Every finding on record at The Arbor

Based on record review and staff interview, the facility failed to electronically submit direct care staffing information based on payroll data to the Centers for Medicare and Medicaid (CMS) as required for quarter 3 of federal fiscal year (FY) 2024 (April 1 through June 30, 2024). This failure occurred for 1 of 4 quarters reviewed. The findings included: Review of the Payroll Based Journal (PBJ) Staffing Data report from the Certification and Survey Provider Enhanced Reports (CASPER) database revealed the facility failed to submit the required PBJ Staffing Data for the third quarter of federal FY 2024. The PBJ Staffing Data for the third quarter of the federal FY 2024 was blank. An interview with the Administrator on 03/11/2025 at 4:04 PM revealed she was aware the PBJ data for the third quarter of federal FY 2024 had not been submitted. The Administrator stated she attempted to submit the PBJ data on 08/13/2024. The Administrator stated each time she attempted to submit the PBJ data she received an error reading. The PBJ data was rejected each time. As a result, an error notification was displayed with each PBJ data submission attempt. The Administrator was not able to submit the PBJ data before the deadline of 08/14/2024. A follow-up interview on 03/12/2025 at 9:28 AM revealed the Administrator contacted the Quality Improvement and Evaluation System (QIES) help desk 09/26/2024 and was able to resubmit the PBJ data without error the fourth quarter of the federal FY 2024 on 11/14/2024. The Administrator verbalized she was educated by CMS support on how to run a PBJ Finale File Validation Report (FFVR) to verify PBJ data submissions. The facility provided the following corrective action plan with a completion date of 11/14/24. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. The facility failed to submit the required Payroll Based Journal (PBJ) Staffing Data for the third quarter of the federal fiscal year 2024. The PBJ Staffing Data for the third quarter of federal FY 2024 was blank. No residents were affected by the 3rd quarter PBJ staffing submission rejection. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. The root cause of the error in submission was the format of the zip file. The file was created but did not contain the data. Upon review by the Administrator in facility quarterly QAPI star rating reviews, the PBJ Staffing Data for the 1st and 2nd quarter of federal fiscal year 2024 were submitted correctly. The 3rd quarter PBJ data was submitted by the Administrator on August 13, 2024, however rejected and not resubmitted because on 9/26/24, CMS support indicated it would not be used if submitted past the due date. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. CMS support educated Administrator on reports to run in QIES-CASPER to verify that submissions are accepted on 09/26/2024. The report is the PBJ Final File Validation Report (FFVR). Monthly reviews of PBJ report accuracy began in September 2024. PBJ preview reports are run in our scheduling/time clock system (OnShift) and reviewed for accuracy of the data and for file format by the Administrator. The goal is for these reviews to be completed by the 15th of the following month. PBJ staffing data is now reviewed monthly for completeness and accuracy by the Administrator and verified by the Staffing Coordinator. The file format review is an addition since this was a new problem with that submission and is completed by the Administrator. The Administrator is responsible for submitting the PBJ data. Moving forward, quarterly submissions of PBJ data will be completed 30 days after the completion of the fiscal quarter, which is 15 days prior to the deadline. This allows for correction of errors if the file is rejected. This will begin with the submission for the second quarter of fiscal year 2025. For 4th quarter PBJ data for federal fiscal year 2024, the data was submitted on 11/13/2024 initially and errors were found with the submission. The error notification was found by running the FFVR report in CASPER. The QIES help desk technician was able to assist on the afternoon of 11/13/2024 with the file submission and it was accepted on 11/14/2024 and verified accepted using the FFVR report in CASPER. The QIES help desk technician was able to help identify the file format issue and the Administrator was then able to make the correction. It was a compression issue which was corrected by creating the file and then converting it to a zip file outside of our staffing software (OnShift). Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Care Compare star rating data is routinely reviewed as part of our quarterly QAPI program and items identified as needing improvement addressed through an improvement process. The Staffing piece is reviewed and is directly related to the quarterly PBJ staffing submissions. This has been a part of our QAPI program since March of 2023. Beginning in September of 2024, the Administrator completes monthly reviews of the PBJ submission data for accuracy and correct file format along with the Staffing Coordinator by the 15th of the following month. It is recorded as complete on a spreadsheet once finished. This continues monthly indefinitely. There have been no issues identified with monthly reviews of staffing data or file format since the submission on November 14, 2024, and the submission of the PBJ data for the 4th quarter of federal fiscal year 2024 was successful, and the next submission is due May 1, 2025. The submission and accuracy audits will be done monthly, and audited records will be reviewed by the Risk Management/Quality Assurance Committee at our quarterly QAPI meeting. The first QAPI review that included the submission failure and subsequent corrections was 2/19/2025. The deadline for the next submission is May 15, 2025, but the facility plans to submit on May 1, 2025, so there is an opportunity to correct any errors. The audits by the Administrator and the Staffing Coordinator are completed monthly. PBJ submissions will be reviewed indefinitely at future QAPI meetings and presented by the Administrator. Corrective action completion date: 11/14/2024. The corrective action plan was validated on 3/12/2025 and concluded the facility implemented an acceptable corrective action plan. Interviews conducted with the Administrator revealed there had been no further noncompliance with the submission of PBJ data. Review of PBJ for the 4th fiscal quarter revealed compliance. The completion date of 11/14/2024 for the corrective action plan was validated.

