Every finding on record at The Glebe

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure a bariatric (a specialized medical support surface engineered for patients with a high body mass index) mattress was compatible with a bed frame for (1) one of (15) fifteen sampled residents, Resident #24. Resident #24's bariatric mattress measured 46 (forty-six) inches and was placed on a bed frame that extended to 42 (forty-two) inches, resulting in an overlay. While being provided with incontinence care on 03/13/2026, Resident #24 fell out of bed landing face down between the bed and the wall. Resident #24 sustained a hematoma to the forehead and a laceration to the bridge of the nose, resulting in transfer to a higher level of care, thus constituting harm. Findings included:A facility policy titled, Bed Safety and Side Rail Utilization with an effective date of 11/2025, specified communities will conduct regular inspections of all bed frames and mattresses as part of a regular bed safety program to identify safety hazards. Under the heading, Procedures Item #1 Evaluate Equipment read in part, a. Bed safety inspections will be conducted when a bed is brought into the community (new or used), and/or when a bed accessory is changed. c. i. Prior to using any model of bed in the community, the bed is evaluated by a designated team member to ensure compatibility of the bed and mattress intended to use with the bed. An admission Record disclosed Resident #24 was admitted to the facility on [DATE]. According to the admission Record the resident's diagnosis list indicated diagnoses, which included, but not limited to, morbid obesity, unilateral osteoarthritis right hip, adult failure to thrive, Alzheimer's, vascular dementia, and dementia with agitation. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 03/24/2026 was coded in Section C (Cognitive Patterns) to reflect the resident had short and long-term memory problems and was severely impaired in cognitive skills for daily decision making. A review of Resident #24's clinical record disclosed the following: A Health Status Note dated 03/13/2026 disclosed that during nursing care provided by a CNA (Certified Nursing Assistant), the resident fell from the bed while being repositioned for peri-care (the medical practice of washing and maintaining the hygiene of the genitals, anus, and the surrounding sensitive region known as the perineum.) The resident's bed was locked and equipped with an air mattress and was positioned against the wall. At the time of the incident, the resident landed face-down between the bed and the wall. The resident was observed to have nasal bleeding, a small bruise on the mid-forehead area, and was found crying out. The bleeding was controlled, and the family was immediately contacted as the resident was on comfort care. The family decided to transfer the resident to the hospital. The provider was notified and agreed with the transfer. EMS (Emergency Medical Services) was contacted, and the resident was transported. A review of a Post Fall Review assessment dated [DATE], disclosed the resident had a fall from the bed on 03/13/2026. Under Section C (Intervention Recommendations) Item #1 (Investigation/Findings/Conclusion) disclosed a Route Cause Analysis was performed on the resident's fall and indicated that the mattress was too big for the bed. Requested and received manufacturer bed specifications for Resident #24's bed at the time of the fall on 03/13/2026. The manufacturer specifications did not note bariatric mattress extension specifications. On 06/03/2026 at 2:02 PM, the Administrator (ADM) was interviewed and stated the facility received new bed frames in November 2025 and Resident #24's bariatric mattress was placed on a new bed frame with the bariatric extender. The ADM provided a Plan of Correction (POC) that was completed for the incident that occurred on 03/13/2026. A review of the POC for the resident's fall on 3/13/26 disclosed that on 11/24/2025, Resident #24 received a new bed that had a bariatric extender. The resident's bariatric air mattress was placed on the new bed frame in the extended bariatric position. Resident #24's mattress measured 46 inches wide. The bariatric extension on the bed expanded to 42 inches wide. The IDT (interdisciplinary team) identified the bariatric bed mattress did not properly fit the resident's bed frame. The new bed was not assessed for the mattress being too large. The POC file included a witness statement from Certified Nursing Assistant #1 (CNA#1) which read in part, .was completing my round on resident (Resident #24) .is a bariatric resident that has a bariatric air mattress on a standard nursing bed. This makes the air mattress have an overhang on the left side of approximately 3 - 5 inches of unsupported bed support.gathered my supplies to change the resident.I proceeded to turn the resident onto [their] side (left side) when I turned [resident] over [resident] continued to roll towards the wall and as I tried to reach for [the resident] [the resident] sunk into the crack in between the bed/wall and fell to the floor. The Plan of Correction (POC) had a completion date of 03/20/2026 and read as follows: 1. What was done immediately for problem identified:Resident was assessed for injuries, EMS (emergency medical services) activated, medical provider notified, resident family notified of incident and requested imminent transport to hospital (as resident was on comfort care), medical provider gave order to send resident to hospital. Maintenance immediately brought resident a bariatric bed frame and put it in place on 03/13/2026. 2. How were other residents that had potential to be affected by the problem identified:All residents on bariatric mattresses were at risk. An audit of all mattresses was completed by Administrator/Nursing Supervisor on 03/13/2026. All mattresses were determined to be the correct size for the bed frames. 3. Education - what was done to prevent reoccurrence:As the facility beds do not extend past 42 inches, the facility will provide bariatric bed frames to any resident admitting that needs one. Nursing staff will be educated by the DON/Designee on or before 03/20/2026 to alert DON/Nursing supervisor if a mattress is too large for a bed frame immediately. 4. How is this going to be monitored ongoing:The DON/Designee will complete an audit 1 time a week for 6 weeks to ensure all bed frames are large enough to fit mattresses. Any instances of noncompliance will be corrected immediately. Trends of noncompliance will be reviewed at the facilities QAPI (Quality Assurance Performance Improvement) committee meeting. 5. Completion DateCompliance will be attained on or before 03/20/2026. Credible Evidence Review: A review of the credible evidence for the POC on 06/04/2026 disclosed education had been completed addressing the facility nursing staff's responsibility to ensure that the mattresses are the correct size for the bed frames. The education specified that if something is noticed that does not appear to be correct with a resident's bed, a member of the leadership team is to be notified so the safety of the resident's bed can be addressed. A list of new hire education since the incident on 03/13/2026 verified new nursing staff also receive the above education. Further review of the credible evidence for the POC on 06/04/2026 disclosed that all the facility beds had been evaluated for correct mattress sizing/bed frames on 03/20/2026 and a Bed Safety Checklist had been revised/developed to include examination of mattress and bedframe compatibility of resident beds. A review of the weekly audits disclosed the audits had been completed as indicated in the POC on 03/16/2026, 03/20/2026, 03/30/2026, 04/06/2026, 04/13/2026, and 04/20/2026. On 06/02/2026, an initial walk-through/observation of the facility was conducted. No standard and/or bariatric beds were observed to have incorrect bed frames and/or mattresses. On 06/03/2026 at 8:42 AM, Resident #24's bed was observed and the bariatric mattress was noted to fit the bed frame correctly. On 6/3/26 at 3:24 PM, Certified Nursing Assistant #1 (CNA#1) was interviewed via phone conversation and stated she continues to work with Resident #24 and believes the resident's bed to be safe to transfer and reposition the resident. CNA#1 stated after the incident on 03/13/2026, the nursing staff received education to inform the charge nurse or upper management if there are any issues with the residents' beds. On 06/04/2026, CNA #2, CNA #3, CNA #4, and CNA #5 were interviewed, and they all concurred they were provided education on proper bed size/mattresses and/or concerns with resident bed safety. Each of the CNAs voiced the proper notification procedures when concerns were identified, reporting to charge nurse and if unavailable, they are to report to the DON or administration. On 06/04/2026, Licensed Practical Nurse #3 (LPN #3) and Licensed Practical Nurse #4 (LPN #4) were interviewed, and both LPNs concurred they had received education regarding bed/mattress safety. Both LPNs also agreed that they would report any concerns about bed/mattress safety to the Director of Nursing and/or Unit Manager and ensure the mattress/bed was switched. On 6/4/26 at 12:20 PM, the Administrator (ADM) was interviewed and stated after the incident on 03/13/2026, they revised the bed safety checklist, and it now includes ensuring the mattresses fit the beds. The ADM stated staff received education on alerting management staff about any mattresses and beds that do not fit or have any other types of issues. This concern was discussed on 06/04/2026 at 1:30 PM, at the pre-exit meeting with the Administrator, Director of Nursing, Unit Supervisor, Executive Director, and Associate Executive Director. No further information was provided prior to exit on 06/04/2026.