernail extended approximately one inch past the fingertip. The remaining fingernails of the left hand extended approximately half inch. A brown substance was observed under the nails. Resident #118 was not observed wearing any positioning device to her hands. On 9/17/24 at 10:34 a.m., in an interview, CNA Staff F said she was aware the resident's fingernails were very long. She said, I'm afraid I will hurt her. She pulls her hand back and I don't want to cut her. I tried to trim the nails for her, but she won't let me. I'm afraid I might hurt her. On 9/18/24 at 12:17 p.m., a joint observation of Resident #17's fingernails was done with Unit Manager Staff H. In an interview Staff H said some of the resident's fingernails were very thick and she did not know if they could cut them. She said she'll see if the podiatrist could come in and do the nail care. Review of the clinical record for Resident #17 revealed a physician's order with a start date of 8/6/24 to apply a splint to the right hand in the monring and remove in the afternoon. The order specified the resident may wear the splint for up to six hours a day. Nursing was to check for skin integrity. Review of the Treatment Administration Record (TAR) showed the splint was applied to the resident's right hand on 9/1/24 to 9/3/24, 9/5/24, 9/6/24, 9/9/24, 9/11/24, 9/12/24, 9/13/24, 9/16/24, and 9/17/24. On 9/18/24 the TAR documented not applicable for the right hand splint. On 9/18/24 at 12:07 p.m., in an interview Unit Manager Staff H said she was not aware Resident #17 had an order for a right hand splint. Staff H reviewed the clinical record and confirmed Resident #17 had an order for a right hand splint. On 9/18/24 at 12:47 p.m., in an interview Registered Nurse (RN) Staff M said she did not know if Resident #17 had a splint. Staff M searched the resident's room and was not able to locate a splint. RN Staff M confirmed Resident #17 had an order for a right hand splint that was not applied. Review of the CNA Kardex (Provides instructions for care) revealed to apply a splint or brace to the right hand in the morning and remove at bed time, wear up to four hours as tolerated. Review of the CNA task documentation for September 2024 showed on 9/3/24, 9/4/24, 9/5/24, 9/6/24, 9/9/24, 9/10/24, 9/11/24, 9/12/24, 9/13/24, 8/14/24, 9/16/24, 9/17/24, and 9/18/24 Staff F documented applying the splint to the resident's right hand. On 9/18/24 at 12:55 p.m., in an interview CNA Staff F said she had not seen a splint for the resident. She said if she had known Resident #17 had an order for a right hand splint, she would have applied it for her. Staff F verified she signed the CNA documentation indicating the splint was applied. 3. Review of the clinical record revealed Resident #95 had an admitted [DATE] with diagnoses including hemiparesis (weakness) and hemiplegia (paralysis) of the left side, cerebral infarction, and contracture of left and right hand. The Admission MDS dated [DATE] documented the resident required staff assistance with all care needs. The MDS noted the residents' cognitive skills for daily decision making were moderately impaired. Review of the CNA Care Kardex showed, The resident is totally dependent on 1 staff for personal hygiene and oral care. On 9/16/24 at 10:22 a.m., Resident #95 was observed in bed with approximately three days of facial hair growth. In an interview Resident #95 said sometimes the staff shave him and sometimes they don't. Resident #95 said he would ask the staff to shave him today. Review of the CNA documentation for September 2024 showed Resident #95 was bathed on 9/16/24 during the 3:00 p.m., to 11:00 p.m. shift. On 9/17/24 at 10:51 a.m., and 9/18/24 at 11:16 a.m., Resident #95 was observed unshaven. On 9/18/24 at 11:16 a.m., in an interview Resident #95 said no one had shaved him and he does not refuse care when offered. On 9/18/24 at 1:34 p.m., in an interview Unit Manager Staff H said residents are shaved on shower days and when needed. Staff H said she would see that the resident was shaved today. On 9/19/24 at 10:48 a.m., in an interview CNA Staff I was asked how often she shaved her residents and how she identified the resident care needs. The CNA was not able to answer the questions. 30599 4. Review of the clinical record revealed Resident #47 was admitted to the facility on [DATE]. Diagnoses included Dementia. Review of the Admission MDS with a target date of 8/2/24 noted the resident's cognitive skills for daily decision making were severely impaired with a Brief Interview for Mental Status score of 03. The MDS noted the resident was dependent on staff for personal hygiene,(Helper does all of the effort. Resident does none of the effort to complete the activity). The CNA Kardex noted the resident preferred to be bathed on Tuesdays and Fridays during the 3:00 p.m. to 11:00 p.m. shift. The Kardex specified to check nail length and clean on bath days as necessary. On 9/16/24 at 10:44 a.m., Resident #47 was observed in bed. The resident looked unkempt with long, dull hair covering his ears. Long strands of hair were protruding through the resident's nose and ears. The resident's fingernails on both hands extended approximately a quarter of an inch from the tip of the fingers with brown film like residue under the nails. Review of the CNA electronic documentation showed Resident #47 received a bed bath on 9/17/24. On 9/18/24 at 8:59 a.m., Resident #47's hair remained long, uncombed, covering his ears, and strands of hair protruding out of his nose and ears. His fingernails remained uncut with the brown film residue under all his nails. On 9/18/24 at 10:54 a.m., in a joint observation, CNA Staff M verified Resident #47's hair remained long, uncombed, covering his ears, and strands of hair protruding out of his nose and ears. His fingernails remained uncut with the brown film residue under all his nails. She said CNAs did not cut residents hair. She said she would trim his nails on shower days and whenever they needed to be cleaned or cut. On 9/18/24 at 11:18 a.m., in an interview Licensed Practical Nurse Staff L said Resident #47 needed a hair cut and needed to have the hair protruding from his nose and ears trimmed. She said the Social worker would be the one to arrange for the haircut if the resident did not have the funds to pay for it. On 9/18/24 at 11:25 a.m., in an interview the Social Worker said Resident #47 could not get his hair cut if he did not have the funds to pay for it. On 9/18/24 at 11:38 a.m., in an interview the Regional Business Office Manager said if the resident needed a hair cut and did not have the money to pay for the services, the facility would pay for the haircut.