Based on Medical Director, Psychiatrist, Director of Nursing, and Consultant Pharmacist interviews, and record reviews, the facility failed to identify the need to clarify a physician's medication order for crushing Bupropion HCl SR (a sustained release antidepressant) for 1 of 6 residents reviewed for significant medication errors (Resident #65). This resulted in Resident #65 receiving 11 crushed doses of the medication over a 6-day period. Findings included: Resident #65 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder, vascular dementia, and cognitive communication deficit. Resident #65's admission Minimum Data Set (MDS) assessment dated [DATE] indicated her cognition was moderately impaired and she received an antidepressant 7 out of 7 days since admission. Resident #65 care plan initiated on 02/15/23 indicated she used antidepressant medication related to diagnoses of anxiety disorder. The goal included, in part, that she would be free from discomfort or adverse reactions related to antidepressant therapy. The intervention included, in part, to administer antidepressant medication as ordered by physician. A physician order dated 02/02/23 with an end date dated 03/08/23 indicated she would receive Bupropion HCl Extended Release (XL) 300 milligrams 1 time a day by mouth for depression. Another physician order dated 03/03/23 with an end date dated 03/08/23 indicated she would receive Bupropion HCl Sustained Release (SR) 100 milligrams by mouth two times a day for depression for 1 week and may crush in applesauce then increase to 150 milligrams. Review of the March 2023 Medication Administration Record indicated she received the following doses of the crushed Bupropion HCl SR: - 03/03/23 at 8:00 PM - 03/04/23 at 8:00 AM - 03/04/23 at 8:00 PM - 03/05/23 at 8:00 AM - 03/05/23 at 8:00 PM - 03/06/23 at 8:00 AM - 03/06/23 at 8:00 PM - 03/07/23 at 8:00 AM - 03/07/23 at 8:00 PM - 03/08/23 at 8:00 AM - 03/08/23 at 8:00 PM A physician note by the Medical Director dated 03/03/23 indicated Resident #65 was not taking Bupropion regularly and suggested to titrate Bupropion HCl SR so it could be crushed. A psychiatrist note dated 03/07/23 indicated Bupropion Extended Release (XL) was changed to the SR formulation with an order to crush. The noted stated neither the XL nor SR formulation should be crushed. Doing so would destroy the slow-release mechanism and can create a rush or other side effects. A review of the nurses notes from 03/03/23 through 03/08/23 indicated her mood was pleasant and there was no documentation of increased sadness or adverse side effects. During a telephone interview with the Consultant Pharmacist on 01/09/24 at 10:42 AM, she stated she would not recommend delayed release medications to be crushed. She stated even though Bupropion SR was being crushed for 6 days, she would not expect there be adverse side effects because it was a short amount of time. In a telephone interview with the Psychiatrist on 01/09/24 at 10:36 AM she stated prior to Resident #65 being admitted to the facility, she was hospitalized after a fall and hit her head without loss of consciousness. Prior to her admission to the facility, she was on a different antidepressant, but it was discontinued before her admission. She stated Bupropion was started at the time of her admission to the facility. She stated the XR nor SR formulation should be crushed because it could cause adverse side effects. She stated she did not know if any adverse side effects occurred when the Bupropion SR was being crushed because Resident #65 was already decompensating after her most recent hospitalization . During a telephone interview with the Medical Director on 01/10/24 at 11:44 AM, she stated Resident #65 had dementia and her health had been declining prior to her admission to the facility. She stated she was notified of Resident #65 not taking the Bupropion XR regularly because she was spitting it out. She stated she changed the order to Bupropion SR with the order to be crushed. She stated she was notified by the pharmacy that the medication should not be crushed. She stated the crushed doses that she received would not have caused any adverse side effects. Attempts to reach the nurses who administered the crushed Bupropion SR were not successful. The Director of Nursing (DON) was interviewed on 01/10/24 at 2:50 PM. She stated she was not the DON at that time. She stated if she noticed an order to crush a medication that should not have been crushed, she would have notified the Medical Director and would have sought clarification.