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure the resident environment remained free of accident hazards as is possible for (1) one of (15) fifteen current sampled residents, Resident #24. Resident #24's bariatric mattress measured 46 (forty-six) inches and was placed on a bed frame that extended to only 42 (forty-two) inches, resulting in an overlay. While being provided with incontinence care on 03/13/2026, Resident #24 fell out of bed landing face down between the bed and the wall. Resident #24 sustained a hematoma to the forehead and a laceration to the bridge of the nose, resulting in transfer to a higher level of care, thus constituting harm. Findings included: An admission Record disclosed Resident #24 was admitted to the facility on [DATE]. According to the admission Record the resident's diagnosis list indicated diagnoses, which included, but not limited to, morbid obesity, unilateral osteoarthritis right hip, adult failure to thrive, Alzheimer's, vascular dementia, and dementia with agitation. The most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/24/2026 was coded in Section C (Cognitive Patterns) to reflect the resident had short and long-term memory problems and was severely impaired in cognitive skills for daily decision making. A review of Resident #24's clinical record disclosed the following documentation: A Health Status Note dated 03/13/2026 disclosed that during nursing care provided by a CNA (Certified Nursing Assistant), the resident fell from the bed while being repositioned for peri-care (the medical practice of washing and maintaining the hygiene of the genitals, anus, and the surrounding sensitive region known as the perineum.) The resident's bed was locked and equipped with an air mattress and was positioned against the wall. At the time of the incident, the resident landed face-down between the bed and the wall. The resident was observed to have nasal bleeding, a small bruise on the mid-forehead area, and was found crying out. The bleeding was controlled, and the family was immediately contacted as the resident was on comfort care. The family decided to transfer the resident to the hospital. The provider was notified and agreed with the transfer. EMS (Emergency Medical Services) was contacted, and the resident was transported. A Post Fall Data progress note dated 3/13/2026 disclosed Resident #24 arrived back at the facility at around 12:30 AM. The resident had scattered bruising noted to left and right hands and to face r/t (related to) fall. Resident had a blood scab above lip and blood in nose and mouth r/t fall. Bed had been moved away from wall; side rails added to bed to promote safety when in bed and care was being provided and team had been educated on 2 (two) person care when turning resident in the bed. A Post Fall Review dated 03/16/2026, under Section C (Intervention Recommendations) Item #1 (Investigation/Findings/Conclusion) disclosed a Route Cause Analysis was performed on the resident's fall and indicated that the mattress was too big for the bed. The bed frame was replaced with a bariatric bed frame and the bed was moved away from the wall to promote resident safety. A review of Resident #24's comprehensive person-centered care plan identified a focus that the resident was at risk for falls related to Alzheimer's disease. An intervention associated with this focus included to review information on past falls and attempt to determine the cause of falls, record possible root causes, alter/remove any potential causes if possible, and educate resident/family/caregivers/IDT (interdisciplinary team) as to causes. On 06/03/2026 at 2:02 PM, the Administrator (ADM) was interviewed and stated the facility received new bed frames in November 2025 and Resident #24 was in a bariatric bed and the mattress was too big for the new bed frame. The ADM stated the new bed frames extended out 42 (forty-two) inches and the resident's bariatric mattress was 46 (forty-six) inches. The ADM stated a Plan of Correction (POC) was completed and a copy of the POC was provided. The POC file included a witness statement from Certified Nursing Assistant #1 (CNA#1) which read in part, .was completing my round on resident (Resident #24).is a bariatric resident that has a bariatric air mattress on a standard nursing bed. This makes the air mattress have an overhang on the left side of approximately 3 - 5 inches of unsupported bed support.gathered my supplies to change the resident.I proceeded to turn the resident onto [their] side (left side) when I turned [resident] over [resident] continued to roll towards the wall and as I tried to reach for [the resident] [the resident] sunk into the crack in between the bed/wall and fell to the floor.I immediately screamed for help for the charge nurse for assistance. He (charge nurse) came in, unlocked the bed to give care for the resident and noticed blood coming from [Resident #24's] nose when we turned [resident] on [their] side. He (charge nurse) called 911. I stayed with the resident, cleaned [resident's] face and nose. Comforted [resident].talked with [resident] continuously to re-assure [resident] that everything was going to be ok. On 6/3/26 at 3:24 PM, CNA #1 was interviewed via phone conversation and stated she was providing peri-care to Resident #24 on 03/13/2026 and she rolled the resident over. She recalled the resident's mattress was bigger than the bed frame and there was an over-hang on the left side of the bed towards the wall. Requested and received bed manufacturer specifications for Resident #24's bed at the time of the fall on 03/13/2026. The manufacturer specifications did not note bariatric mattress extension specifications.A review of a hospital ED (Emergency Department) provider note dated 03/13/2026 disclosed there might be a tiny non-displaced (still aligned well) fracture of the nose bone. Resident #24 was noted to have a hematoma to the forehead, small laceration to the bridge of the nose, and dried blood in bilateral nares (the nostrils on both sides of the nose). A Health Status progress note date 03/15/2026 16:12 (4:12 PM) disclosed a medical provider ordered an x-ray of the resident's nose for follow-up from the emergency department x-ray. A review of Radiology results for 03/17/2026 specified the nasal x-ray results were reviewed by a medical provider and there was no acute nasal fracture or dislocation and the nasal septum was intact and midline. This concern was discussed on 06/03/2026 at 4:03 PM at the end of day meeting with the Administrator and Director of Nursing. The Plan of Correction (POC) had a completion date of 03/20/2026 and read as follows: 1. What was done immediately for problem identified:Resident was assessed for injuries, EMS (emergency medical services) activated, medical provider notified, resident family notified of incident and requested imminent transport to hospital (as resident was on comfort care), medical provider gave order to send resident to hospital. Maintenance immediately brought resident a bariatric bed frame and put it in place on 03/13/2026. 2. How were other residents that had potential to be affected by the problem identified:All residents on bariatric mattresses were at risk. An audit of all mattresses was completed by Administrator/Nursing Supervisor on 03/13/2026. All mattresses were determined to be the correct size for the bed frames. 3. Education - what was done to prevent reoccurrence:As the facility beds do not extend past 42 inches, the facility will provide bariatric bed frames to any resident admitting that needs one. Nursing staff will be educated by the DON/Designee on or before 03/20/2026 to alert DON/Nursing supervisor if a mattress is too large for a bed frame immediately. 4. How is this going to be monitored ongoing:The DON/Designee will complete an audit 1 time a week for 6 weeks to ensure all bed frames are large enough to fit mattresses. Any instances of noncompliance will be corrected immediately. Trends of noncompliance will be reviewed at the facilities QAPI (Quality Assurance Performance Improvement) committee meeting. 5. Completion DateCompliance will be attained on or before 03/20/2026. Credible Evidence Review: A review of the credible evidence for the POC on 06/04/2026 disclosed education had been completed addressing the facility nursing staff's responsibility to ensure that the mattresses are the correct size for the bed frames. The education specified that if something is noticed that does not appear to be correct with a resident's bed, a member of the leadership team is to be notified so the safety of the resident's bed can be addressed. A list of new hire education since the incident on 03/13/2026 verified new nursing staff also receive the above education. Further review of the credible evidence for the POC on 06/04/2026 disclosed that all the facility beds had been evaluated for correct mattress sizing/bed frames on 03/20/2026 and a Bed Safety Checklist had been revised/developed to include examination of mattress and bedframe compatibility of resident beds. A review of the weekly audits disclosed the audits had been completed as indicated in the POC on 03/16/2026, 03/20/2026, 03/30/2026, 04/06/2026, 04/13/2026, and 04/20/2026. On 06/02/2026, an initial walk-through/observation of the facility was conducted. No standard and/or bariatric beds were observed to have incorrect bed frames and/or mattresses. On 06/03/2026 at 8:42 AM, Resident #24's bed was observed and the bariatric mattress was noted to fit the bed frame correctly. On 6/3/26 at 3:24 PM, Certified Nursing Assistant #1 (CNA#1) was interviewed via phone conversation and stated she continues to work with Resident #24 and believes the resident's bed to be safe to transfer and reposition the resident. CNA#1 stated after the incident on 03/13/2026, the resident is now a two-person assist and the nursing staff received education to inform the charge nurse or upper management if there are any issues with the residents' beds. On 06/04/2026, CNA #2, CNA #3, CNA #4, and CNA #5 were interviewed, and they all concurred they were provided education on proper bed size/mattresses and/or concerns with resident bed safety. Each of the CNAs voiced the proper notification procedures when concerns were identified, reporting to charge nurse and if unavailable, they are to report to the DON or administration. On 06/04/2026, Licensed Practical Nurse #3 (LPN #3) and Licensed Practical Nurse #4 (LPN #4) were interviewed, and both LPNs concurred they had received education regarding bed/mattress safety. Both LPNs also agreed that they would report any concerns about bed/mattress safety to the Director of Nursing and/or Unit Manager and ensure the mattress/bed was switched. On 6/4/26 at 12:20 PM, the Administrator (ADM) was interviewed and stated after the incident on 03/13/2026, they revised the bed safety checklist and it now includes ensuring the mattresses fit the beds. The ADM stated staff received education on alerting management staff about any mattresses and beds that do not fit or have any other types of issues. No further information was provided prior to exit on 06/04/2026. This is a past non-compliance deficiency.