Based on observation, review of the clinical record, review of the facility policy and procedure and resident and staff interviews, the facility failed to ensure appropriate treatment, equipment and services to maintain mobility for 2 (Resident #17 and #95) of 5 residents reviewed with contractures and splinting devices. The findings included: Review of the facility policy Assistive Devices and Equipment documented, Our facility provides, maintains, and supervises the use of assistive devices and equipment for residents. Devices and equipment that assist with resident mobility, safety and independence are provided for residents. Recommendations for the use of devices and equipment are based on the comprehensive assessment and documented in the resident's plan of care. 1. Review of the clinical record revealed Resident #17 had an admitted [DATE] with diagnoses including type 2 diabetes, anxiety, left breast neoplasm and dementia. The Quarterly Minimum Data Set (MDS) dated [DATE] documented, Resident #17 was dependent on staff for all her care needs. Resident #17's cognitive skills for daily decision making were severely impaired. Review of the care plan initiated on 5/31/24 documented Right hand splint as ordered, nursing to monitor skin integrity and circulation. Review of the physician order dated 8/6/20 documented, Right-hand splint on in a.m., off in p.m. may wear up to six hours a day. Nursing to check for skin integrity every day shift for restorative. During random observations on 9/16/24 at 11:00 a.m., 9/17/24 at 10:30 a.m., and 9/18/24 at 9:58 a.m., Resident #17 was in bed holding both hands in a tight fist. She was nonverbal and did not respond to verbal stimuli. The resident was holding both hands in fisted position and there were no splinting devices on her hands. Review of the nursing Treatment Administration Record (TAR) revealed the licensed nurses documented the splint was applied to the resident's right hand on 9/1/24, 9/2/24, 9/3/24, 9/5/24, 9/6/24, 9/9/24, 9/10/24, 9/12/24, 9/13/24, 9/14/24, 9/16/24 and 9/17/24. On 9/1/24 and 9/18/24 the TAR documented N/A (not applicable). On 9/18/24 at 12:07 p.m., in an interview Unit Manager Staff H said she was not aware Resident #17 had an order for a right hand splint. Staff H reviewed the clinical record and confirmed Resident #17 had an order for a right hand splint. On 9/18/24 at 12:47 p.m., in an interview Registered Nurse (RN) Staff M said she did not know if Resident #17 had a splint. Staff M searched the resident's room and was not able to locate a splint. RN Staff M confirmed Resident #17 had an order for a right hand splint that was not applied. Review of the CNA Kardex (Provides instructions for care) revealed to apply a splint or brace to the right hand in the morning and remove at bedtime, wear up to four hours as tolerated. Review of the CNA task documentation for September 2024 showed on 9/3/24, 9/4/24, 9/5/24, 9/6/24, 9/9/24, 9/10/24, 9/11/24, 9/12/24, 9/13/24, 8/14/24, 9/16/24, 9/17/24, and 9/18/24 Certified Nursing Assistant (CNA) Staff F documented applying the splint to the resident's right hand. On 9/18/24 at 12:55 p.m., in an interview CNA Staff F said she had not seen a splint for the resident. She said if she had known Resident #17 had an order for a right hand splint, she would have applied it for her. Staff F verified she signed the CNA documentation indicating the splint was applied. On 9/19/24 at 11:14 a.m., in an interview the Director of Rehab said Resident #17 had not been on caseload for quite a while and she did not know about a right-hand splint. On 9/19/24 at 11:35 a.m., in a follow up interview the Director of Rehab said the company she works for took over six months ago and she did not have access to the previous therapy records. She said she could not find any information for a right hand splint for Resident #17 . The Director of Rehab said she spoke with the staff and is aware of the order for a right-hand splint. She said since she did not have access to the previous records, Occupational Therapy will put the resident on caseload to address the contractures and the use of the splint to the right hand. 2. Review of the clinical record revealed Resident #95 had an admitted [DATE]. Diagnoses included with diagnoses including hemiparesis (weakness) and hemiplegia (paralysis) of the left side, and contracture of the left and right hands. The Admission MDS dated [DATE] documented the resident required staff assistance with all care needs. The MDS noted the residents' cognitive skills for daily decision making were moderately impaired. Review of the CNA Care Kardex documented, Contractures, the resident to wear bilateral palm guards as ordered to manage contractures of the (bilateral hands). Provide skin care to keep clean. On 9/16/24 at 10:25 a.m., during an observation Resident #95 was noted to have a contracture of the left hand. There were two splints observed on the nightstand. The resident said both of his hands were contracted and no one had applied the splints in a while. During random observations on 9/17/24 at 10:58 a.m., and 9/18/24 at 12:00 p.m., Resident #95 was observed without the splints on his hands. Both splints remained on the nightstand. On 9/17/24 at 10:53 a.m., in an interview Rehab Tech CNA Staff O said Resident #95 was on caseload for the splints but he had been discharged to the care of the unit staff. He said if a resident refuses to wear the ordered splint, he would let therapy know. He said he had not heard Resident #95 had been refusing to wear the splints. Review of Occupational Therapy (OT) discharge summary dated 9/13/24 documented Manual Tx (treatment) stretching of shortened connective tissue and joint mobilization techniques to prepare for application of palm guards, techniques included soft tissue manipulation, slow sustained stretching to increase wrist and digit extension and PROM (passive range of motion) at digits. Application of palm guards post manual therapy with skin checks. Pt (patient) and caregiver training instructed patient and primary care givers in positioning maneuvers, self-care/skin checks and splinting/orthotic schedule to order with 100% carryover demonstrated by primary caregivers. On 9/18/24 at 12:37 p.m., in an interview Unit Manager Licensed Practical Nurse Staff H confirmed Resident #95 had two splints on the nightstand. Staff H said she was not aware the resident had any splints and said she would check his record and see if he has an order for them. The Unit Manager said she checked the clinical record and the resident did not have an order for the splints. She said she will check with therapy and see if he is supposed to wear splints. On 9/18/24 at 1:46 p.m., in an interview Resident #95 said he was not able to open his hands, he could move his fingers, but had difficulty moving the right shoulder and arm. The splints were observed on the nightstand. Resident #95 said no one tried to put them on for him. On 9/18/24 a physician order was written for the splints: Pt (patient) to wear bilateral palm guards during the day as tolerated for contracture management. On 9/19/24 at 11:18 a.m., in an interview the Rehab Director said Resident #95 recently came off Occupational Therapy (OT) services for the hand contractures. She said the Occupational Therapist developed a functional maintenance program for Resident #95's hand contractures, the resident needed to wear the splints to both hands for contractures. On 9/19/24 at 11:38 a.m., in a follow up interview Resident #95 said no one has placed the palm guards in his hands. He said both his hands were contracted, the left hand was worse. He said the nurse came in the day before and told him he had to wear the splints (palm guards). He said they might help but he won't know until they are applied.

Based on observations, staff and resident interview and record review the facility failed to safely store medication to prevent unauthorized access for 3 (Resident #6, #24, and #94) of 3 residents observed with unsecured medications at bedside. The findings included: Review of the facility's policy titled, Administering medications with a revision date of 2/21/24 revealed Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. Review of facility policy titled: 5.0 Medication Storage noted, Medications will be stored in a manner that maintains the integrity of the product and ensures the safety of the residents and is in accordance with Florida Department of Health guidelines. With the exception of Emergency Drug Kits, all medications will be stored in a locked cabinet, cart, or medication room that is accessible only to authorized personnel, as defined by facility policy. 1. On 9/16/24 at 9:22 a.m., a bottle of Flonase nasal spray was observed unsecured on Resident #6's bedside table. In an interview, Resident #6 said the Unit Manager gave her permission to keep the spray at bedside. Photographic evidence obtained. On 9/17/24 at 9:44 a.m., in an interview,Certified Nursing Assistant (CNA) Staff K stated Resident #6 has had the nasal spray out on bedside table previously. On 9/18/24 at 10:35 a.m., Licensed Practical Nurse Staff G verified Resident #6 had an unsecured bottle of Flonase stored at the bedside. She said Resident #6 had a new order to keep the medication at the bedside and was provided a locked box to store the medication. 41155 2. On 9/16/24 at 11:21 a.m., a clear plastic medication cup with six unidentified pills were observed on Resident #24's bedside table. In an interview, Resident #24 said the pills were antacid tablets. He used them for his stomach. On 9/17/24 at 9:03 a.m., the medication cup with the six pills remained unlabeled and unsecured on Resident #24's bedside table. Review of the physician orders dated 6/25/21 documented Cal-Gest Antacid Tablet Chewable 500 milligrams (Calcium Carbonate Antacid) give 1 tablet by mouth at bedtime for acid reflux / indigestion. On 9/17/24 at 3:41 p.m., in an interview Unit Manager Licensed Practical Nurse Staff H said Resident #24 had an order for antacid tablets but not to keep them at bedside. Staff H said she will go and remove the medication from the resident's room and explain to him that he could not have them at bedside. 41905 3. On 9/17/24 at 11:13 a.m., a small clear plastic medication cup with several pills of different colors and sizes were observed unsecured on Resident #94's bedside table. In an interview, Resident #94 said the nurse gave her the cup of medications but she fell asleep and did not take them. On 9/17/24 at approximately 11:15 a.m., in an interview LPN Staff D verified the observation of the unsecured medications at the resident's bedside. She said she gave the resident the cup of pills but was called to another room before she could observe Resident #94 take the medications. She said the expectation was to observe the resident take the medications then document in the Medication Administration Record (MAR). Staff D said she did not come back to the room to make sure the resident took the medications. On 9/19/24 at 9:22 a.m., in an interview the Director of Nursing (DON) said she was not sure which medications were found at Resident #94's bedside but the expectation was to make sure the resident swallows the medication before they sign it off on the MAR.

Based on observation, record review, resident representative and staff interviews, the facility failed to act on the designated Health Care Surrogate request for a change of treatment for 1 (Resident #118) of 2 residents reviewed for choices and representative involvement in care plan and decision making. The findings included: Review of the clinical record revealed Resident #118 was admitted to the facility on [DATE]. Diagnoses included Dementia with psychotic disturbance, Alzheimer's disease, Atrial Fibrillation (irregular heartbeat), and cardiac pacemaker (implanted device that regulated the heart's rhythm). The Advance Health Care Directive in the clinical record revealed on November 20, 1995, Resident #118 designated her husband to be her healthcare surrogate. If her husband was unable or unwilling to serve in this capacity, the resident designated her daughter to serve as her healthcare surrogate. Review of the Admission Minimum Data Set (MDS) assessment with a target date of 8/29/24 noted Resident #118 was a widow. On 8/26/24 the Attending Physician evaluated Resident #118 and determined she lacked capacity to give informed consent and make health care decisions. On 9/16/24 at 1:46 p.m., in a telephone interview the designated Health Care Surrogate said Resident #118 had a diagnosis of dementia and needed long term placement. She said she did not want to prolong her life is her heart stopped or she stopped breathing. The Health Care Surrogate said she requested several times to have the pacemaker deactivated. She said she also spoke with the Social Worker and requested to have the pacemaker deactivated, and they have not arranged for it to be done. The clinical record lacked documentation the Health Care Surrogate's request was communicated to the physician to address the request to have the cardiac pacemaker deactivated. On 9/18/24 at 9:40 a.m., in an interview the Social Service Director verified Resident #118's Health Care Surrogate told her she wanted to have the cardiac pacemaker deactivated. She said she communicated the request to the Unit Manager, Licensed Practical Nurse Staff B but did not document the Health Care Surrogate's request or her conversation with the Unit Manager. She said she should have notified the Attending Physician of the request to get the process started but she did not. On 9/18/24 at 10:06 a.m., in an interview Unit Manager Staff B said she was not aware of the Health Care Surrogate's request to have the pacemaker deactivated. She said she would have notified the physician. On 9/18/24 at 10:07 a.m., in an interview the Director of Nursing no one informed her of the designated Health Care Surrogate's request to have the cardiac pacemaker deactivated. She said the facility did not have a policy for pacemakers but the process would be to schedule a cardiology appointment to have the pacemaker deactivated.