Based on record reviews, observations, and staff resident interviews, the facility failed to administer oxygen at the prescribed rate for 1 of 1 resident reviewed for respiratory care (Residents #64). The findings included: Resident #64 was admitted to the facility on [DATE] with diagnoses which included acute respiratory failure with hypoxia, vascular dementia, and hypertension. Resident #64's admission summary dated 01/05/24 indicated he had cognitive impairment and was using oxygen. A review of the physician orders for Resident #64 indicated an order dated 01/05/24 to apply 2 liters of oxygen for shortness of breath or for oxygen saturations of 90% or less as needed for shortness of breath. Resident #64's care plan dated 01/08/24 indicated a focus area of Resident #64 had oxygen therapy related to congestive heart failure and respiratory illness. The goal indicated Resident #64 would have no signs or symptoms of poor oxygen absorption through the review date. Interventions included, in part, oxygen settings were to be at 2 liters continuously via nasal cannula. Resident #31's oxygen saturations were documented in his Electronic Medical Chart as followed: 01/08/24 at 6:24 PM - 98% via nasal cannula 01/09/24 at 9:48 AM - 96% via nasal cannula 01/09/24 at 7:45 PM - 96% via nasal cannula On 01/08/24 at 2:08 PM Resident #64 was observed to be sitting in his wheelchair with his eyes open. He did not appear to be in distress. The oxygen regulator on the concentrator was set to 1.5 liters flow when viewed horizontally at eye level. On 01/09/24 at 8:41 AM Resident #64 was observed to be sitting in a chair, awake, and eating breakfast. He did not appear to be in distress. The oxygen regulator on the concentrator was set to 1.5 liters flow when viewed horizontally at eye level. On 01/09/24 at 10:13 AM Resident #64 was observed to be lying in bed, with his eyes open, and watching TV. He did not appear to be in distress. The oxygen regulator on the concentrator was set to 1.5 liters flow when viewed horizontally at eye level. On 01/10/24 at 8:55 AM Resident #64 was observed to be sitting in a chair, awake, and eating breakfast. He did not appear to be in distress. The oxygen regulator on the concentrator was set to 1.5 liters flow when viewed horizontally at eye level. On 01/10/24 at 12:51 PM Resident #64 was observed to be sitting in a chair, awake, and eating lunch. He did not appear to be in distress. The oxygen regulator on the concentrator was set to 1.5 liters flow when viewed horizontally at eye level. On 01/10/24 at 2:00 PM Resident #64 was observed to be sitting upright in his chair with his eyes closed. He did not appear to be in distress. The oxygen regulator on the concentrator was set to 1.5 liters flow when viewed horizontally at eye level. During an observation and interview on 01/10/24 at 2:09 PM with Nurse #1 she stated she was Resident #64's assigned nurse during the duration of the survey and checked the setting on the concentrator once a shift. She stated she viewed the settings at eye level. She stated she thought it was set at 2 liters because the top of the ball was touching the 2-liter line. She then adjusted the flow to administer 2 liters of oxygen as ordered. Resident #64 did not appear to be in distress during the observation. Nurse #1 checked his oxygen saturation during the observation, and it was 100% via nasal cannula. During an interview with the Director of Nursing on 01/10/24 at 2:40 PM, she indicated Nurse #1 was a new nurse; however, it was her expectation for oxygen to be delivered at the ordered rate.

Based on observations, record review and staff interviews, the facility failed to discard expired medications in 1 of 1 medication storage room (Juniper Hall Med Storage Room). Findings included: An observation was conducted on 01/08/24 at 10:11 AM of the Juniper Hall medication storage room in the presence of Nurse #1. The observation revealed 9 unopened bottles of aspirin Enteric Coated (EC) 81mg tablets with an expiration date of 12/2023 marked on each bottle. Nurse #1 verified the bottles of aspirin were expired, removed them from the cabinet and put them in a basket to return to pharmacy. Nurse #1 confirmed the medications should not have been in the medication storage room. An interview was conducted on 01/10/24 01:49 PM with the Director of Nursing (DON). She stated the facility stopped ordering bottles of over the counter (OTC) medications a long time ago and the pharmacy had been sending all OTC medications to each resident in bubble cards. The medications that were expired in the medication room were overlooked as they have not stored any OTC medications in the storage room for a long time now. The night shift supervisor checks the medication carts nightly for expired medications.