Based on observation, staff interview, and clinical record review, the facility staff failed to attempt to use appropriate alternatives prior to installing side rail(s) for (2) two of (15) fifteen sampled residents, Resident #5 and Resident #24. Findings included: 1. For Resident #5, the facility staff failed to provide evidence that appropriate alternatives were attempted prior to the installation of bilateral side rails. Resident #5's diagnosis list indicated diagnoses, which included, but not limited to, right leg below knee amputation, osteoporosis, right artificial shoulder joint, muscle weakness, and adult failure to thrive. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 03/07/2026 assigned the resident a brief interview for mental status (BIMS) summary score of 6 out of 15 for cognitive abilities, indicating the resident was severely impaired in cognition. On 06/03/2026 at 11:36 AM, Resident #5 was observed in their room. An observation of the resident's bed revealed bilateral side rails were present on the resident's bed and in the upright position. A review of the clinical record disclosed the following information: A review of a Side Rail Consent dated 08/24/2024 disclosed the use of alternative devices and/or approaches had been considered by the interdisciplinary team. The Side Rail Consent did not provide any evidence of what alternative devices and/or approaches were considered/attempted. A medical provider orders with a start date of 08/05/2025 disclosed the resident may use bilateral side rails to assist with bed mobility and functional positioning. A review of a Bed Rail Assessment dated 03/05/2026 did not disclose any evidence that appropriate alternatives were attempted prior to the installation of side rails. A review of Resident #5's comprehensive person-centered care plan disclosed the resident had an ADL (activities of daily living) self-care performance deficit and an intervention associated with the focus read in part, .Side Rails.rails up as per Dr.s (Doctor's) order. Requested evidence appropriate alternatives were attempted prior to the installation of side rails on Resident #5's bed. On 06/03/2026 at 1:59 PM, the Director of Nursing (DON) stated that no evidence could be located that appropriate alternatives were attempted prior to the installation of the side rails. This concern was discussed on 06/03/2026 at 4:03 PM at the end of day meeting with the Administrator and DON. No further information was provided prior to exit on 06/04/2026. 2. For Resident #24 the facility staff failed to provide evidence that appropriate alternatives were attempted prior to the installation of bilateral side rails.Resident #24's diagnosis list indicated diagnoses, which included, but not limited to, morbid obesity, unilateral osteoarthritis right hip, adult failure to thrive, Alzheimer's, vascular dementia, and dementia with agitation. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 03/24/2026 was coded in Section C (Cognitive Patterns) to reflect the resident had short and long-term memory problems and was severely impaired in cognitive skills for daily decision making. On 06/03/2026 at 8:42 AM, Resident#24 was observed and bilateral side rails were observed on the resident's bed and noted to be in the upright position. A review of the clinical record disclosed the following information: A review of a Side Rail Consent dated 03/13/2026 disclosed the use of alternative devices and/or approaches had been considered by the interdisciplinary team. The Side Rail Consent did not provide any evidence of what alternative devices and/or approaches were considered/attempted. A medical provider orders with a start date of 03/13/2026 disclosed an order which specified bilateral positioning rails to promote safety while resident is receiving care in bed. A review of a Bed Rail Assessment dated 03/22/2026 did not disclose any evidence that appropriate alternatives were attempted prior to the installation of side rails. A review of Resident #24's comprehensive person-centered care plan disclosed the resident had an ADL (activities of daily living) self-care performance deficit and an intervention associated with the focus read in part, .Side Rails.rails up as per MD (Medical Doctor) order. Requested evidence appropriate alternatives were attempted prior to the installation of side rails on Resident #24's bed. On 06/03/2026 at 2:02 PM, the Director of Nursing (DON) stated that no evidence could be located that appropriate alternatives were attempted prior to the installation of the side rails. This concern was discussed on 06/04/2026 at 1:30 PM, at the pre-exit meeting with the Administrator, Director of Nursing, Unit Supervisor, Executive Director, and Associate Executive Director. No further information was provided prior to exit on 06/04/2026.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to accurately document the correct size of side rails utilized on a resident's bed on a medical provider order and on the comprehensive person-centered care plan for (1) one of (15) fifteen sampled residents, Resident #5. Findings included:Resident #5's diagnosis list indicated diagnoses, which included, but not limited to, right leg below knee amputation, osteoporosis, right artificial shoulder joint, muscle weakness, and adult failure to thrive. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 03/07/2026 assigned the resident a brief interview for mental status (BIMS) summary score of 6 out of 15 for cognitive abilities, indicating the resident was severely impaired in cognition. On 06/03/2026 at 11:36 AM, Resident #5 was observed in their room. An observation of the resident's bed revealed one-fourth (1/4) bilateral side rails were present on the resident's bed. Requested and received manufacturer's specifications for Resident #5's bed. The #703 bed model confirmed 1/4 side rails were utilized on the resident's bed. A medical provider orders with a start date of 08/05/2025 disclosed the resident may use bilateral 1/2 (one-half) side rails to assist with bed mobility and functional positioning. A review of Resident #5's comprehensive person-centered care plan disclosed the resident had an ADL (activities of daily living) self-care performance deficit and an intervention associated with the focus read in part, .Side Rails: Half rails up as per Dr.s (Doctor's) order. On 06/03/2026 at 1:59 PM, the Director of Nursing (DON) was interviewed and stated Resident #5 originally had a bed from Hospice that had 1/2 side rails and when the facility completed renovations the resident's bed was replaced with this new bed that has 1/4 rails. The DON agreed that the medical provider order and care plan were overlooked for revision after the bed was replaced and stated that the medical provider was going to provide a new order and the care plan would be revised. This concern was discussed on 06/03/2026 at 4:03 PM at the end of day meeting with the Administrator and DON. No further information was provided prior to exit on 06/04/2026.

Based on interviews and the review of documents, it was determined the facility staff failed to ensure the Infection Preventionist (IP) had completed specialized training in infection control and prevention. The findings include: The facility's Infection Preventionist (IP) had not completed specialized training in infection control and prevention. The facility's job description for the IP included the following statement: Certification in infection control preferred; if not certified, will be required to complete Infection Prevention Specialized Training (IPCO) through AHCA within 6 months of hire. The facility's IP had signed this job description on 7/31/19; the facility's director of nursing (DON) confirmed the date the IP had signed this job description was 7/31/19. The IP was interviewed on 1/21/21 at 12:55 p.m. The IP reported they had not completed the infection control and prevention training. The IP reported they had been working on the training but had been unable to complete it due to the COVID-19 pandemic occurring. The IP reported they were working under the supervision of the facility's DON. Review of the facility's IP's CDC Nursing Home Infection Preventionist Training Course documentation indicated the IP had not completed the entire course. The IP had completed three (3) of the fifteen training modules; the IP had started a fourth module. During an interview on 1/22/21 at 10:24 a.m., the facility's DON stated the IP is currently allowed to take the Centers for Disease Control and Prevention (CDC) Nursing Home Infection Preventionist Training Course instead of the training identified in the above job description. The failure the facility's IP to complete specialized training in infection control and prevention discussed for a final time with the facility's DON. The DON (who was supervising the IP) reported they also had not completed the specialized training in infection control and prevention.