Based on observation, record review and Interview, the facility failed to ensure the resident's right to include representative in care planning for 1 (Resident #47) of 2 cognitively impaired residents reviewed for choices and care planning. The findings included: Review of the clinical record revealed Resident #47 was admitted to the facility on [DATE]. Diagnoses included Malnutrition and Dementia. Review of the Notification & Consent for Medical Services & Medications form dated 7/26/24 showed Resident #47 signed the form authorizing medical services and medications. The Admission Minimum Data Set (MDS) Assessment with a target date of 8/2/24 noted Resident #47 scored a 06 on the Brief Interview for Mental Status, indicating severe cognitive impairment. On 8/2/24 Resident #47 signed a consent for wound care. The resident's signature was witnessed by a facility staff. On 8/7/24 the Medical Director documented Resident #47 was alert and oriented to 1-2 (Person and place). On 9/16/24 at 10:44 a.m., and 9/18/24 at 8:59 a.m., Resident #47 was observed lying in bed. He was not able to respond appropriately to interview questions. On 9/18/24 at 10:36 a.m., in an interview the Social Service Director said Resident #47 was not completely alert and oriented. She said Resident #47 told her he did not have any family but some family members have contacted her expressing concerns about his well-being. She said she did not get back in touch with them to discuss advocacy for his care. Review of the Admission Record Information revealed two family members and a friend were listed as emergency contacts. On 9/18/24 at 11:38 a.m., in an interview the Regional Business Office Manager said the Business Office would be responsible to ensure steps were being taken to obtain a guardian to ensure the residents rights were being honored. The Business Office Manager would contact an attorney with legal aid and the facility would pay for the services. On 9/18/24 at 12:33 p.m., in an interview the Medical Director said Resident #47 was not capable of making his own medical decisions but had not yet documented the information in the clinical record.

Based on observation, record review, resident representative and staff interviews, the facility failed to make prompt efforts to resolve a grievance related to missing personal property for 1 (Resident #118) of 3 residents reviewed for resolution of grievances. The findings included: Review of the clinical record revealed Resident #118 was admitted to the facility on [DATE]. Diagnoses included Dementia. On 9/16/24 at 9:50 a.m., Resident #118 was observed wandering in her bedroom. Resident #118 was not able to answer interview questions. An empty eyeglass case was observed in a drawer in the resident's dresser. Resident #118 was not able to say where her glasses were. Review of the personal items inventory list signed by Resident #118, and dated 8/25/24 showed an X next to glasses, indicating Resident #118 was admitted to the facility with a pair of glasses. Review of Resident #118's Inventory of Personal Effects dated 8/25/24, there is an X mark next to glasses indicating the resident was admitted with a pair of glasses. The resident signed the inventory sheet, but the space for the staff member's signature was blank. The care plan initiated on 8/26/24 noted Resident #118 had a Health Care Surrogate. On 9/16/24 at 1:46 p.m., in a telephone interview the Health Care Surrogate said Resident #118 was admitted to the facility with prescription lenses. She said she visits Resident #118 every day and her prescription glasses have been missing the day after her admission. The Health Care Surrogate said she did not file a written grievance but has asked several staff members numerous times to find the glasses. She said the glasses were still missing. Review of the grievance log for August and September 2024 revealed no documentation of a grievance for Resident #118's missing prescription eyeglasses. On 9/17/24 at 3:38 p.m., in an interview Certified Nursing Assistant, CNA Staff A said Resident #118 was transferred from a different room without eyeglasses. On 9/17/24 at 3:41 p.m., Resident #118 was observed in the bedroom doorway. The resident was not wearing eyeglasses. The empty eyeglass case remained in a drawer of the resident's dresser. On 9/18/24 at 8:59 a.m., in a follow up telephone interview the Health Care Surrogate said Resident #118's vision was very poor and she needed to wear her prescription glasses every day. On 9/18/24 at 9:40 a.m., in an interview the Social Service Director said she was responsible for filing grievances and address concerns for missing personal property but no one told her Resident #118's glasses were missing. On 9/18/24 at 10:07 a.m., in an interview the Director of Nursing (DON) said no one told her Resident #118's prescription glasses were missing. On 9/18/24 at 12:26 p.m., the DON said the missing eyeglasses were found in a drawer at the nurse's station and returned to the resident. On 9/19/24 10:20 a.m., in a telephone interview Resident #118's Health Care Surrogate verified the prescription eyeglasses were found and returned to her.

Based on interviews and record review, the facility failed to ensure an accurate Level I Preadmission Screening and Resident Review (PASRR) screen was completed for 1 (Resident #86) of 4 residents with diagnoses of mental illness, and failed to refer the resident to the appropriate state designated authority for a comprehensive evaluation within the specified time frame. The findings included: Review of the facility policy for PASSR (Preadmission Screening and Resident Review) reviewed April 2022 revealed, It is the policy of the center to follow the Federal and State regulations with regards to pre-screening residents with a mental disorder and individuals with intellectual disability for individuals requiring more than 30 days in the Center. Review of the Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 12/20/21 revealed Resident #86 was admitted to the facility on [DATE] with diagnoses including bipolar disorder, and depression. The list of diagnoses noted Bipolar Disorder and Major Depressive Disorder, recurrent were present on admission. The care plan initiated on 12/20/21 noted Resident #86 had behaviors related to Bipolar Disorder, Major Depressive Disorder and Anxiety Disorder. On 9/26/23, review of Resident #86's medical record revealed a PASRR Level I dated 11/21/21. The Level I PASRR did not list the resident's diagnoses of Bipolar disorder or Depression. The Level I PASRR noted Resident #86's admission to the facility was a hospital discharge exemption with the condition, a PASRR Level II evaluation must be completed no later than the 40th day of admission. There was no PASRR Level II evaluation in the medical record. On 9/25/23 at 11:16 a.m., Resident #86 said he sees the psychiatrist and the psychologist at the center because of, going stir crazy in bed, change of life three years ago, spinal fusion and stroke that left him bed ridden. On 9/27/23 at 11:24 a.m., the Director of Nursing (DON) confirmed a PASRR Level II evaluation was never completed for Resident #86 as required. The DON confirmed Resident #86 has been a resident in the facility since 12/6/21 and the PASRR Level II was overdue.

Based on record review, and interview, the facility failed to appropriately address the consultant pharmacist's recommendations for 1 (Resident #48) of 5 residents reviewed for unnecessary medications. The findings included: Review of Resident #48's medical record revealed an order for Acetaminophen Tablet 325 milligrams (mg), give 2 tablets by mouth every 6 hours for chronic pain. Do not exceed 3000 mg in 24 hours, start date 1/18/2023 at 2:00 p.m. Review of the record revealed a separate order for Percocet Oral Tablet 7.5-325 mg (Oxycodone 7.5 mg with Acetaminophen 325 mg), give 1 tablet by mouth every 6 hours as needed for moderate to severe pain, hold for sedation and altered mental status (AMS), start date 3/21/2023 at 5:15 p.m. Review of the medical record revealed on 5/8/23 the consultant pharmacist documented Resident #48 was currently receiving Oxycodone/Acetaminophen as needed which was used daily along with standing order for Acetaminophen 650 mg every 6 hours. Please evaluate current pain management and consider switching to Oxycodone twice daily and PRN (as needed) to reduce risk of exceeding Acetaminophen maximum daily dose, if appropriate. The Medical Director disagreed with the recommendation on 5/9/23, with the reason, ordered by pain management. Review of the orders for Resident #48 revealed no change or modifications in the orders for Acetaminophen and the Oxycodone/Acetaminophen (Percocet) for Resident #48 after the pharmacist made the recommendation. The clinical record lacked documentation the pain management physician was notified of the consultant pharmacist's recommendations. On 9/28/23 at 12:43 p.m., the Medical Director said he was not sure he was notified of the recommendation because all pain medication orders are addressed by the pain management physician. He said if he was notified, he would have deferred to the pain management physician. He said the risk of complications is greater in the elderly with the higher amounts of Acetaminophen. He said the order should have been fixed. On 9/28/23 at 1:58 p.m., The Director of Nursing (DON) said she is responsible for notifying the physician of the pharmacy recommendations. She said she thought she took care of the recommendation dated 5/8/23 and confirmed she signed the form implying it was done. The DON confirmed the orders for Acetaminophen and Percocet had not been changed since the recommendation of 5/8/23, and the daily Acetaminophen dose had exceeded 3000 mg on numerous days. The DON did not have documentation verifying the pain management physician was notified of the recommendation. On 9/28/23 at 3:17 p.m., during a telephone interview the consultant pharmacist said the Acetaminophen irregularity was identified 5/8/23. The facility was giving over 3000 mg of Acetaminophen almost daily to Resident #48. On 9/28/23 at 4:04 p.m., during a telephone interview, the pain management physician said he could not recall if he was notified or not of the pharmacy recommendation on 5/8/23. He said he spoke to the DON earlier in the day, and the Acetaminophen dose will be adjusted.