Based on record review and interviews with the resident, the resident's representative and staff, the facility failed to educate and offer the COVID-19 vaccine on admission and failed to maintain a resident's record of COVID-19 vaccine history. This was for 1 of 5 residents reviewed for immunizations (Resident #2). Findings included: Review of the undated facility policy revealed in part: The facility will educate and offer the COVID-19 vaccine to residents, resident representative, or staff and maintain documentation of such. The resident's medical record will include documentation of the following: a. Education to the resident or resident representative regarding the risks, benefits, and potential side effects of the COVID-19 vaccine. b. Each dose of COVID-19 vaccine administered to the resident. c. If the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal. Resident #2 was admitted to the facility on [DATE]. Resident #2's admission Minimum Data Set (MDS) assessment dated [DATE] indicated she was cognitively intact. Review of Resident #2's medical record revealed no documentation that the COVID-19 vaccine was offered, contraindicated, administered, or refused. No documentation that the COVID-19 vaccine education was provided, and no documentation of previous COVID-19 vaccines received. An interview was conducted on 01/10/24 at 9:59 AM with Resident #2 and her representative. They both stated that Resident #2 had not been offered a COVID-19 vaccine nor had the facility asked for proof of vaccinations on admission. Resident #2 and her representative both indicated they thought she had received all doses of the COVID-19 vaccine. An interview was conducted on 01/09/24 at 11:05 AM with the Infection Control Preventionist/Assistant Director of Nursing (ICP/ADON). She indicated that vaccines should be discussed and offered on admission to the facility by the admitting nurse. If the resident has had some or all vaccines that information should be obtained and entered into the resident's medical record. Refusals should be documented in the nurses notes and under the immunization tab. She stated the COVID-19 vaccine was not offered to Resident #2 on admission. She further stated that prior to Resident #2's admission she was scheduled to receive a COVID-19 vaccine on 10/25/23, but she did not show up to the clinic to do so. The COVID-19 vaccine had not been offered or administered to Resident #2 as of 01/09/24. An interview was conducted on 01/10/24 at 1:14 PM with the Infection Control Preventionist/Assistant Director of Nursing (ICP/ADON). She stated she spoke to Resident #2 and her representative related to the COVID-19 vaccine in which they stated the resident had previously received them. She then stated upon further investigation Resident #2 had not received the COVID-19 vaccine and was not offered the vaccine upon admission. She confirmed Resident #2's medical record did not include her COVID-19 vaccine history, nor did it include documentation that the COVID-19 vaccine was discussed or offered on admission to the skilled facility. She felt it was an oversight that her COVID-19 status had not been discussed on admission. An interview was conducted on 01/10/24 at 1:49 PM with the Director of Nursing (DON). She indicated that vaccines should be discussed and offered on admission to the facility. If the resident has had some or all vaccines that information should be obtained and entered into the resident's medical record. She was unaware Resident #2's vaccination information was not in her medical record. She felt it was an oversight that Resident #2's COVID-19 status was not addressed on admission.

Based on staff interviews and record review, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of Hospice for Resident #7 and #5. This was for 2 of 8 residents reviewed for MDS accuracy. The findings included: 1. Resident #7 was admitted to the facility on [DATE] with diagnosis that included chronic systolic congestive heart failure (CHF), and nonrheumatic aortic stenosis. Record review revealed Resident #7 started receiving Hospice services on 02/13/23. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #7's cognition was severely impaired. Resident #7 was coded as not having a condition or chronic disease that may result in a life expectancy of less than 6 months although she was coded as receiving Hospice services while being a resident. Resident #7's active care plan, last reviewed on 11/24/23, included a focus area that read Resident #7 had a terminal prognosis. The interventions included for staff to work with Hospice team to ensure the residents spiritual, emotional, intellectual, physical and social needs are met. An interview was conducted on 01/10/24 at 11:51 AM with the Minimum Data Set (MDS) nurse. She verified Resident #7's Section J1400 was coded as No. She stated she was unaware she was to look at the Hospice physician's notes and that she only looked at the facility physician's notes for Resident #7's life expectancy diagnosis. She then indicated she had not been doing MDS that long and it was an oversight (Had been in the MDS position since April of 2023). She further stated it was an oversight that she miscoded this question. She verified the resident was covered by Hospice and had a life expectancy of 6 months or less. An interview was conducted on 01/10/24 at 1:49 PM with the Director of Nursing (DON). She stated the Minimum Data Set (MDS) assessment should have been coded to reflect Resident #7's Hospice status accurately. 2. Resident #5 was admitted to the facility on [DATE] with diagnosis that included chronic systolic congestive heart failure (CHF), and nonrheumatic aortic stenosis. Record review revealed Resident #5 started receiving Hospice services on 11/24/23. The significant change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #5's cognition was moderately impaired. Resident #5 was coded as not having a condition or chronic disease that may result in a life expectancy of less than 6 months although she was coded as receiving Hospice services while being a resident. Resident #5's active care plan, last reviewed on 11/24/23, included a focus area that read Resident #5 had a terminal prognosis. The interventions included for staff to work with Hospice team to ensure the residents spiritual, emotional, intellectual, physical and social needs are met. An interview was conducted on 01/10/24 at 11:51 AM with the Minimum Data Set (MDS) nurse. She verified Resident #5's section J under prognosis was coded as No. She stated it was an oversight that she miscoded this question. She verified the resident was covered by Hospice and had a life expectancy of 6 months or less. An interview was conducted on 01/10/24 at 1:49 PM with the Director of Nursing (DON). She stated the Minimum Data Set (MDS) assessment should have been coded to reflect Resident #5 ' s Hospice status accurately.