Based on observations, interviews, and the review of documents, it was determined the facility staff failed to properly implement COVID-19 prevention and/or control measures. The findings include: Observations of the facility on 1/20/21 revealed one (1) staff member using a N95 mask with an exhalation valve. On 1/20/21 at 2:55 p.m., a facility registered nurse (RN #1) was observed to be wearing a N95 mask with an exhalation valve; no additional covering was in place over the exhalation valve. RN #1 reported they had been successfully fit-tested for the N95 mask in question. The facility's director of nursing (DON) reported that two (2) staff members of the long term care facility and one (1) dietary staff member involved with preparing food and/or trays for the long term care facility's residents had been fit-tested to use the N95 mask with the exhalation valve. The DON stated it was not an expectation that an employee using the N95 mask in question would wear a second mask/covering to cover the exhalation valve. The following information was found in a facility policy titled COVID-19 Prevention, Control and Management Summary (revised 4/22/2020): Per the CMS April 2, 2020 guidance, all long-term care facility personnel should wear a facemask while they are in the facility. All staff will wear a mask when they are in the community. This did not address facemasks with exhalation valves. The following information was found in a facility policy titled COVID-19 Facemask Use - Medical and Non-Medical (with an effective date of 4/7/2020): .a face mask is a device covering the mouth and nose to prevent inhalation of dangerous substances or to prevent the dispersal of exhaled infectious material. The following information was found in a CDC (Centers for Disease Control and Prevention) document entitled Considerations for Wearing Masks - Help Slow the Spread of COVID-19 (updated December 18, 2020): CDC does not recommend using masks with exhalation valves or vents because this type of mask my not prevent you from spreading COVID-19 to others. The hole in the material may allow your respiratory droplets to escape and reach others (downloaded on January 22, 2021). The following information was found in a CDC document entitled Personal Protective Equipment: Questions and Answers (updated August 8, 2020): Wear a respirator without an exhalation valve when both source control and respiratory protection are required (downloaded on January 22, 2021). The use of N95 masks with exhalation valves was discussed for a final time with the facility's DON on 1/22/21 at 10:24 a.m.