Based on record review, staff and resident interview, the facility failed to provide documented evidence resident and/or representative, if applicable, were provided with a copy of a written summary of the baseline care plan which included initial goals, a summary of current medications, and dietary instructions for 8 (Resident #54, #100, #112, #160, #261, #262, #266, and #267) of 8 residents reviewed for baseline care plans. The findings included: On 10/27/21, review of facility policy Plan of Care, revised 9/25/17, revealed Develop and implement an individualized Person-Centered baseline plan of care within 48 hours of admission that includes, but not limited to, initial goals based on the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 1. On 10/27/21 at 3:00 p.m., record review of Resident #112 revealed there was no documented evidence a copy of a written summary of the baseline care plan which included initial goals, a summary of current medications, and dietary instructions was provided to the resident or resident's representative as required. 2. On 10/27/21 at 3:10 p.m., record review of Resident #54 revealed there was no documented evidence a copy of a written summary of the baseline care plan which included initial goals, a summary of current medications, and dietary instructions was provided to the resident or resident's representative as required. 3. On 10/27/21 at 3:25 p.m., record review of Resident #100 revealed there was no documented evidence a copy of a written summary of the baseline care plan which included initial goals, a summary of current medications, and dietary instructions was provided to the resident or resident's representative as required. On 10/27/21 at approximately 3:46 p.m., in an interview, the facility Director of Nursing confirmed there was no documented evidence Resident #54, #112, and #100, or resident's representative if applicable, were provided with a copy of a written summary of the baseline care plan that included initial goals and a summary of current medications and dietary instructions. 4. Resident #262's clinical record revealed an admitted [DATE] and a baseline care plan completed by a licensed nurse on 10/15/21. In an interview on 10/27/21 at 12:58 p.m., Resident #262 said he did not recall getting a list of his medications and summary of his orders. There was no evidence a copy of the baseline care plan was provided to the resident and/or his representative. 5. Resident #266's clinical record revealed an admitted [DATE] and a baseline care plan was signed as completed by Licensed Practical Nurse (LPN) Staff B. There was no evidence the baseline care plan was reviewed and/or a copy given to the resident's representative. On 10/27/21 at 1:00 p.m., Resident #266 was unable to answer if he had received a copy of his baseline care plan. There was no evidence a written summary of the baseline care plan which included initial goals, a summary of current medications, and dietary instructions was actually provided as required. 6. Resident #267's clinical record revealed an admitted [DATE] and a baseline care plan was signed as completed by the licensed nurse. There was no evidence the baseline care plan was reviewed and/or a copy given to the resident's representative. On 10/27/21 at 1:05 p.m., Resident #267 said he did not recall receiving a written summary of his baseline care plan and would not be able to read anything without his glasses, as he left them at his daughter's house. 7. Resident #261's clinical record revealed an admitted [DATE] and a baseline care plan signed as completed by LPN Staff C. The baseline care plan was not reviewed with the resident's representative until 10/26/21. There was no evidence a written summary of the baseline care plan which included initial goals, a summary of current medications, and dietary instructions was actually provided as required. On 10/28/21 at 9:17 a.m., Resident #261 said she had been in quarantine for a few days when she arrived and did not get any summary of her medications or a baseline care plan. In an interview on 10/28/21 at 9:41 a.m., LPN Staff B said he did go in and review the baseline care plan with Resident #261 but did not give her a copy. 8. The baseline care plan for Resident #160 was completed 9/29/21 (the date of admission) and signed by the nurse and verbal signature of resident's representative. There was no documentation the resident or resident's representative was given a copy. On 10/27/21 at approximately 3:46 p.m., in an interview, the facility Director of Nursing confirmed there was no documented evidence Resident #54, #100, #112, #160, #261, #262, #266 and #267, or resident's representative if applicable, were provided with a copy of a written summary of the baseline care plan that included initial goals and a summary of current medications and dietary instructions.

Based on record review and staff interview, the facility failed to ensure accuracy of the Minimum Data Set (MDS) assessment in the area of documentation of the number and stage of pressure ulcers on a required admission assessment for 1 (Resident # 261) of 2 residents reviewed with pressure ulcers. In addition, the facility failed to have accurate MDS assessments for 2 (Resident #110 and #2) of 5 residents reviewed for discharge. Inaccurate encoding of the MDS can adversely affect the care provided to the resident. The findings included: 1. Review of the Resident Assessment Instrument (RAI) dated October 2019 showed the steps for assessment include: Examine the resident and determine whether any ulcers, injuries, scars, or non-removable dressings/devices are present. Assess key areas for pressure ulcer/injury development (e.g., sacrum, coccyx, trochanters, ischial tuberosities, and heels). Also assess bony prominences (e.g., elbows and ankles) and skin that is under braces or subjected to pressure (e.g., ears from oxygen tubing) . Without a full body skin assessment, a pressure ulcer can be missed. Examine the resident in a well-lit room. Adequate lighting is important for detecting skin changes. For any pressure ulcers identified, measure and record the deepest anatomical stage. On 10/27/21, review of Resident #261's clinical record revealed a facility Admission/Readmission Data Collection form which indicated the resident was admitted on [DATE] with pressure wounds to her bilateral buttocks and sacrum, (bone just below the lower vertebrae) and mushy discoloration to both heels. On 10/10/21, Licensed Practical Nurse (LPN) Staff B completed Pressure Ulcer Wound Round forms for Resident #261. The wound forms indicated the resident had been admitted with the following pressure ulcers: a deep tissue injury (DTI) on the left heel; a DTI on the right heel; a stage II (partial thickness loss of dermis) pressure ulcer to the sacrum; a stage 1 (superficial reddening of the skin) pressure ulcer to the left elbow; and a stage 1 pressure ulcer to the right elbow. A Non-Pressure Skin Condition form completed by LPN Staff B on 10/10/21, indicated the resident had an arterial wound (ulcer caused by arterial insufficiency) on the left lower leg. LPN Staff B confirmed he was not able to assess or stage a wound as this needed to be done by a Registered Nurse (RN). He said the Director of Nursing was present for the wound assessments and told him the stage. A review of the Admission Minimum Data Set (MDS) Assessment, with an assessment reference date (ARD) of 10/14/21, showed under Section M Skin Conditions that a total of 3 pressure ulcers were coded and 0 venous/arterial ulcer. Description as follows: Item 300A Number of Stage 1 pressure injuries was incorrectly coded as 1 (Yes). M300 C1 Number of Stage 3 pressure ulcers was incorrectly coded as 1 (yes). M300 C2 Number of these Stage 3 pressure ulcers that were present upon admission/entry or reentry was incorrectly coded as 1 (Yes) G1. Number of unstageable pressure injuries presenting as deep tissue injury was incorrectly coded as 1 (Yes) G2. Number of these unstageable pressure injuries that were present upon admission/entry or reentry was incorrectly coded as 1 (Yes) Enter the total number of venous and arterial ulcers present was incorrectly coded as 0 (none). On 10/28/21 at 10:08 a.m., in an interview, MDS Staff D confirmed the ARD date as 10/14/21 and reviewed her coding under section M of the MDS assessment. MDS Staff D said she coded the MDS based on documentation in the medical record. She acknowledged there were 5 skin issues on admission and only coded 3 skin issues not 5 and did not code arterial ulcer as well. MDS Staff D confirmed Resident #261's admission assessment was not accurate. MDS Staff D said she may have used the wound assessment dated [DATE] (a day after the ARD) as documentation for the admission assessment. 2. Resident #2's clinical closed record revealed a discharge MDS dated [DATE]. The MDS was inaccurately coded to reflect the resident's payor source was Medicare when the resident was admitted to the facility on [DATE] and discharged on [DATE] under a managed care payor. MDS staff transmitted a 5-day MDS to Centers for Medicare & Medicaid Services (CMS) for payment causing the discharge MDS to flag/trigger resulting in episode of care at facility remaining opened. In an interview on 10/27/21 at 11:25 a.m., MDS Staff D confirmed the MDS had been coded incorrectly for Resident #2's payor source and the submission of a 5 day MDS to CMS for payment had been an error as the resident's stay was being covered by Managed Care not Medicare. 3. A discharge MDS 3.0 assessment was completed for Resident #110 on 8/3/21. The MDS was coded to indicate the resident was discharged to an acute hospital. A review of Resident #110 clinical record indicated he was discharged home on 8/3/21 with medications and home health services. On 10/26/21 at 3:00 p.m., interview with Director of Nursing (DON) confirmed the discharge MDS was incorrectly coded for Resident #110.