Based on record review and family member and staff interview, the facility failed to ensure a written grievance investigation summary with resolution was provided to the person filing the grievance for 1 of 1 sampled resident reviewed for grievances (Resident #5). Findings included: Resident #5 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The significant change in status Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #5 had memory and decision making problems and rarely/never understood and rarely/ never understand others. The assessment also indicated that Resident #5 was totally dependent on the staff for all activities of daily living (ADL). Review of the facility's grievance log was conducted. There was 1 grievance filed by Resident #5's family member dated 4/19/19 regarding missing items. The grievance/complaint report dated 4/19/19 was reviewed. The grievance was reported to Social Worker (SW) #1 and Nurse Supervisor during the care plan meeting on 4/19/19. Resident #5's family member reported that 3 rings were missing from their mother, (1) solitaire, (1) with 3 stones and (1) plain band and the rings had sentimental value to their mother. The form indicated that the Nurse Supervisor and the SW #1 were designated to take action on this grievance. The form revealed that several searches for the items and staff interviews were conducted and no rings matching the description were found. The form was completed and signed by SW #1 on 4/24/19. On 6/24/19 at 9:48 AM, a family member of Resident #5 was interviewed. The family member stated the family members visited Resident #5 in (MONTH) 2019 and the resident was wearing 3 rings (wedding ring with diamond, engagement ring with diamond and a wedding band). The family member indicated that they (brother and sister) came to visit their mother the day prior to the care plan meeting and noticed the 3 rings were missing. The family member reported that they were upset because the rings meant so much to their mother. The family member indicated that she asked a young nurse (didn't know her name) about the rings and the young nurse informed her that the rings were removed from Resident #5's fingers because her fingers were swollen. The family member also stated that a male nurse aide (NA) also told the family member that the rings were removed and were left on the night stand. The family members attended the care plan meeting on 4/19/19 and informed the SW and the Nurse Supervisor about the 3 rings that were missing. The family members were told that they (staff) would be looking for the 3 rings. The family member stated that the family members had not received a call or had not received a letter regarding the resolution to the missing rings. The family member stated that SW #1 had sent her a message saying that the facility was not responsible for any missing items. On 6/24/19 at 11:17 AM, the Administrator was interviewed. She stated that when the missing rings were reported, the investigation was started, a care plan meeting was held with the family, and the visitation log was reviewed thinking the family might have removed the rings. She reported that the investigation did not verify the rings were taken by an employee. She stated that she had called Resident #5's daughter by phone that the rings could not be found and the Police was notified. The Administrator admitted that she did not provide a written grievance summary with resolution to the family member about the missing rings. On 6/25/19 at 9:05 AM, SW #1 was interviewed. She stated that she became aware of Resident #5's missing rings during the care plan meeting on 4/19/19. She filled out a grievance form and submitted it to the Administrator. She admitted that she had sent a message to Resident #5's daughter informing her that the investigation/search was still ongoing. She verified that she did not provide the family member with a written grievance summary with resolution about the missing rings. On 6/25/19 at 4:10 PM, a follow up interview with the Administrator was conducted. The Administrator stated that she did not know that there was a regulation to provide a written grievance summary to the person filing the grievance.