Based on observations, interviews, and the review of documents, it was determined the facility staff failed to ensure an employee providing services for the long term care (LTC) facility was tested for COVID-19 at the required frequency; this finding was identified in one (1) of three (3) employees selected for COVID-19 testing reviewed (Staff Member (SM) #2). The findings include: An employee (Staff Member (SM) #2) providing services for the long term care (LTC) facility had not been tested for COVID-19 at the required frequency. On the afternoon of 1/20/21, SM #2 screened the surveyor for COVID-19 symptoms prior to the surveyor being allowed to enter the area of the building that housed the LTC facility's residents. SM #2 reported they would be screening non-employee individuals who were entering the area that housed the LTC facility's residents. (This LTC facility is part of a larger complex that includes independent living residents, assisted living facility residents, and LTC facility residents.) SM #2 was screening visitors to both the LTC facility and the assisted living facility. On 1/21/21 at 10:07 a.m., the surveyor asked the facility's director of nursing (DON) for SM #2's recent COVID-19 test results. The DON reported that SM #2 had only been tested on ce during the past two (2) weeks. The DON stated that SM #2 is not an employee of the LTC facility therefore SM #2 had not been test at the frequency required by employees of the LTC facility. The DON reported SM #2 was screening visitors for both the LTC facility and the assisted living facility. The DON reported visitation was limited for the LTC facility. The DON provided examples of individuals who would be screened, prior to being allowed entry to the LTC facility, at the desk where SM #2 had been working; these examples included hospice nurses and mobile radiology staff. The surveyor was provided COVID-19 test results for SM #2 dated 1/8/2021 and 1/21/2021; both test results were negative. The DON reported the LTC facility had been completing outbreak COVID-19 testing since 11/12/2020. The DON reported SM #2 had no COVID-19 test results prior to 1/8/2021. The following information was found in a facility policy and procedure titled COVID-19 Testing - Routine, Symptomatic, and Outbreak (with a revised date of 9/23/2020): For outbreak testing . Test all team members and residents who previously tested negative until no new cases are identified (retest every 3 to 7 days until testing identifies no new cases among team members or residents for at least 14 days since the most recent positive result). During an interview on 1/22/21 at 10:24 a.m., the failure of the facility staff to ensure SM #2 was tested for COVID-19 at the required frequency was discussed with the facility's DON. The DON stated that SM #2 was not tested for COVID-19 more often because SM #2 was not considered an employee of LTC facility. During earlier communication with the DON, the DON reported SM #2 worked under Resident Services not as part of the Healthcare Team. This LTC facility was part of a large campus that included independent living residents, assisted living residents, and LTC residents. SM #2 was selected for review by the surveyor due to SM #2 completing COVID-19 screening of the surveyor prior to the survey being provided access to the LTC facility being surveyed.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to ensure 6 of 15 residents were free of unnecessary [MEDICAL CONDITION] medications that affected Resident #3, Resident #19, Resident #20, Resident #22, Resident #23, and Resident #31. The findings included: 1. The facility staff failed to monitor behaviors associated with the use of [MEDICATION NAME] for Resident #3. The clinical record of Resident #3 was reviewed 3/27/19 through 3/29/19. Resident #3 was admitted to the facility 3/6/17 with [DIAGNOSES REDACTED]. Resident #3's quarterly MDS (minimum data set) assessment with an assessment reference date (ARD) of 12/27/18 assessed the resident with a BIMS (brief interview for mental status) as 3/15. Resident #3 was not assessed with [REDACTED]. Resident #3's (MONTH) 2019 physician's orders [REDACTED]. The current comprehensive care plan dated 4/8/18 identified [MEDICAL CONDITION] Drugs as a concern. The care plan read in part Resident #3 is on [MEDICAL CONDITION] medication related to anxiety and depression. (G) Resident #3 will be free of depressive behaviors and adverse effects of med through the review date. (A) Monitor and document all behaviors related to depression such as episodes of tearfulness, withdrawal from friends/family. (A) Monitor and document side effects of antidepressant such as lethargy, irritability, excitability, constipation, dry mouth. Monitor for least effective dose. The surveyor was unable to locate any evidence of monitoring of the targeted behaviors associated with the use of [MEDICATION NAME]. The surveyor informed the director of nursing (DON) of the above concern on 3/29/19 at 9:33 a.m. and requested the monitoring sheets for [MEDICATION NAME]. The DON stated, We don't monitor antidepressants, hypnotics or antianxiety medications-only antipsychotics. The surveyor requested the facility policy on [MEDICAL CONDITION] medications on 3/29/19. The facility policy titled [MEDICAL CONDITION] Drugs read in part: Individuals who are prescribed [MEDICAL CONDITION] drugs shall be regularly and systematically assessed and evaluated for tardive dyskinesia. The policy did not contain any other information about [MEDICAL CONDITION] medications other than tardive dyskinesia. The surveyor informed the administrator, the director of nursing, the infection preventionist, and the executive director of the above concern in the end of the survey meeting on 3/29/19 at 11:41 a.m. No further information was provided prior to the exit conference on 3/29/19. 2. The facility staff failed to monitor resident specific targeted behaviors, offer/implement non-pharmacological interventions prior to the use of [MEDICATION NAME], and monitor for side effectsassociated with the use of the hypnotic [MEDICATION NAME] for Resident # 19. The clinical record of Resident #19 was reviewed 3/27/19 through 3/29/19. Resident #19 was admitted to the facility 3/6/19 with [DIAGNOSES REDACTED]. Resident #19's fourteen (14) day MDS (minimum data set) assessment with an assessment reference date (ARD) of 3/20/19 assessed the resident with a BIMS (brief interview for mental status) summary score as 15/15. There were no assessed signs or symptoms of [MEDICAL CONDITIONS], or behaviors affecting others. The current comprehensive care plan dated 3/19/19 identified an area that read: [MEDICAL CONDITION] Drugs-Resident requires us of [MEDICAL CONDITION] Medication to manage [MEDICAL CONDITION]-see [MEDICAL CONDITION] CP (care plan). Alteration in sleep pattern related to [MEDICAL CONDITION]. The care plan identified attempts to manage environment as able-minimize noise and light, allow soft music, use scent cammomille (sic), [MEDICATION NAME] for relaxation, soft soothing music. Manage comfort level-warm milk, position with pillows, back rub, pain control. Administer hypnotic, antianxiety or antidepressant as ordered-see POS (physicians order sheet) for med (medication), dose, and schedule. Assess effectiveness of med on sleep patterns. Resident #19's (MONTH) 2019 physician's orders [REDACTED]. A second order dated 3/18/19 read [MEDICATION NAME] 15 mg capsule give 1 capsule (15 mg) by oral route once daily at bedtime for [MEDICAL CONDITION]. A review of the (MONTH) 2019 Medication Administration Record [REDACTED]. The surveyor found no non-pharmacological interventions prior to the use of the medication documented on the reverse side of the (MONTH) 2019 MAR. A review of the interdisciplinary notes indicated there were no non-pharmacological interventions prior to the use of the medication. 3/7/19 2:49:21 interdisciplinary note read [MEDICATION NAME] given for [MEDICAL CONDITION] at 2330 (11:30 p.m.). No non-pharmacological interventions offered or documented prior to use on the (MONTH) MAR indicated [REDACTED] 3/8/19 (MONTH) MAR indicated [REDACTED]. No non-pharmacological interventions offered or documented prior to use on the (MONTH) MAR indicated [REDACTED] 3/9/19 21:30:46 (9:30:46 p.m.) interdisciplinary note read Medicated for pain and [MEDICAL CONDITION]. No non-pharmacological interventions offered or documented prior to use on the (MONTH) MAR indicated [REDACTED] 3/10/19 (MONTH) MAR indicated [REDACTED]. Rsd request for sleep. No non-pharmacological interventions offered or documented prior to use on the (MONTH) MAR indicated [REDACTED] 3/11/19 (MONTH) MAR indicated [REDACTED]. Rsd request for sleep. No non-pharmacological interventions offered or documented prior to use on the (MONTH) MAR indicated [REDACTED] 3/12/19 (MONTH) MAR indicated [REDACTED]. Requested for sleep. No non-pharmacological interventions offered or documented prior to use on the (MONTH) MAR indicated [REDACTED] 3/13/19 01:43:11 note read in part Rsd (resident) requested pain medication and sleep medication @ (at) 9pm d/t (due to) facial pain and chronic [MEDICAL CONDITION]. Rsd (resident) given prn [MEDICATION NAME] 15 mg to help with noted pain to face and [MEDICAL CONDITION]. No non-pharmacological interventions offered or documented prior to use. 3/13/19 22:43:30 (10:22:30 p.m.) read in part PRN pain medication and PRN [MEDICAL CONDITION] medication requested by resident; both administered at HS (bedtime). No non-pharmacological interventions offered or documented prior to use. 3/15/19 (MONTH) MAR indicated [REDACTED]. Rsd request-sleep. No non-pharmacological interventions offered or documented prior to use. 3/16/19 (MONTH) MAR indicated [REDACTED]. [MEDICAL CONDITION] qhs. No non-pharmacological interventions offered or documented prior to use. 3/17/19 02:24:10 a.m. interdisciplinary note read in part Rsd requested PRN [MEDICATION NAME] 5/325 mg + [MEDICATION NAME] 15 mg @ 9pm (QHS-every bedtime) for facial pain and [MEDICAL CONDITION]. Rsd requests these each evening QHS. Noted in MD (medical doctor) communication book about considering scheduling medications at bedtime d/t (due to) use. No non-pharmacological interventions offered or documented prior to use. The medication was ordered for nightly administration on 3/18/19 and the staff monitored the medication [MEDICATION NAME] nightly from 3/18/19 through 3/25/19 to include targeted behaviors. The monitoring of the hypnotic was done for 1 week and then stopped. The director of nursing was notified of the above concern on 3/29/19 at 10:47 a.m. The DON stated the staff monitor for 7 days and then stop. The DON stated the staff do not monitor antidepressants, antianxiety medications or hypnotics. The DON stated the staff do monitor antipsychotic medications. The surveyor informed the administrator, the director or nursing, the infection preventionist and the executive director of the above concern on 3/29/19 at 11:41 a.m. No further information was provided prior to the exit conference on 3/29/19. 3. The facility staff failed to monitor targeted behaviors while Resident #20 was receiving [MEDICATION NAME] and [MEDICATION NAME]. Resident #20 was admitted to the facility on [DATE] with the following diagnoses, but not limited [MEDICAL CONDITION], heart failure, high blood pressure, [MEDICAL CONDITION] disorder, anxiety and depression. On the admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/13/19, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15. Resident #20 was also coded as requiring extensive assistance of 1 staff member for dressing and limited assist of 1 staff member for personal hygiene. The resident was coded as being totally dependent on 1 staff member for bathing. During the clinical record review, the surveyor noted physician's orders [REDACTED]. The [MEDICATION NAME] had a start date of 3/8/19 and the [MEDICATION NAME] had a start date of 3/1/19. The surveyor reviewed the clinical record and could not find any behavior monitoring for the targeted behaviors that the staff was to monitor while a resident was on [MEDICATION NAME] and [MEDICATION NAME]. On 3/29/19 at approximately 10 am, the surveyor notified the DON (Director of Nursing) that the surveyor could not find any behavior monitoring for the [MEDICATION NAME] and [MEDICATION NAME] that Resident #20 had been ordered and given. The DON stated, We monitor the behaviors for the first 7 days then it is stopped. We don't continue the monitoring after that. On 3/29/19 at 11:48, the surveyor notified the administrative team of the above documented findings. No further information was provided to the surveyor prior to the exit conference on 3/29/19. 4. The facility staff failed to monitor targeted behaviors while Resident #22 was receiving [MEDICATION NAME] and [MEDICATION NAME]. Resident #22 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the significant change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/27/19, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 6 out of a possible score of 15. Resident #22 was also coded as requiring extensive assistance of 1 staff member for dressing and personal hygiene and was totally dependent on 1 staff member for bathing. During the clinical record review on 3/29/19, the surveyor noted that the physician had ordered [MEDICATION NAME] 60 mg (milligram) by oral (mouth) route once daily for anxiety disorders and [MEDICATION NAME] 15 mg give 1 capsule by oral route daily at bedtime. These medications were originally ordered by the physician on 8/1/18 and was renewed by the physician on 3/7/19. The surveyor reviewed the clinical record for behavior monitoring of the targeted behaviors for these medications. On 3/29/19 at approximately 11 am, the surveyor notified the DON (director of nursing) of the above documented findings. The DON stated, We monitor the behaviors for the first 7 days then it is stopped. We don't continue the monitoring after that. The administrative team was notified of the above documented findings at 11:48 in the conference room. No further information was provided to the surveyor prior to the exit conference on 3/29/19. 5. The facility staff failed to monitor targeted behaviors while Resident #23 was receiving [MEDICATION NAME] and [MEDICATION NAME]. Resident #23 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/1/19, the resident was coded as having short term and long-term memory problems and was severely impaired daily decision making. Resident #23 was also coded as requiring extensive assistance with 1 staff member for dressing and personal hygiene. The resident was totally dependent on 1 staff member for bathing. During the clinical record review on 3/29/19, the surveyor noted the that the physician had ordered [MEDICATION NAME] 20 mg (milligram) 1 tablet by mouth daily for depressive episodes and [MEDICATION NAME] 0.5 mg 1 tablet by mouth daily for anxiety disorder. There were no monitoring of targeted behaviors while the resident was receiving these medications. The surveyor notified the DON (director of nursing) was notified of the above documented findings at approximately 11 am. The DON stated, We monitor the behaviors for the first 7 days then it is stopped. We don't continue the monitoring after that. The surveyor notified the administrative team of the above documented findings at 11:48 am in the conference room. No further information was provided to the surveyor prior to the exit conference on 3/29/19. 6. The facility staff failed to monitor targeted behaviors while Resident #31 was receiving [MEDICATION NAME] and [MEDICATION NAME]. Resident #31 admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/8/19, coded the resident as requiring extensive assistance of 1 staff member for dressing, personal hygiene and bathing. Resident #31 was also coded as having short term and long term memory problems with being severely impaired in making daily decisions. During the clinical record review on 4/4/19, the surveyor notes that the physician had ordered [MEDICATION NAME] 15 mg (milligram) 1 tablet by mouth daily before bedtime, [MEDICATION NAME] 125 mg by mouth daily in the mornings and [MEDICATION NAME] 2 mg by mouth daily for mood disorder. The surveyor reviewed the MAR (medication administration record) for (MONTH) and (MONTH) 2019 and noted the following: .Monitor for targeted behaviors and/or side effects utilizing the facility's Behavioral and Side Effect Monitoring flow sheet for psycho-tropic medication use . There were nurses' initial in the boxes on the MAR indicated [REDACTED]. There were no specific targeted behaviors for the nurse to monitor for Resident #31 while receiving the above documented medications. The surveyor notified the DON (director of nursing) of the above documented findings at 11:07. The DON stated, We monitor the behaviors for the first 7 days then it is stopped. We don't continue the monitoring after that. The surveyor notified the administrative team of the above documented findings at 11:48 am in the conference room. No further information was provided to the surveyor prior to the exit conference on 3/29/19.