Based on record review and staff interview, the facility failed to maintain complete and accurate records in the area of wound assessments for 1 (Resident #261) of 2 sampled residents reviewed for pressure ulcers. Accurate and complete records are necessary to document the course of a resident's care provided by the facility. The findings included: The facility's Clinical/Medical Records policy- MR195, revised on 8/25/17; stated Clinical records are maintained in accordance with professional practice standards to provide complete and accurate information on each resident for continuity of care. The purpose of the clinical record is to document the course of the resident's plan of care and to provide a medium of communication among health care professionals involved in this care. On 10/27/21, review of Resident #261's clinical record revealed a facility Admission/Readmission Data Collection form which indicated the resident was admitted on [DATE] at 3:15 p.m. Under the section M. skin, Licensed Practical Nurse (LPN) Staff C noted the resident had pressure wounds to bilateral buttocks and sacrum, (triangular bone just below the lower vertebrae) and mushy discoloration to both heels. On 10/10/21 at 12:19 p.m., 12:21 p.m., 12:24 p.m., 12:27 p.m., and 12:28 p.m., LPN Staff B completed Pressure Ulcer Wound Round forms for Resident #261. The wound forms indicated the resident had been admitted with the following pressure ulcers: a deep tissue injury (DTI) on the left heel measuring 3.0 centimeters (cm) by 3.0 cm in size; a DTI on the right heel measuring 3.0 cm by 4.0 cm in size; a stage II (partial thickness loss of dermis) pressure ulcer to the sacrum measuring 4.0 cm by 4.0 cm in size with a depth of 0.1 cm; a stage 1 (superficial reddening of the skin) pressure ulcer measuring 2.0 cm by 2.0 cm in size to the left elbow; and a stage 1 pressure ulcer to the right elbow measuring 3.0 cm by 2.0 cm in size. A Non-Pressure Skin Condition form was completed by LPN Staff B on 10/10/21 at 12:23 p.m., indicating the resident had an arterial wound (ulcer caused by arterial insufficiency) on the left lower leg measuring 2.3 cm by 0.8 cm in size. The wound assessments were dated as being completed 2 hours and 45 minutes before the resident arrived at the facility. On 10/15/21 the Advanced Practice wound care nurse noted Resident #261 had a stage III (full thickness skin loss) pressure injury on the left buttock measuring 0.7 cm by 1.0 cm in size with a depth of 0.2 cm.; a stage III pressure injury to the sacrococcygeal area measuring 0.5 cm by 0.5 cm with a depth of 0.1 cm.; a stage I to the right buttocks measuring 1.0 cm by 1.0 cm in size; and a DTPI (deep tissue pressure injury) measuring 5.0 cm by 6.0 cm in size on the right heel. There was no documentation by the clinician of the presence of an arterial ulcer on the resident's left lower leg or status of the left heel DTI and stage I pressure injury to both elbows. On 10/27/21 at 9:11 a.m., in an interview, LPN Staff B said the admitting nurse does the initial skin assessment and he does a second skin assessment to verify the findings. LPN Staff B said the first assessment for Resident #261 was on 10/10/21 at 3:15 p.m., at the time of her admission and identified pressure wounds to both buttocks and sacrum. LPN Staff B said he would not have been on duty the evening of Resident #261's admission and said the wound assessments he completed were dated wrong and would have been the next day (10/11/21). LPN Staff B said he measured the sacrum as one large area instead of 3 separate areas. He identified the area on the resident's lower leg as an arterial ulcer because of the location. He confirmed there was no documentation by a physician in the resident's record of an arterial ulcer being present or any further documentation of pressure injuries to the left heel and elbows or when they were resolved. At 9:15 a.m., LPN Staff B confirmed he was not able to assess or stage a wound as this needed to be done by a Registered Nurse (RN). He said the Director of Nursing was present for the wound rounds and told him the stage. On 10/27/21 at 10:02 a.m., in an interview, the Director of Nursing said she made wound rounds with LPN Staff B on 10/11/21. She did not know where the documentation of the arterial ulcer came from as she did not identify this and would have to be done by a clinician. She confirmed the record was inaccurate as to when the assessments were completed and did not document she was the one doing the assessments as the RN.

Based on observation, record review, staff interview, and review of the facility's policies titled, COVID-19 Pandemic Plan and Isolation-Categories of Transmission Based Precautions, the facility failed to follow their isolation-transmission based precautions policy by not placing all new and readmitted residents on contact and droplet precautions immediately after admission and failed to ensure that staff wore appropriate Personal Protective Equipment (PPE) when caring for residents on contact and droplet precautions. This failure affected six (6) of nine (9) sampled residents, (Resident's #1, #5, #6, #7, #8 and #9). In addition, the facility failed to follow the facility's policy for transmission based precautions (TBP) for persons under investigation (PUI) by not placing signs indicating the type of isolation and what type of PPE is required before entering the room for one (1) of nine (9) sampled residents (Resident #3) who tested COVID-19 positive. This resulted in an Immediate Jeopardy. On 11/18/20 at 5:25 p.m., the facility's Executive Director (ED), Regional Director of Clinical Services, and the Director of Nursing/Infection Preventionist (DON/IP) were notified that an Immediate Jeopardy was identified at 483.50 Infection Control, F-880 for failure to place all new and readmitted residents on Transmission Based Precautions (TBP) and failed to ensure staff wore appropriate Personal Protection Equipment (PPE) while providing resident care and appropriate notification was placed on the resident's doors. The Immediate Jeopardy was removed on 11/19/20 at 4:30 p.m., after an acceptable plan of correction was received and was validated by the surveyor which included immediately placing new and readmitted residents on droplet precautions and contact isolation with full PPE used by staff, and review of inservice records for staff. The facility remained out of compliance at a lower scope and severity of E (no actual harm with the potential for more than minimal harm that is not an Immediate Jeopardy) for deficiencies at F880. The findings include: 1. During the initial tour of the facility on 11/18/20 at 10:15 a.m., the 500-509 hallway was identified by the DON/IP as the admission unit that housed new and readmission residents on quarantine. An observation during this time revealed there were no notifications of isolation posted on the doors to the resident rooms or any PPE supplies for staff to use that indicated the residents were on contact and droplet precautions. a. On 11/18/20 at 12:14 p.m., Certified Nursing Assistant (CNA) #1 was observed entering Resident #9's room on the 500-509 hallway. CNA #1 assisted the resident with drinking a glass of milk, touched the resident on the shoulder and back and then removed the resident's lunch tray from the room. CNA #1 was only wearing a mask and no other PPE at the time of the observation. Review of the medical record revealed Resident #9 was admitted from an acute care hospital on [DATE]. Review of a lab report dated 11/11/20 revealed the resident tested negative for COVID-19, two days prior to admission to the facility. Review of the progress notes dated, 11/13-11/18/20 revealed Resident #9 was not on isolation. b. On 11/18/20 at 12:16 p.m., CNA #1 entered Resident #7's room on the 500-509 hall to remove the resident's lunch tray. CNA #1 was not wearing any PPE except for a face mask. A second observation at 12: 27 p.m., revealed CNA #1 took blankets into Resident #7's room and placed one of the blankets on the resident. The only PPE CNA #1 was wearing at the time of this observation was a mask. Review of Resident #7's medical record revealed the resident was admitted to the facility on [DATE] and was placed on the 500-509 hall. According to hospital records, three days prior to admission, Resident #7 tested negative for COVID-19. Review of the progress notes dated, 11/13-18/20 revealed the resident was not on any type of isolation. c. During an observation on 11/18//20 at 12:28 p.m., the Medical Records Coordinator/CNA answered the call light for Resident #5, provided a urinal to the resident and removed the lunch tray. The only PPE observed being worn at the time was a mask. Record review for Resident #5 revealed the resident was admitted to the facility and placed on the 500-509 hall on 11/13/20. Further review of the progress notes dated 11/14-11/18/20 revealed the resident was not on isolation. d. Record review for Resident #1 revealed an admitted to the 500-509 hall on 11/13/20. Review of lab results from hospital dated 11/13/20, revealed the resident tested negative for COVID-19. Progress notes dated 11/13-18/20 revealed the resident was not on isolation. e. Record review for Resident #6 revealed the resident was admitted to the 500-509 hall on 11/16/20. Lab results dated the same day as admission revealed the resident had tested negative for COVID-19. Review of the progress notes dated 11/17-18/20 revealed the resident was not on isolation. f. Record review for Resident #8 revealed the resident was admitted to the facility and the 500-509 hall on 11/10/20. Lab results from the hospital dated, 10/30/20 revealed the resident had tested negative for COVID-19. Review of the progress notes revealed from 11/11-17/20 revealed Resident #8 was not on isolation. During an interview on 11/18/20 at 12:27 p.m., the Medical Record Coordinator/CNA stated that none of the residents residing on the 500-509 hall were on isolation. The Coordinator explained that quarantine isolation means that the resident is confined in a private room for 10-14 days. During an interview on 11/18/20 at 12:32 p.m., CNA #1 stated that there were no residents on the 500-509 hall that were on isolation or quarantine. CNA #1 also stated that when residents are admitted from the hospital, they are on quarantine for 14 days only and when a resident is on isolation, a bag of supplies will be placed on the door to the room. On 11/18/20 at 12:35 p.m., Licensed Practical Nurse (LPN) #2 stated that isolation quarantine meant that new admissions from the hospital were placed in a private room and told to stay in their room. Contact isolation means that staff are expected to wear gloves and perform hand hygiene when providing care. LPN #2 also stated there were no residents currently on the 500-509 hallway on quarantine. During an interview on 11/18/20 at 12:50 p.m., the DON/IP stated that quarantine isolation was self-isolation in the resident's room and that the resident was not allowed to come out of their room. The DON/IP confirmed that the 500-509 hall was designated for admissions who were on quarantine. However, according to the DON/IP, there was no expectation that staff used PPE required for contact or droplet precautions and staff was only required to wear a mask and perform hand hygiene. Review of the facility policy titled COVID-19 Pandemic Plan, dated 03/02/20 and revised on 10/28/20, indicated, The center will designate an area and cohort new admissions/re-admissions whose COVID-19 status is known (negative) .Place resident in a private room initiate transmission-based precautions (standard, contact, and droplet). Review of the facility's policy titled Isolation-Categories of Transmission Based Precautions, dated 2001 and revised October 2018, indicated Droplet Isolation PPE includes .masks, gowns, gloves and goggles. Contact isolation PPE includes .gown and gloves. Continued review of the facility's policy titled Isolation-Categories of Transmission Based Precautions, dated 2001 and revised October 2018, indicated When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door so that personnel and visitors are aware of the need for and the type of precaution. The signage informs the staff of the type of CDC (Centers for Disease Control and Prevention) precaution(s), instructions for use of PPE. 2. Review of the 11/15/20 progress note for Resident #3 revealed the resident had received positive results on the rapid COVID-19 test. The resident was placed on droplet isolation, for Persons Under Investigation (PUI) and a second nasal swab test had been collected. During the tour of the 300 Hall on 11/18/10 at 1:00 p.m., Resident #3's room was noted with a bag of PPE supplies hanging on the door entering the room. A stop sign was the only notification on the door directing everyone to see the nurse prior to entering the room. During an interview on 11/18/20 at 2:15 p.m., the Social Services Director/Infection Preventionist stated that residents on PUI should have a sign on the door which designated the type of isolation required, as well as what PPE was to be worn before entering the room. On 11/18/20 at 2:27 p.m., the DON/IP confirmed Resident #3 was a PUI and the sign that was posted on the resident's door was not the correct sign to be used. The DON/IP stated that the sign on the door should have noted that the resident was on droplet/contact precautions so staff would know what PPE to use prior to entering the room. Review of the facility's policy titled Isolation-Categories of Transmission Based Precautions, dated 2001 and revised October 2018, indicated When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door so that personnel and visitors are aware of the need for and the type of precaution. The signage informs the staff of the type of Center for Disease Control (CDC) precaution(s), instructions for use of PPE. The facility presented an acceptable removal plan for the Immediate Jeopardy on 11/19/20 at 2:15 p.m. that read: To remove immediacy, the facility has initiated the following as it relates to F-880: As of 11/18/2020 at 5:25 p.m., a quality review of new admissions/readmissions within 14 days was completed by the Director of Clinical Services, RN. As of 11/18/2020 at 6:00 p.m., 9 residents admitted /readmitted within 14 days, identified during the quality review, were placed on contact/droplet precautions. An updated facility pandemic plan was created on 11/18/2020 and initiated on 11/19/2020. All staff received education beginning on 11/18/2020 by the Director of Clinical Services, RN regarding residents being newly admitted /readmitted are placed on the PUI (patient under investigation) unit on droplet precautions and staff will wear full PPE (Personal Protective Equipment) to include N-95, eye protection and gown. All staff beginning 11/18/2020, will receive education daily every shift until all staff have been in attendance. Any staff member that did not receive education related to the above mentioned will be send a certified letter as of 11/19/2020 indicating they may not return to work until the education is received. Newly hired staff will receive education in orientation. An ADHOC Quality Improvement Performance Committee meeting was held on 11/18/2020 to review the results of facility wide quality review completed and any education initiated with staff. The following team members were in attendance on 11/18/2020. Executive Director, Director of Clinical Services, Medical Director, MDS, Dietary Manager, Social Services Director, Activities Director, Housekeeping Supervisor, Unit manager, Assistant Director of Clinical Services, Regional Director of Clinical Services. Moving forward, a member of the corporate regional staff will be included in the QAPI meeting for the next 6 months to ensure items identified through QAPI are followed through and that the QAPI program is being maintained. The ADHOC QAPI Committee approved the recommendations.