Based on record review and family member and staff interview, the facility failed to report an allegation of a resident missing three rings immediately but not later than 24 hours after the allegation was made to the Administrator, Adult Protective Services (APS) and to the state agency (SA) and the results of the investigation was sent to the state agency within 5 working days of the incident for 1 of 1 sampled resident reviewed for misappropriation of resident property (Resident #5). Findings included: Resident #5 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The significant change in status Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #5 had memory and decision making problems and rarely/never understood and rarely/ never understand others. The assessment also indicated that Resident #5 was totally dependent on the staff for all activities of daily living (ADL). Review of the facility's grievance log was conducted. There was 1 grievance filed by Resident #5's family member dated 4/19/19 regarding missing items. The grievance/complaint report dated 4/19/19 was reviewed. The grievance was reported to Social Worker (SW) #1 and Nurse Supervisor during the care plan meeting on 4/19/19. Resident #5's family member reported that 3 rings were missing from their mother, 1 solitaire, 1 with 3 stones and 1 plain band and the rings had sentimental value to their mother. The form indicated that the Nurse Supervisor and the SW #1 were designated to take action on this grievance. The form revealed that several searches for the items and staff interviews were conducted and no rings matching the description were found. The form was completed and signed by SW #1 on 4/24/19. On 6/24/19 at 9:48 AM, a family member of Resident #5 was interviewed. The family member stated the family members visited Resident #5 in (MONTH) 2019 and the resident was wearing her 3 rings (wedding ring with diamond, engagement ring with diamond and a wedding band). The family member indicated that they (brother and sister) came to visit their mother the day prior to the care plan meeting and noticed the 3 rings were missing. The family member reported that they were upset because the rings meant so much to their mother. The family members (sons and daughter) attended the care plan meeting on 4/19/19 and informed the SW and the Nurse Supervisor about the 3 rings that were missing. The family members were told that they (staff) would be looking for the 3 rings. On 6/24/19 at 10:46 AM, the Nurse Supervisor was interviewed. She reported that it was reported by Resident #5's daughter on 4/18/19 that her mother's rings were missing. A care plan meeting was scheduled on 4/19/19 and again the missing rings were discussed. She stated that she started her investigation on 4/19/19 by interviewing the staff and by searching the rooms (resident's room, dining room, restroom, laundry room) for the rings. The Nurse Supervisor reported that she had submitted her investigation reports to the Administrator on 4/29/19. On 6/25/19 at 9:05 AM, SW #1 was interviewed. She stated that she became aware of the missing rings during the care plan meeting on 4/19/19. She filled out a grievance form and submitted it to the Administrator on 4/24/19. She stated that she was not responsible for the reporting to the SA or APS. On 6/25/19 at 10:55 AM, a follow up interview was conducted with the Nurse Supervisor. She verified that on 4/18/19 she was informed by a staff member (didn't remember the staff member) that Resident #5's rings were missing and on 4/19/19 during the care plan meeting, the family member again reported the 3 rings that were missing, (1) solitaire ring, (1) trinity ring and a band with small stones. She indicated that she did not notify the Administrator and the Director of Nursing (DON) immediately of the missing rings. She added that she only notified the Administrator and the DON immediately if the grievance for abuse or misappropriation was true or there was a theft. The Nurse Supervisor stated that she was not responsible for the reporting to the SA or APS. On 6/25/19 at 2:40 PM, a follow up interview was conducted with the Administrator. She stated that the Nurse Supervisor did not notify her when the rings were reported missing because the grievance from the daughter did not indicate that the rings were stolen. She revealed that she did not report allegation like this (missing rings) to the APS and she had sent 24 hour and 5 day report only when there was a reasonable theft. The Administrator also reported that she was notified on 4/29/19 of the missing rings not found and so she sent the 24 hour report to the state agency on 4/30 and the 5 day report on 5/7/19.

Based on record review and staff interview, the facility failed to completely assess a resident on the comprehensive assessment in the area of mental status for one of five sampled residents (Resident #12) reviewed for unnecessary medications. The findings included: Resident #12 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #12 had unclear speech, was sometimes able to make herself understood, and was sometimes able to understand others. Section C, the Cognitive Patterns section, was not fully completed. Question C0100 was coded to indicate a brief interview for mental status (questions C0200 through C0500) was to be conducted. Questions C0200 through C0500 were coded with dashes that indicated the questions were not answered. An interview was conducted with the Social Worker (SW) on 7/6/16 at 3:20 PM. She indicated she was responsible for the completion of Section C of the MDS. Section C of the quarterly MDS dated [DATE] for Resident #12 was reviewed with the SW. She stated she began working at the facility on 4/25/16 and she was new to MDS coding at the time she completed the quarterly MDS dated [DATE] for Resident #12. She indicated when she completed this quarterly assessment for Resident #12 she had not known it was necessary to attempt to complete the brief interview for mental status for all residents unless they were rarely/never understood. She stated she was now aware of the requirements for the coding of Section C.