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to assess for pain prior to wound care for 1 of 15 residents in the survey sample (Resident #29). The findings included: The facility staff failed to assess for pain prior to providing the wound care to Resident #29 on 3/28/19. Resident #29 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/19/19, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 13 out of a possible score of 15. Resident #29 was also coded as requiring limited assistance with dressing, personal hygiene and bathing. During the wound care observation made by the surveyor on 3/28/19 at 10 am, the nurse did not assess for pain prior to the performing wound care on Resident #29. The surveyor reviewed the MAR (medication administration record) for (MONTH) 2019 and noted the following: .Monitor Pain using Universal Pain Assessment Tool . This pain monitoring was signed off as being carried out for the shifts of 7:00am-3:00pm, 3:00pm - 11 pm and 11pm-7:00 am. However, this pain monitoring was not specific to the time that RN (registered nurse) #1 had assessed for pain prior to the wound care that was observed by the surveyor. At 10:46 am, the surveyor notified the Infection Preventionist of the above documented findings. On 5:00 pm, the surveyor notified the administrative team of the above documented findings. The surveyor asked if the expectation by this team was for the nurses to assess for pain prior to performing wound care. The Infection Preventionist stated, Yes, I would expect them to do this before performing any procedure. No further information was provided to the surveyor prior to the exit conference on 3/29/19.

Based on observation, staff interview facility document review, and clinical record review, the facility staff failed to follow infection control guidelines for wound care for 1 of 15 residents (Resident #29). The findings included: Resident #29 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/19/19, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 13 out of a possible score of 15. Resident #29 was also coded as requiring limited assistance with dressing, personal hygiene and bathing. During the wound care observation made by the surveyor on 3/28/19 at 10 am, the surveyor observed RN (registered nurse) #1perform a dressing change to the coccyx area of Resident #29. RN #1 placed a paper towel on the counter beside the sink. This surveyor did not observe RN #1 cleaning this area prior to putting paper towels down as a barrier. RN #1 washed her hands and applied clean gloves. The old dressing was removed from the area on the coccyx and a clean 4x4 that was folded by the RN was moistened with sterile water. RN #1 cleaned the wound by using a patting method up and down the wound from the top to the bottom. The nurse did not change gloves nor wash her hands prior to applying the clean dressing. RN #1 cut the clean [MEDICATION NAME] with scissors that she took out of her pocket. RN #1 continued to wear the gloves that she wore when removing the old dressing from the resident's wound. At 1:30 pm, the infection control nurse was notified of the above documented findings that the surveyor observed during the dressing change to Resident #29. The infection control nurse stated, She should had taken her gloves off after she removed the old dressing and washed her hands. The surveyor notified the administrative team of the above documented findings on 3/28/19 at 5 pm in the conference room. The surveyor requested copies of the facility's policies on infection control while performing a dressing change. On 3/29/19, the surveyor received a copy of the facility's policy titled Dressings, Dry/Clean which read in part: .Establish a clean field . Loosen tape and remove old dressing. Pull glove over dressing and discard into a plastic or biohazard bag. Wash and dry your hands thoroughly. Open dry, clean dressing(s) by pulling corners of the exterior wrapping outward, touching only the exterior surface . If using gauze, use clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area (usually, from the center outward) . No further information was provided to the surveyor prior to the exit conference on 3/29/19.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide the comprehensive care plan goals to the receiving provider for 2 of 15 residents (Resident #15 and Resident #23). The findings included: 1. The facility staff failed to provide the receiving provider the comprehensive care plan goals for Resident #15 when the resident was admitted to the hospital 3/5/19. The clinical record of Resident #15 was reviewed 3/27/19 through 3/29/19. Resident #15 was admitted to the facility 2/21/19 with [DIAGNOSES REDACTED]. Resident #15's 14 day MDS (minimum data set) assessment with an assessment reference date (ARD) of 3/21/19 assessed the resident with a BIMS (brief interview for mental status) summary score as 15/15. The interdisciplinary note dated 3/5/19 at 4:09:39 read, Left unit for cardiac procedure. The clinical record had no documentation of what information was sent with Resident #15 when the resident was admitted to the hospital 3/5/19. The surveyor interviewed the director of nursing on 3/28/19 at 4:02 p.m. The DON was asked what information was sent with residents when they are transferred to the hospital. The DON stated the facility provided the bed hold policy, transfer/discharge form, a copy of the medication list, notification to ombudsman, advanced directive, and face sheet. The DON was asked if the comprehensive care plan goals were sent with the resident to the receiving provider. The DON stated care plans were not sent. The surveyor informed the administrator, the director of nursing, the infection preventionist, and the executive director of the above concern on 3/28/19 at 5:00 p.m. and again on 3/29/19 at 11:41 a.m. No further information was provided prior to the exit conference on 3/29/19. 2. The facility staff failed to send the CCP (Comprehensive Care Plan) goals when Resident #23 had to be transferred to the emergency roiagnom on [DATE]. Resident #23 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/1/19, the resident was coded as having short term and long-term memory problems and was severely impaired daily decision making. Resident #23 was also coded as requiring extensive assistance with 1 staff member for dressing and personal hygiene. The resident was totally dependent on 1 staff member for bathing. During the clinical record review conducted on 3/28/19 for this resident, the surveyor noted the resident had sustained facial injuries that occurred with a fall on 2/1/19. The surveyor could not find documentation of the CCP goals being sent to the emergency roiagnom on [DATE]. At 4:02 pm, the surveyor asked the DON (director of nursing) what information is sent with a resident when they go to the emergency room . The DON stated, transfer/discharge form, copy of the med (medication) list. We also notify the RP (Responsible Party) of the bed hold policy and notify the Ombudsman if the resident is admitted to the hospital. The surveyor asked the DON if the CCP goals are sent with the resident when they are transferred to the emergency. The DON stated that she would get back with the surveyor on this. At 4:29 pm, the Don returned and stated, The care plan goals are not sent. On 3/29/19 at 11:48 am, the surveyor notified the administrative team of the above documented findings. No further information was provided to the surveyor prior to the exit conference on 3/29/19.