Based on record review and interview, the facility failed to provide needed care and services in accordance with residents or resident representatives preferences for 3 (Residents #1, # 2, and #3) of 3 residents reviewed for end of life care. This has the potential to deprive terminally ill patients and/or family members of services to maintain physical, psychosocial, spiritual and emotional needs. The findings included: 1. On [DATE], a record review of Resident #1's chart revealed an order dated [DATE] that read comfort measures only as per family. Chart showed Resident #1 died in the facility on [DATE]. On [DATE] at 2:36 p.m., Resident #1's daughter said she had talked with the facility twice to get her mother placed on hospice services. Resident #1's daughter said the facility staff told her due to the pandemic restrictions they could not put her mother on hospice but instead would place her on comfort care. Resident #1's daughter said the facility staff told her they could do everything for her mother that hospice could do. Resident #1's daughter said her mother died shortly after these conversations and she'd had no idea her mother had been that close to death. On [DATE] at 11:34 a.m., the Administrator said hospice is only allowed in if a resident is actively dying, otherwise it would be over the phone. The Administrator said the facility doctors and nurses would make the decision that a resident is actively dying. On [DATE] at 1:01 p.m., Social Worker Staff A said Resident #1's daughter had asked about hospice. Staff A said she went to nursing and given the restrictions with COVID and hospice, the facility would be providing the care for her. Staff A said she told Resident #1's daughter there was nothing the facility medical doctor couldn't do that hospice could do. Staff A said the guidance that hospice doesn't come in the facility comes from the Centers for Disease Control. Staff A said she had documentation of her conversations with Resident #1's daughter, however, was unable to produce any documentation. On [DATE] at 1:07 p.m., Staff B Registered Nurse (RN) Unit Manager said she spoke with Resident #1's daughter who had made a request for hospice. Staff B said the daughter said she was talking to hospice and when Staff B spoke with her the next day, the daughter was still undecisive. Staff B said she thought she had documented this but was unable to find any documentation. Staff B said either way at the conclusion, the daughter was still undecided. 2. On [DATE], a record review of Resident #2's chart revealed she was admitted to hospice services on [DATE] with prognosis of less than 6 months. Chart revealed a hospice interdisciplinary care plan for the certification period beginning [DATE] that indicated resident would be receiving hospice skilled nursing visits ,[DATE] times per week for 13 weeks. The chart did not contain any documentation that hospice skilled nursing visits had occurred, nor was there any documentation of hospice visits in the nurse's progress notes. On [DATE] at 12:51 p.m., the hospice Registered Nurse (RN) said hospice hadn't been in to see Resident #2 since [DATE]. She said the facility does not allow hospice to enter the building. She said she has to call the facility on a weekly basis to get an update via the telephone or the facility will call hospice if there is a need of medication or diet changes. The hospice RN said she felt it would definitely be better if she could come in to see the resident and do her own assessment. On [DATE] at 12:25 p.m., the Director of Nursing (DON) said hospice was not being allowed in the building as there had been a few buildings where hospice went in and the hospice nurse who came in had COVID. The DON said that decision was made by the former Executive Director. 3. Record review of Resident #3's chart revealed a physician's orders [REDACTED]. Orders from hospice dated [DATE] were found in the chart for medications. No documentation was found in the chart that hospice had been in to assess Resident #3 for admission to hospice services. The chart revealed Resident #3 died [DATE]. On [DATE] at 2:11 p.m., the Administrator said hospice never came to the building to see Resident #3. She said he had been accepted into hospice through telephone discussions and he passed away before anyone from hospice saw him. On [DATE] at 1:14 p.m., the DON provided corporate policy titled COVID 19 Pandemic Plan [DATE] Revised [DATE], page 2 bullet 4 lists essential health care personnel allowed to enter the building and the list includes hospice Nurse/CNA (Certified Nursing Assistant). On [DATE] at 3:15 p.m., the Administrator agreed the corporate COVID 19 policy lists hospice as essential healthcare personnel and they should be allowed in to assess their residents.

Based on observation, and staff interview the facility failed to maintain the kitchen in a clean, safe, and sanitary manner that is in good repair by not having clean floors in food storage areas, clean surfaces on food preparation equipment, and not maintaining the ice machine in a manner to prevent potential contamination. The lack of sanitation in the kitchen has a potential to affect nearly all residents and staff. The findings included: 1. On 1/27/20 at 7:30 a.m., observations during the initial tour of the kitchen found the following: The floors throughout the kitchen and food storage areas were heavily soiled with debris to include food particles, packaging, and other items on the floors under the carts and tables. In the walk-in refrigerator, the floor was heavily soiled/stained with debris present under the carts. An open cart with food trays was soiled with crumbs and debris; food spillage was present next to food being stored on the metal trays. Kitchen counters and shelves were soiled with food residue and spillage. The shelf below the coffee maker and floor had food residue, crumbs, and liquid spills. Metal food prep tables had rusted/corroded/soiled legs, the wheels to several of the carts and tables were heavily corroded with rust and debris. The metal hood and sprinkler pipe over the cook stove was heavily soiled with dust hanging over food in open pans on the stove. The front of the stove was heavily soiled with drippage. The rack of the toaster was heavily soiled with crumbs; the metal table under the toaster and microwave has rusted legs. The bottom of stand-up oven was soiled and had a sign out of order. The front of the ice machine was heavily soiled/stained. The top of the shelf over the ice chest has standing water along the seam of the upper condenser unit; the edge of the seam was rusted where the water was pooling; the water extends near the lid to the ice chest below. There was a hole in ceiling around pipes above the ice machine. In the pot & pan sink area, Dietary Staff I was filling 3 compartments; the floor underneath was covered with pooling water leaking from the pipes and not going into the drain below. Staff I said she thought maintenance had fixed this and emptied the sanitizing sink. The vent over the pan storage rack was heavily soiled with brown/black bio-growth. The floor along edges was soiled with debris. The floor in the dry storage area was heavily soiled with stains and debris; edge of floor/cove-base near the entry door had chipped tile and was soiled with debris. The food storage carts were soiled and the wall behind the cart was soiled with spillage. 2. On 1/28/20 at 9:24 a.m., Director of Maintenance was working on the plumbing under the 3 compartment sink. He said the drain had clogged and he was notified of this on 1/27/20. The Director of Maintenance denied being notified of any previous issues with the plumbing under the 3 compartment sink. The ice machine was observed again with water pooled along the top of the ice chest near the lid of the ice below. The Director of Maintenance also observed this and said the machine had been repaired but may need to replace this one. On 1/28/20 at 9:28 a.m., the contracted food service District Dietary Manager (DDM) was in the kitchen cleaning the equipment. He observed the ice machine and confirmed this had the potential to contaminate the ice being stored inside the chest below and would take it out of use. The DDM said this was currently the only ice machine for the facility. The other ice machine in the kitchenette was out of order. They would have to get ice from outside. In an interview on 1/28/20 at 9:30 a.m., Dietary Manager Staff H observed the ice machine. She said she had not noticed the pooling of water or been told about this before now. On 1/28/20 at 9:42 a.m., reviewed the above kitchen sanitation concerns with the Administrator who said she had gone in on Friday and had noted these same concerns. She had instructed staff to clean the kitchen at that time. She went back in yesterday and acknowledged several areas of concern were still present. The pooling of water on the ice machine was noted on 1/27/20 tour and was still present. The Administrator said she was not aware of the leakage from the top of the unit but had just been notified and they would get ice from outside until it was repaired. 3. On 1/29/20 at 1:45 p.m. a tour of kitchen was again conducted. The sprinkler pipes were still coated with dust and food was present on the stove. The floors were still heavily soiled with debris throughout the kitchen and along the edges under the carts. The 3 compartment sink was filled with water and leaking along the pipe underneath with splashing and pooling on the floor. The District Manager was present and said the issue with the plumbing was a quick fix on 1/28/20 and confirmed it was still leaking. Regarding the hole in the ceiling above the ice machine, said he would let maintenance know. *Photographic evidence obtained*