Based on record review and staff interview, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of active [DIAGNOSES REDACTED].#1, #21, #12 & #13) of 5 sampled residents reviewed for unnecessary medications. Findings included: 1. Resident #1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #1 had received an antidepressant medication. The assessment also revealed that Depression, [MEDICAL CONDITIONS] reflux disease (GERD) and [MEDICAL CONDITION] were not checked under active diagnoses. The June and July 2016 physician's orders [REDACTED]. The doctor's progress notes dated 6/7/16 were reviewed. The notes indicated that Resident #1 had medical problems including [MEDICAL CONDITION] and was on [MEDICATION NAME], [MEDICAL CONDITION] and was on [MEDICATION NAME] was on [MEDICATION NAME]. The drug regimen review dated 6/16/16 indicated that Resident #1 was on [MEDICATION NAME] for Depression. On 7/6/16 at 3:15 PM, the MDS Nurse was interviewed. The MDS Nurse stated that her interpretation of section I (active diagnoses) was if a resident was on a medication with a [DIAGNOSES REDACTED]. 2. Resident #21 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] indicated that Resident #21 had received antidepressant and antianxiety medications. The assessment also revealed that Depression and Anxiety were not checked under active diagnoses. The physician's orders [REDACTED]. The orders included [MEDICATION NAME] (anti-anxiety drug) 0.5 mgs by mouth twice a day and [MEDICATION NAME] 25 mgs by mouth daily. The May 2016 Medication Administration Records revealed that Resident #21 had received [MEDICATION NAME] and [MEDICATION NAME]. On 7/6/16 at 3:15 PM, the MDS Nurse was interviewed. The MDS Nurse stated that her interpretation of section I (active diagnoses) was if a resident was on a medication with a [DIAGNOSES REDACTED]. 3. Resident #12 was admitted to the facility on [DATE]. Her cumulative [DIAGNOSES REDACTED].#12's medical record revealed a physician's orders [REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #12 had significant cognitive impairment. Resident #12 had received antidepressant medication on 7 of 7 days during the 5/27/16 MDS look back period. Section I, the Active [DIAGNOSES REDACTED].#12 indicated depression was not an active diagnosis. A physician's progress note dated 5/27/16 indicated Resident #12's active problems list included depression. The May 2016 Medication Administration Record [REDACTED]. An interview was conducted with the MDS Nurse on 7/6/16 at 3:15 PM. She stated she was responsible for completion of Section I, the Active [DIAGNOSES REDACTED]. The MDS Nurse indicated her interpretation of the coding requirements for Section I was that if a resident was on a medication for a specific [DIAGNOSES REDACTED]. 4. Resident #13 was admitted to the facility on [DATE]. Her cumulative [DIAGNOSES REDACTED].#13's medical record revealed a physician's orders [REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #13 had significant cognitive impairment. Resident #13 had received antidepressant medication on 7 of 7 days during the 5/20/16 MDS look back period. Section I, the Active [DIAGNOSES REDACTED].#13 indicated depression was not an active diagnosis. The May 2016 Medication Administration Record [REDACTED]. An interview was conducted with the MDS Nurse on 7/6/16 at 3:15 PM. She stated she was responsible for completion of Section I, the Active [DIAGNOSES REDACTED]. The MDS Nurse indicated her interpretation of the coding requirements for Section I was that if a resident was on a medication for a specific [DIAGNOSES REDACTED].

Based on staff interview, record review and observations, the facility failed to monitor freezer temperatures in one of one nourishment freezer. The findings included: A review of the Nightly Fridge Temps log for August 2015 revealed the temperature of the nourishment freezer was not monitored and documented. An observation of the nourishment freezer was made on 8/12/15 at 10:14 AM. A thermometer was not observed in the nourishment freezer. One container of vanilla ice cream, one container of Oreo ice cream, multiple containers of orange cream ice cream and multiple containers of mighty shakes were observed in the nourishment freezer. One opened container of sorbet labeled with a resident ' s name was observed in the nourishment freezer. An interview was conducted with Administrative Staff #1 on 8/12/15 at 10:21 AM. She stated the facility did not have a policy regarding the monitoring of temperatures in the nourishment freezer. Administrative Staff #1 stated the ice cream contained in the nourishment freezer was provided to the residents during activities.