Based on staff interview and clinical record review, the facility staff failed to have scheduled medications available for administration to 2 of 15 residents (Resident #23 and Resident #28). The findings included: 1. The facility staff failed to have a scheduled medication, Donapezil, available for Resident #23. Resident #23 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/1/19, the resident was coded as having short term and long-term memory problems and was severely impaired daily decision making. Resident #23 was also coded as requiring extensive assistance with 1 staff member for dressing and personal hygiene. The resident was totally dependent on 1 staff member for bathing. During the clinical record review on 3/28/19, the surveyor noted on the (MONTH) 2019 MAR (medication administrative record) the following: . 2/16/19 9 pm .Donepezil 10 mg (milligram) tab (tablet) none available-awaiting from Rx (pharmacy) . The surveyor notified the DON (director of nursing) of the above documented findings on 3/28/19 at 5 pm in the conference room. The DON stated, I didn't realize this was not available. The surveyor notified the administrative team of the above documented findings on 3/29/19 at 11:48 am. No further information was provided to the surveyor prior to the exit conference on 3/29/19. 2. The facility failed to have a scheduled medication, [MEDICATION NAME], available for administration to Resident #28. Resident #28 was originally admitted to the facility on [DATE] but was redmitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/4/19, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 2 out of a possible score of 15. Resident #28 was also coded as requiring limited assistance for dressing, personal hygiene and bathing. During the clinical record review on 3/27/19, the surveyor noted the following on the (MONTH) 2019 MAR (Medication Administrative Record): .2/11/19 9 pm .[MEDICATION NAME] 0.5mg (milligram) 1 po (by mouth) unavailable to give qhs (every night at bedtime). Meds (medicine) is reordered. Pharmacy is aware . On 3/28/19 at 5 pm, the surveyor notified the administrative team of the above documented findings. The DON (director of nursing) stated, Since this medication was a controlled medicine, the pharmacy would not do an emergency run because we were out. In addition, we couldn't use the backup pharmacy because the doctor would have to give us a hard script and then call and arrange this with the backup pharmacy. The physician had ordered this medication to be administrated daily at 9 pm. The surveyor notified the administrative team of the above documented findings on 3/29/19 at 11:48 am. No further information was provided to the surveyor prior to the exit conference on 3/29/19.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to follow the physician orders [REDACTED].#1). The findings included: The facility staff failed to follow the physician orders [REDACTED].#1. The x-ray was obtained on the right hand-not the left hand as ordered. The clinical record of Resident #1 was reviewed 3/27/19 through 3/29/19. Resident #1 was admitted to the facility 9/19/18 with [DIAGNOSES REDACTED]. Resident #1's significant change in minimum data set (MDS) assessment with an assessment reference date (ARD) of 12/26/18 assessed the resident with a BIMS (brief interview for mental status) as 8/15. An order dated 11/5/18 read in part X-ray of L (left in a circle) hand pain/swelling 3rd digit. A review of the laboratory section/radiologic section revealed the results of a right hand x-ray completed 11/5/18. The surveyor was unable to locate the x-ray results for the left hand. The surveyor informed the director of nursing of the above concern on 3/28/19 at 3:57 p.m. The surveyor informed the administrator, the director of nursing, the infection preventionist, and the executive director of the above concern during the end of the day meeting on 3/28/19 at 5:00 p.m. and again 3/29/19 at 11:41 a.m. and in addition, requested the facility contract with the x-ray company. The contract with the x-ray company read in part 2.2.4 only perform tests as requested in writing by a physician on a test requisition form. The DON stated the x-ray technician did the x-ray on the wrong hand. No further information was provided prior to the exit conference on 3/29/19.

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to administer the correct amount of eye drops to 1 of 15 residents (Resident #21). The findings included: The facility staff failed to administer the correct amount of eye drops to Resident #21 during a medication pass and pour observation. Licensed practical nurse #1 administered two (2)-eye drops of [MEDICATION NAME] in Resident #21's right eye-not one drop as ordered. The surveyor observed a medication pass on 3/28/19 with licensed practical nurse #1 beginning at 7:51 a.m. [MI]P.N. #1 prepared medications for Resident #21 at the medication cart, entered the resident's room and administered the oral medications without any issues. [MI]P.N. #1 donned gloves. [MI]P.N. #1 attempted to administer [MEDICATION NAME] 0.2-0.5% eye drops one (1) drop in the left eye but missed the eye. [MI]P.N. #1 then administered one drop in the left eye. [MI]P.N. #1 then administered two (2) drops of [MEDICATION NAME] in the resident's right eye. [MI]P.N. #1 removed gloves and hands were washed. The surveyor reconciled the medications administered with the current (MONTH) 2019 physician's orders [REDACTED]. The surveyor informed [MI]P.N. #1 of the observation on 03/28/19 10:00 AM [MI]P.N. #1 stated she thought she had only given the resident 1 drop in each eye. The surveyor informed the director of nursing of the medication observation on 3/28/19 at 10:29 a.m. and requested the facility policy on medication administration. The facility policy titled Medication Administration and Documentation read in part C. Administer the medication verifying the 6 Rights 1. Right resident 2. Right medication 3. Right dosage 4. Right route 5. Right time 6. Right documentation Resident #21 was admitted to the facility 3/11/19 with diagnoses, that included but not limited to, poisoning by other opioids, accidental, [MEDICAL CONDITION], hypertension, pain, allergic rhinitis, Vitamin D deficiency, [MEDICAL CONDITIONS], constipation, and urinary tract infection. Resident #21's admission MDS (minimum data set) assessment with an assessment reference date (ARD) of 3/18/19 assessed the resident with a BIMS (brief interview for mental status) summary score as 15/15. The resident was interviewable. The surveyor interviewed the resident after informing the director of nursing of the medication pass observation on 3/28/19 at 10:29 a.m. Resident #21 stated the nurse gave her one drop of her eye drops in each eye. Resident #21 did not acknowledge the missed attempt of medication in the left eye. The surveyor informed the administrator, the director of nursing, the infection preventionist, and the executive director of the above concern during the end of the day meeting on 3/28/19 at 5:00 p.m. No further information was provided prior to the exit conference on 3/29/19.

Based on observation, staff interview and clinical document review it was determined the facility staff failed to assess and adequately monitor the behaviors for 1 of 17 residents (Residents #26) who were receiving antipsychotic medications. Findings: 1. Facility staff failed to assess and adequately monitor behaviors for Resident #26 who was receiving a daily administration of the antipsychotic, [MEDICATION NAME]. The resident's clinical record was reviewed on 2/1/18 at 9:00 AM. Resident #26 was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. The latest MDS (minimum data set) assessment dated [DATE] coded the resident with severely impaired cognitive skills. The resident required the assistance of at least one staff member to accomplish the ADLs (activities of daily living). Resident #26's CCP (comprehensive care plan), dated 12/30/17, documented the resident was taking [MEDICAL CONDITION] drugs (antidepressant & psychoactive medications). The interventions to staff included: 1. Monitor and document targeted behaviors to include but not limited to irritability, increased anxiety, refusal of care needs and non-compliance with attending recommendations for care. ***The careplanned behaviors were observed to be the same in other residents who were careplanned for antipsychotics. Resident #26's physician's orders [REDACTED]. The clinical record was reviewed for the signs and symptoms indicative of delusional disorder. There was no documentation by nursing staff or the prescribing physician that indicated the medical symptoms/behaviors manifested by delusional disorder. On 2/1/18 at 11:20 AM LPN I was interviewed about Resident #26's targeted symptoms as described on the MAR (medication administration record) and the Behavior and Side Effect Monitoring tool provided to the medication nurses. The targeted behaviors for this resident were documented to be irritability, increased anxiety, refusal of care needs and non-compliance. The behavior sheet did not contain the name or class of the medication the resident was taking. ****These behaviors were observed to be the same documented on the behavior monitoring tool for other residents taking an antipsychotic medication. LPN I was asked what medication the resident was taking that warranted a behavior monitoring tool. The LPN said they were monitoring the behaviors because the resident was taking [MEDICATION NAME] to control the behaviors. She said she had not observed this resident with any behaviors. (Resident #26 was not taking [MEDICATION NAME]--which is prescribed for mood disorders). On 2/1/18 at 11:20 AM the DON was asked why many of the residents were documented with the same set of behaviors and was also asked to describe the medical symptoms (or actual targeted behaviors associated with delusional disorder) for which Resident #26 was receiving an antipsychotic medication. The DON stated, Everyone has the same set of behaviors on the monitoring plan. We know we have issues with this. We have work to do. These observations were shared with the administrative staff prior to the survey team exit. No additional info was provided.