Based on observation, record review, and staff interview the facility failed to ensure dignity was provided by not covering the urinary (Foley) catheter bag for 1 (Resident #116) of 3 residents reviewed for dignity. The findings included: On 1/27/20 at 1:36 p.m., observed Resident #116 lying in bed with an uncovered urinary drainage bag attached to the bed. The uncovered bag was readily visible from the hallway. On 1/27/20 at 2:50 p.m., observed Resident #116 being wheeled by therapist with uncovered urinary bag attached to wheelchair. The uncovered bag was readily visible while being pushed to the therapy room. On 1/30/20 at 11:09 a.m., observed Resident #116 in his room sitting up in wheelchair with his back facing the door with an uncovered urinary drainage bag under wheelchair. The uncovered bag was readily visible with bag full of urine visible from the hallway. On 1/30/20 at 3:56 p.m., observed Resident #116 lying in bed with an uncovered urinary drainage bag attached to the bed. The uncovered bag was readily visible from the hallway. On 1/30/20, review of Resident #116's Medication Administration Record [REDACTED]. In an interview on 1/30/20 at 4:07 p.m., Assistant Director of Nursing, confirmed the urinary catheter bag for Resident #116 was not covered with a privacy bag and was readily visible from the hallway.

Based on record review and staff interview the facility failed to accurately assess and code the areas of behaviors and medications for 2 (Resident #217 and #79) of 5 residents reviewed for dementia care of 77 residents with dementia. The assessment process systematically interprets information recorded on the Minimum Data Set (MDS) assessments so an appropriate care plans can be developed. The findings included: 1. Resident #217's clinical record revealed a [DIAGNOSES REDACTED]. An admission MDS assessment with a reference date of 1/20/20, indicated the resident had no behaviors. Section E0900 was coded 0 for no wandering behavior exhibited. In an interview on 1/29/20 at 9:16 a.m., the Social Services Director said she completes the section for behaviors on the MDS. She gets her information from the behavior monitoring sheets nursing fills out and her own observations. She said Resident #217's family member reported the resident was quite a wanderer at home, but he has not exhibited any of this behavior at the facility. Behavioral Monitoring records for Resident #217 were reviewed from 1/15/20 to 1/20/20 and identified the target behaviors of anger, restlessness and wandering. The behavior sheets indicated the resident had wandered on a daily basis and exhibited this behavior for 7 times on day shift; 16 times on the evening shift; and 7 times on the night shift. Nursing progress notes were reviewed from 1/13/20 to 1/20/20. There was documentation of the resident wandering in corridors and into the rooms of other residents despite redirecting and required frequent surveillance. In an interview on 1/29/20 at 11:20 a.m., MDS Coordinator Staff [NAME] said behaviors had not triggered as a problem to consider for a care plan due to the MDS not being coded accurately to reflect Resident #217's wandering behavior. Staff [NAME] confirmed there was no care plan developed to address the behaviors requiring the use of the antipsychotic medication to include target behaviors and interventions to minimize these behaviors. 2. On 1/29/20, review of Resident #79's medication records revealed the resident received [MEDICATION NAME] (an antibiotic) by injection daily from 12/17/19 to 12/20/19 (4 days). The Quarterly MDS had a look back period from 12/17/19 to 12/23/19. Section N0300, the number of days with injections of any type was coded 0. Resident #79's medication records showed had been receiving [MEDICATION NAME] antipsychotic medication (a drug used to treat severe mental disorders) from admission to 5/28/19 when it was discontinued. A gradual dose reduction (GDR) was attempted beginning on 5/4/19. The medication was restarted on 6/5/19. The Quarterly MDS, Section N0450A, received an antipsychotic since admission was coded 0. Section N0450B and N0450C, GDR attempts were blank. In an interview on 1/30/19 at 3:55 p.m., MDS Coordinator Staff [NAME] confirmed the coding for Section N0300, N0410, N450A, N450B and N450C was incorrect and needed to be corrected to accurately reflect resident status at the time.

Based on observation, record review, and staff interview the facility failed to provide Restorative Nursing Program as recommended by Rehabilitation Therapy to prevent decline and maintain abilities with Activities of Daily Living (ADLs) for 1 (Resident #40) of 3 residents reviewed. This has the potential to lead to a decline in functional ability. The findings included: The facility Restorative Nursing Services policy (RN-100, revised 8/24/17) directs: Restorative Nursing will be provided to residents as indicated upon evaluation to assist in achieving the highest practicable level of physical functioning as possible. The procedure includes: Therapy may refer a resident to restorative upon discharge from therapy services as deemed appropriate. When being referred by a therapist: Therapist will complete Communication to Restorative Nursing Form Therapist will review with the Restorative Aid After review, the Therapist, Restorative Nurse and Restorative Aide will sign the form. On 1/27/20 at 8:15 a.m., on 1/28/20 at 9:33 a.m., on 1/29/20 at 10:19 a.m., and on 1/30/20 at 4:00 p.m., Resident #40 was observed sitting in his wheelchair. Resident #40 was roaming the halls in his wheelchair interacting with other residents or staff. Review of Resident #40's clinical record indicated he was admitted on [DATE] and received Physical Therapy (PT) from 9/1/19 through 12/19/19. The resident was ambulating up to 100 feet using a rolling walker with contact guard assist upon discharge from therapy. A Restorative Nursing Program (RNP) referral was made on 12/19/19 for use of a therapeutic exercise system for his legs for 15 minutes. Gait with contact guard assist/minimal assistance with use of rolling walker up to 100 feet on level surfaces, wheelchair following for safety. The referral noted 3 times per week for 8 weeks. The PT Summary of Care included, Patient will continue on RNP for both legs on the therapeutic exercise system and ambulation, in order to minimize a decline and fall risk as well as maintain current level of leg range of motion/strength, preserve skin integrity, and prevent leg contractures. On 1/29/20 review of the facility's Restorative Program list revealed residents who were currently receiveing RNP services as well as those who completed their RNP. Resident #40's name was not on the list. In an interview on 1/29/20 at 10:19 a.m., Resident #40 stated no one walks with him. In an interview on 1/30/20 at 12:57 p.m., Director of Rehab Services stated Resident #40 was discharged from therapy on 12/19/19 and recommendations were given to the Restorative Department. In an interview on 1/30/20 at 3:52 p.m., Restorative Nurse Staff L and Restorative Aid Staff K confirmed Resident #40 was not on a RNP.