Based on staff interview and record reviews, the facility failed to respond to the pharmacist's request for a gradual dose reduction (GDR) of Cymbalta (antidepressant drug)for 1 or 5 sampled residents (Resident #15) reviewed for unnecessary medications. The findings included: Resident #15 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. The Plan of Care dated 2/5/15 indicated the resident was assessed with [REDACTED]. The interventions stated that a GDR, under close supervision, should be attempted to determine if symptoms, conditions or risks could be managed by a lower dose or if the medication could be discontinued. A review of the Minimum (MDS) data set [DATE] revealed Resident #15 was assessed with [REDACTED]. A record review revealed a note to Attending Physician/Prescriber dated 5/22/15 and signed by the consultant pharmacist which read This resident is currently receiving the following antidepressant: Cymbalta 60 mg every day. It is now time to review this resident for the possibility of GDR. Please evaluate resident's depression and, IF APPROPRIATE, consider a trial at 30 mg every day. A review of the note revealed the physician did not respond to the pharmacist's request for a possible GDR of Cymbalta. An interview was conducted with Administrative Staff #1 on 8/12/15 at 10:41 AM. Administrative Staff #1 stated she expected the physician to respond to the pharmacist's request for a GDR and to document his or her response on the request form. She stated she expected the pharmacist to follow up with the physician if a response to a request for a GDR was not provided.

Based on record review, observation and staff interview, the facility failed to discard expired medications and failed to date the medication when the foil pouch was opened in one of one medication cart observed. Findings included: On 8/11/15 at 2:15 PM, the medication cart was observed. The following were observed: a bottle of Aspirin (used to treat pain, fever, inflammation and also prevents blood clots and stroke) 81 milligrams (mgs) tablet with an expiration date of 3/11, a bottle of Mucus Relief (Mucinex) (expectorant drug) tablet with expiration date of 4/11 and a bottle of Aspirin 325 mgs tablet with an expiration date of 6/15. There were two opened boxes of Duoneb solution (Ipratropium/Albuterol), a bronchodilator drug, with vials stored outside the foil pouch. The foil pouch had no date of opening. The instruction on the foil pouch read unit dose vials should remain stored in the protective foil pouch at all times. Once removed from the foil pouch, the individual vial should be used within one week. On 8/11/15 at 2:30 PM, Nurse #1 was interviewed. The nurse stated that the foil pouch should have been dated when opened and also indicated that she would discard the vials that were not inside the foil pouch. The nurse further indicated that it was the responsibility of all nurses to check the cart for expired medications.

Based on observations, staff interviews and review of established policies and procedures, the facility failed to ensure that equipment was kept clean, flatware stored dry, the freezer floor and hand washing sink were free of food debris, lids were affixed to ice cream containers, and that dietary staff did not touch the inside of glasses, and that staff picked up flatware by the handles. The findings include: Review of the facility's policy entitled "Daily Arbor Cleaning Schedule," with the review date of 1/15/09, documents, " Hand sink and dish sink free of food and stains ...Clean inside of refrigerator during each shift." The facility's policy entitled, "Storing Frozen Products," dated 1/15/09, documents, "Foods are covered ...Shelves, walls, and floors are clean and free of spills, debris, and ice buildup." During the initial tour of the Pantry kitchen with the main Cook at 7:49 a.m. on 2/15/11, the following concerns were identified: 1. The Server was observed placing wet flatware in the pantry drawer of the service area. He/she placed wet knives, forks and spoons into the drawer for resident use. The Server picked up the flatware by the service end and not by the handles. Also, using one hand, the Server picked up four glasses at one time by placing her fingers inside of the glasses to lift them and place them on the serving tray. The Server performed the same procedure four (4) times, touching the insides of 16 glasses. The Server did not wear gloves while handling the glasses or flatware. Interview with the Cook and Server at that time revealed, the flatware in the pantry drawer was wet and should be stored dry. The Server also confirmed she should not touch the inside of the glasses, and should pick up flatware by the handles. Interview with the Dining Supervisor (DS) on 2/15/11 at 8:08 a.m., revealed the Server in the Pantry kitchen did not handle the glasses and flatware in the correct manner. She also revealed that flatware should be dried and shined before storing it in the drawer for resident use. During the initial tour of the main kitchen with the DS and Registered Dietician (RD) at 8:08 a.m. on 2/15/11, the following concerns were identified: 1. The hand washing sink was splattered with a white substance on all sides. The bottom of the sink contained multiple pieces of colorful food debris. The DS confirmed the sink was dirty. 2. The black rubber gaskets around the inside door of refrigerator #1 contained numerous food particles, and multiple white spots scattered on the inside and outside door. 3. Food debris, brown spots, and several small areas of frozen white liquid, was observed on the freezer floor. 4. Two (2) - 2.5 gallon containers of ice cream did not have lids on them. 5. The racks, sides and bottom of Oven #1 was heavily soiled with black, charred, baked in foods. The Sous Chef confirmed on 2/15/11 at approximately 10:30 a.m., the oven had not been cleaned according to the cleaning schedule. Interview with the DS and the RD conducted at 10:30 a.m. on 2/15/11, revealed the identified issues were a problem and the facility's policy was not followed.