Based on staff interview and clinical record review, the facility staff failed to speak with 1 of 17 sampled residents (Resident #15), respectfully and communicate personal information in a way that maintained confidentiality. Findings: Facility staff failed to speak with Resident #15 respectfully and communicate personal information in a way that maintained confidentiality. The resident's clinical record was reviewed on 2/1/18. Resident #15 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The latest MDS (minimum data set) assessment, dated 11/15/17 coded the resident with some cognitive impairment and noted the resident was usually able to comprehend most verbal communication when staff spoke to him. He required the assistance of at least one nursing staff member to accomplish the ADLS (activities of daily living). The MDS coded the resident as needing the limited assistance of at least one staff member to eat his meals. The resident was documented as receiving a mechanically altered diet to address his dysphagia. Resident #15 CCP (comprehensive care plan) reviewed and revised on 10/24/17, documented the resident at risk for aspiration d/t dysphagia and at risk for altered nutritional status and/or related to dysphagia and a dislike for mechanically altered foods. The interventions to staff: 1. Provide diet as ordered. 2. Encourage maximum independence. Assist resident to complete meal as much as possible. 3. Honor food preferences/requests within dietary restrictions. Replace disliked foods when possible. Resident #15's physician orders, signed and dated 1/22/18, contained an order for [REDACTED]. 01/30/18 05:15 PM the surveyors observed 15 residents in the dining room. Five staff members were assisting residents to eat and provide oversite. At 5:28 PM, Resident #15 asked DA I (dietary aide) if he could have a salad. DA I spoke out loudly and answered NO--YOU CANNOT HAVE A SALAD--here's your pudding, eat this. She then shoved the magic cup across the table towards the resident and walked away. Two surveyors reviewed this exchange and agreed the manner in which she spoke was disrespectful to the adult resident. In addition, DA I did not offer to bring the resident anything else in place of a salad. This observation was shared with the administrator and the DON on 1/31/18 at 4:22 PM. The DON said she would have intervened if she had heard this exchange and said the resident could have been offered a different choice, even though his diet prohibited him from having a salad. No additional information was provided prior to the survey team exit.

Based on observation, resident and staff interview and clinical record review, it was determined the facility staff failed to provide privacy (did not close window shades or the bathroom door) during incontinence care and a skin assessment for 1 of 14 residents (#5.) Findings: Facility staff failed to provide privacy for Resident #5 (by not closing window shades or the bathroom door) during incontinence care and a skin assessment. Resident #5's clinical record was reviewed on 1/31/17 at 3:00 PM. The resident was admitted to the facility on [DATE] for physical therapy after a fall at her home resulted in multiple fractures. Resident #5's [DIAGNOSES REDACTED]. Resident #5's latest MDS (minimum data set) assessment, dated 1/17/17, coded the resident's cognitive status as unimpaired. The resident required the assistance of at least one nursing staff member for all the activities of daily living but was able to eat independently. The resident did require assistance for toileting and was frequently incontinent. The resident's CCP (comprehensive care plan) implemented on 1/9/17 the resident with an alteration in bladder/bowel elimination related to decreased mobility. The staff interventions included Provide privacy during elimination as able while maintaining safety. Resident #5's physician's orders [REDACTED]. On 2/1/17 at 2:00 PM Resident #5 was interviewed by a member of the survey team. The resident told the surveyor she had a very bad rash and a sore bottom from having to lie in feces for long periods of time. She agreed to let the surveyor examine her skin. On 2/1/17 at 3:45 PM LPN I accompanied the surveyor to examine the resident's skin. LPN I took a tube of [MEDICATION NAME] 13% creme with her so she could apply it during the assessment. LPN I rolled the resident into the bathroom in her wheelchair and assisted her to stand at the side of the toilet. She then pulled the resident's pants down and removed her brief. LPN I did not close the bathroom door or the window shade during this time. The surveyor observed the resident's bare buttocks were exposed and visible to the outside window from the area inside the bathroom. After assessing Resident #5's skin and buttocks, LPN I turned the resident and helped her onto the toilet. She then exited the bathroom to get a dry brief from the resident's closet. The surveyor then asked the resident if the staff closed the blinds and shut the bathroom door to provide privacy when providing her incontinence care. Resident #5 stated, Sometimes they do and sometimes they don't. On 2/2/17 at 10:45 AM the administrator and DON were informed of the surveyor's observations and the concerns about privacy. No additional information was provided prior to the survey team exit.

Based on staff interview and clinical record review the facility staff failed to obtain a physician's order prior to obtaining a laboratory test for 1 of 12 Residents, Resident #3. The findings included: For Resident #3 the facility staff obtained a CMP (comprehensive metabolic panel) when the physician had ordered a BMP (basic metabolic panel). Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. The most recent comprehensive MDS (minimum data set) with an ARD (assessment reference date) of 07/07/15 coded the Resident as 1/1/3 in section C, cognitive patterns. Resident #3's clinical record was reviewed on 03/15/15. It contained a signed physician's order dated 02/09/16 which read in part CBC/BMP one time at 02/10/2016. The clinical record also contained a laboratory report for a CMP dated 02/10/16. The surveyor could not locate a physician's order for a CMP to be drawn on this date. The surveyor informed the facility staff of the missing physician's order on 03/16/16 at approximately 0945 and asked them if they could locate it. The facility staff could not locate the physician's order. During a meeting with the administrative staff on 03/16/16 at approximately 1230 the concern of the missing order was discussed. No further information was provided prior to exit.

Based on staff interview and clinical record review the facility staff failed to obtain a physician ordered laboratory test for 1 of 12 Residents, Resident #6. The findings included: For Resident #6 the facility staff failed to obtain a physician ordered lipid panel. Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. The most recent comprehensive MDS (minimum data set) with an ARD (assessment reference date of 01/015/16 coded the Resident as a 12 of 15 in Section C, cognitive patterns. Resident #6's clinical record was reviewed on 03/16/16. It contained a signed physician's orders [REDACTED]. The surveyor could not locate the results of the lipid panel in the clinical record. The surveyor informed the facility staff of the missing lipid panel on 03/16/16 at approximately 1100 and asked them if they could locate it. The facility staff could not locate the results. During a meeting with the administrative staff on 03/16/16 at approximately 1230, the concern of the missing lab results was brought to their attention. No further information was provided prior to exit.

Based on staff interview and clinical record review, it was determined that the facility staff failed to notify the medical doctor when a medication ([MEDICATION NAME]) was held for 1 of 12 residents in the survey sample (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set, an assessment protocol) with an ARD (Assessment Reference Date) of 3/1/2016 coded the resident as having a BIMS (Brief Interview for Mental Status) score of 12 out of a total score of 15. Resident #1 was also coded as requiring extensive assistance of 1 staff member for dressing. The resident is also totally dependent for bathing with the assistance of 1 staff member as coded in Section G. The physician's order [REDACTED]. Hold med if SBP (systolic blood pressure) is less than 100 or DBP (diastolic blood pressure) less than 55. On 1/19/2016, the medication [MEDICATION NAME] was to be given at 9 am per the MAR (medication administration record). The box was initialed by the nurse with a circle around the initials. The blood pressure documented for this date was 107/50 . On the back of this MAR, it was documented, 1/19/16 0900 [MEDICATION NAME] held arrow in the down direction noted (decrease) BP (blood pressure). The surveyor could not find in the clinical record where the nurse had notified the physician of the medication, [MEDICATION NAME], being held on 1/19/16 for decreased blood pressure. Again on 10/23/15 at 9 am, the medication [MEDICATION NAME] box was initialed with a circle around the initials was noted by the surveyor. The documented blood pressure on this date was 114/49 . On 10/25/15 at the 9 am dose for the medication [MEDICATION NAME] was initialed by the nurse with a circle noted around the initials. The documented blood pressure for this date was 134/53 . There was no documentation on the back of the MAR for the reason that this medication was not given. The surveyor reviewed the nursing notes for 10/23/15 and 10/25/15 and could not find documentation of the physician being notified that this medication was held or not given for decreased blood pressure. On 3/16/16 at approximately 9:30 am, the director of nursing was notified of the above documented findings. The director reviewed the clinical record with the surveyor and stated that the circles around the initials on the MAR meant that the medication was not given. The director of nursing also stated that there was no documentation in the clinical record that the nurse informed of the physician of holding the [MEDICATION NAME] for the above documented doses. No further information was provided to the surveyor prior to the exit conference on 3/16/16.