Based on record review, staff interview, policy review and observation the facility failed to attempt alternative interventions, explain risks and benefits, and/or evaluate safety prior to installation of side rails on the beds of 3 (Residents #67, #79, and #110) of 5 residents reviewed for accidents and hazards of 74 residents who need assistance with transfers. This has the potential for serious risks including entrapment. The findings included: Review of facility policy for Side Rail/Bed Rail (N-1282, effective 4/19/18) indicated, The Center, will attempt alternative interventions, and document in the medical record, prior to the use of side rail/bed rail. The procedure included: 1. Prior to installation of side rail/bed rail complete the side rail/bed rail evaluation to evaluate the resident risk of entrapment. and 3. Obtain consent from the resident and/or resident representative. 1. On 1/28/20 at 9:32 a.m., ¼ rails were observed in the up position on Resident #110's bed. On 1/30/20 record review revealed no documented evidence of appropriate alternatives attempted prior to the installation of bed rails on the Resident #110's bed. On 1/30/20 at 12:30 p.m., Director of Nursing (DON) confirmed no alternatives listed on 11/12/19 evaluation form. 2. On 1/27/20 at 10:00 a.m., Resident #67 was observed in his bed wearing a hospital gown. Both upper side rails were observed in the up position. In an interview at this time, Resident #67 said the staff told him he must always have both upper side rails up when he was in his bed for his safety. He said he doesn't remember the staff ever explaining to him the risk and benefits related to the use of the side rail. He said no one from the facility told him there were alternatives that could be used instead of the side rails. On 1/28/20 review of Resident #67's medical records revealed a fall prevention care plan dated 6/12/19. One of the interventions listed the use of bilateral side rails to aid the resident with bed mobility/enabler. The Informed Consent for Use of Bed Rails was dated and signed on 12/6/18 by Resident #67's Health Care Surrogate. The consent stated the potential risks and benefits of using bed rails. A Side Rail Evaluation form was completed on 12/6/18 noting the resident requested the use of the side rails. The Side Rail Alternatives Attempted section is blank and does not list any side rail alternatives attempted prior to the use of the side rails. A Side Rail Evaluation dated 11/13/19 stated the resident requested the use of bed rails but does not list any alternatives attempted prior to the use of the side rails. In an interview on 1/30/20 12:51 p.m., Licensed Practical Nurse / Unit Manager Staff L said it was the facility's policy before side rails could be used, they had to get a side rail consent signed by the resident or their representative and conduct quarterly side rail evaluations to ensure they remained safe for the resident. She said as part of the side rail evaluation, they were required to determine and list the alternatives attempted prior to the use of side rails. Staff L reviewed Resident #67's record and said she was only able to find 2 side rail evaluations dated 12/6/18 and 11/13/19. She said neither side rail evaluation stated the alternatives attempted prior to the use of the side rails. She acknowledged there was no documentation they had attempted alternatives prior to the use of the side rails as required. In an interview on 1/30/20 at 1:34 p.m., Minimum Data Set (MDS) Coordinator and Care Plan Coordinator Staff F said it was the facility's policy if side rails were used on a resident's bed, they are required to obtain a consent form for the side rails and do quarterly assessments to ensure they remained safe for the resident to use. After review of Resident #67's medical record and talking with Staff L, the MDS Coordinator confirmed the facility did not conduct the quarterly side rail evaluation and/or attempted side rail alternatives prior to the use of the side rails for Resident #67 as required per their policy. 3. On 1/28/20 at 8:27 a.m., bilateral ¼ bed rails were observed in the upright position on Resident #79's bed. On 1/29/20, review of Resident #79's record revealed there was no documented evidence the facility reviewed the risks vs benefits with the resident and/or representative, obtained informed consent, completed an assessment for entrapment or attempted alternatives prior to installation of bed rails on Resident #79's bed. On 1/30/20 at 9:30 am, Licensed Practical Nurse / Unit Manager Staff L confirmed there was no documented evidence the facility reviewed the risks vs benefits with the resident and/or representative, obtained informed consent, completed an assessment for entrapment or attempted alternatives prior to installation of bed rails on Resident #79's bed.

Based on observation, record review, and staff interviews, the facility failed to assess the behaviors, identify triggers, plan care and provide individualized interventions to prevent and minimize distress for a resident receiving [MEDICAL CONDITION] medication for 1 (Resident #217) of 5 residents reviewed for dementia care of 77 residents with dementia. The findings included: The facility's policy and procedure for Medication Management-[MEDICAL CONDITION] Medications (N-1255, revised 3/23/18) included, Resident centered non-pharmacological interventions should be initiated as indicated . Care plan to include person centered goals and non-pharmaceutical interventions . On 1/27/20 at 1:16 p.m., Resident #217 was observed sitting up in the chair eating lunch. The resident smiled when approached, was speaking Spanish but confused. Observations on 1/28/20 and 1/29/20, found Resident #217 either lying in bed fully clothed with his hat and coat on, or up walking independently in his room and/or in the corridor. Staff were observed frequently monitoring and redirecting him. Resident #217's clinical record revealed a [DIAGNOSES REDACTED]. An admission Minimum Data Set 3.0 (MDS) assessment with a reference date of 1/20/20, indicated the resident had severe cognitive impairment and exhibited no behaviors. The Care Area Assessment completed on 1/24/20, did not include any assessment of the resident's behaviors requiring the use of an antipsychotic medication. The Behavioral Monitoring records for Resident #217 were reviewed from 1/15/20 to 1/28/20 and identified the target behaviors of anger, restlessness and wandering. The behavior sheets indicated the resident had wandered on a daily basis and exhibited this behavior 20 times on the day shift; 35 times on the evening shift; and 13 times on the night shift. Nursing progress notes were reviewed from 1/13/20 to 1/28/20. There was documentation of the resident wandering in corridors and into the rooms of other residents despite redirecting and required frequent surveillance. On 1/20/20 the nurse noted the resident wanders, was hard to redirect due to his diminished cognition, and at times staff was unable to redirect him. In an interview on 1/28/20 at 3:48 p.m., Certified Nursing Assistant (CNA) Staff A said Resident #217 wanders and sometimes goes room to room. He would also rummage through his closet. If she tried to take off his clothes, the resident would get mad at her and say No, No. She can tell by his facial expression, so leaves him alone and will tell the nurse. They use two staff for care as the resident was not in a good mood all the time. She refers to the CNA Kardex for information on how to care for him. In an interview on 1/28/20 at 4:00 p.m., Licensed Practical Nurse (LPN) Staff C said Resident #217 did wander but nothing like the first few days after admission. The resident would not wear a gown and was reluctant to letting staff undress him. The family said he was going to bed fully clothed including his [NAME]et and shoes as he says had to be ready to go to work. When the resident says no, we back off. Last Sunday, he was going down the hall and staff could not redirect him. When staff tried to bring him back, he started swinging his arms at them indicating No. Staff followed him over to the other side of the building and finally got him to sit in a wheelchair long enough so they could bring him back. Between the language barrier and dementia, he may not fully understand and didn't want to upset him. The resident had not let her do the treatment to his buttock in the evening and didn't like to have his shoes off so they can do the skin prep to his heels. LPN Staff C stated the resident was more receptive to the day shift for this. The family had said they would help with cleaning his nails and would come in to assist anytime when needed for care. He did seem to be looking for his daughter one time after she left, and did go up to a side door once, but staff was able to redirect him. In an interview on 1/29/20 at 9:16 a.m., the Social Services Director said Resident #217's family member reported the resident was quite a wanderer at home and is concerned for his safety. In an interview on 1/29/20 at 11:07 a.m., CNA Staff D said Resident #217 was confused and wanders around a lot. She would try to get him to sit down in his room but 2 to 3 minutes later he was back to same pattern. He did understand English but cooperates better if tell him in Spanish. Sometimes he did not want to be changed; if he was not ready, he tells her later. Goes to bed with his shoes on but was up and down so probably safer. When he was restless, she puts on the Spanish channel on TV or a cassette in the radio his family brought in and he listens to music. Staff on the night shift report he did not want to be changed and would be in same clothes. She obtains resident care information from the Kardex. Resident #217's plan of care was reviewed on 1/29/20. There was no care plan developed to address the behaviors requiring the use of the antipsychotic medication to include target behaviors and interventions for staff to use when the resident exhibited these behaviors. The CNA Kardex did not identify the resident was confused, had behaviors, needed frequent monitoring, and was blank under the section for behavioral interventions. In an interview on 1/29/20 at 11:20 a.m., MDS Coordinator Staff [NAME] confirmed there was no care plan developed for Resident #217 to address the behaviors requiring the use of the antipsychotic medication to include target behaviors and non-pharmacological interventions to minimize these behaviors.

Based on observation, record review and resident and staff interviews the facilty failed to ensure one (Resident #89) of one resident reviewed for participation in care planning was involved in care planning. Observation on 3/24/19 at 12:00 p.m., revealed Resident #89 was in bed with 1/4 rail raised to the left side of the bed. Resident #89 was alert, oriented to time, place and person and able to answer questions appropriately. She said no one had explained the risks versus benefits related to the use of the bed rail and did not remember signing a consent authorizing the use of the rail. Resident #89 said it was extremely important to make her own decisions and be involved in her care. She did not remember participating in any care plan meeting or anyone giving her options about her care. On 3/26/19 at 10:50 a.m., Resident #89 said it was extremely important the facility communicated with her about her care, not her daughter. Resident #89's clinical record revealed an admission date of [DATE]. The minimum data set assessment dated [DATE] indicated the resident scored a 14 on the brief interview for mental status (BIMS), indicating the resident's cognition was intact. A baseline care plan was developed on 2/14/19. The care plan provided instructions for the provision of effective and person-centered care. The care plan addressed cognition, discharge plans, resident's routine and activity's preferences, skin integrity, cardiac status, nutrition and hydration. The care plan was dated 2/14/19 and signed by the resident's daughter. There was no documentation indicating Resident #89 participated in decisions about her care. On 2/26/19, the Care Plan Coordinator documented she reviewed the care plan via phone with the resident's daughter. The clinical record also contained an informed consent signed and dated 2/14/19 by the resident's daughter indicating she voluntarily consented to the use of bed rails for her mother. There was no documentation at the time of the survey the resident was consulted and allowed to participate in the decision to use the bed rail. The clinical record did not contain a social service admission evaluation addressing the resident's customary routines and preferences. On 3/26/19 at 9:53 a.m., the Assistant Director of Nursing said Resident #89 had a questionable cognition when she first came in therefore they allowed the daughter to make all decisions for her. On 3/26/19 at 9:55 a.m., UM Staff C said Resident #89 was confused at the time of her arrival to the facility but her cognition had improved since then. On 3/26/19 at 9:57 a.m., the Care Plan Coordinator said she did not make a direct note as to why the resident was not involved in her care plan meeting and couldn't remember why the resident did not participate. She said the resident refused to attend the care plan meeting but she never went back to discuss the plan of care with the resident and allow her to make choices about important aspects of her life. On 3/26/19 at 10:04 a.m., the Social Services Assistant said she remembered doing the BIMS for the resident but it's not dated. She said she missed doing a social services admission evaluation. On 3/26/19 at 10:03 a.m., the SSD said Resident #89 was her own person and should be allowed to make decisions about her care.