Every finding on record at The Willows at Citation

Based on observation, interview, and review of the facility's policies, it was determined the facility failed to ensure staff observed required hand hygiene practices during the plating of food for the meal service. This deficient practice had the potential to affect 45 current residents who received meals from the kitchen. The findings include: Review of the facility's policy titled, Infection Prevention and Control Program, with a review date of 01/01/2023, revealed it was the purpose of the policy to prevent the spread of infection from one person to another. Further review revealed it stated that hand washing was the most important method of infection prevention and control, and hands should be washed after doing cleaning tasks, before and after eating, when using the restroom, or any other task that provided an opportunity for infection. Per the policy, gloves should be worn when encountering items that were intended to be used by a resident. Review of the facility's policy titled, Guidelines for Handwashing/Hand Hygiene, dated 03/20/2017, revealed handwashing was the single most important factor in preventing transmission of infections. Further review revealed hand hygiene was a term that applied to either handwashing or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). The policy stated health care workers should use hand hygiene at times such as before and after preparing/serving meals, drinks, tube feedings, etc. and before or after having direct physical contact with residents. Observation on 06/24/2025 at 11:45 AM of the lunch meal service revealed the admission Coordinator (AC), who was assisting in serving residents lunch in the Dining Room, touched the counter where there were meal tickets; wrote on the tickets with a pen, touching the meal tickets; and did not perform hand hygiene prior to serving plates of food to residents. The AC was also observed on 06/24/2025 at 11:52 AM touching the cart that the food tray was sitting upon and did not perform hand hygiene prior to distributing residents' food. On 06/24/2025 between 11:45 AM and 11:57 AM, it was observed that the AC served plates of food to three separate tables of residents prior to performing hand sanitization. In an interview on 06/24/2025 at 11:05 AM with the AC, she stated hand hygiene should be performed after serving all the residents at a table. Observation on 06/24/2025 at 12:17 PM revealed Dietary Aide (DA) 1 touched her hair and clothing with her gloved hands and did not change her gloves or perform hand hygiene. Further observation of DA1 revealed that she dropped the lid to a cup onto the floor. She picked up the lid and placed it into her pocket with her gloved hand. She did not change her gloves and did not perform hand hygiene. In an interview on 06/24/2025 at 12:37 AM with DA1, she stated gloves should be changed and hand hygiene performed after she touched anything soiled, such as when she picked up the cup lid from the floor. In an interview on 06/26/2025 at 9:58 AM with the Dietary Manager (DM), he stated kitchen staff should change gloves when soiled. He stated he stressed to his staff that wearing gloves was a way to prevent cross-contamination of surfaces. He stated he told staff just because they were wearing gloves did not mean they did not have to change those gloves and perform hand hygiene. He stated his expectation was that staff performed hand hygiene between each plate of food served in the dining room and after serving each tray in a resident's room. He stated staff should use ABHR to hand sanitize between plates/trays served and after three had been served, they should wash their hands with soap and water. He stated his expectation was that staff should also hand sanitize, and if wearing gloves, change gloves after picking up items off the floor or when touching something dirty such as their face, hair, or clothing. In an interview on 06/26/2025 at 10:09 AM with the Assistant Director of Health Services (ADHS), she stated staff should perform hand hygiene between each tray when serving food to residents in their rooms. In the dining room, she stated hand hygiene should be performed after service of all the plates from a tray, unless the staff member touched a surface such as the table or touched the resident. She stated staff should perform hand hygiene if they touched their face, hair or clothing and if they were to pick something up from the floor. She stated any time a staff member touched a contaminated surface they needed to perform hand hygiene and change their gloves if they were wearing gloves. In an interview on 06/26/2025 at 10:50 AM with the Director of Health Services (DHS), she stated her expectation was that staff performed hand hygiene anytime they touched themselves or a contaminated surface. She stated typically all the plates on a tray (approximately three to four plates) were distributed to residents without performing hand hygiene unless the staff member touched something contaminated. She stated staff members wearing gloves who picked up something from the floor should change gloves and perform hand hygiene. In an interview on 06/26/2025 at 12:07 PM with the Executive Director, he stated his expectation was that prior to distributing food in the Dining Room from a tray, staff members should perform hand hygiene, pass the three plates of food on the tray, and if they did not touch a contaminated surface, then perform hand hygiene. He stated, if staff was wearing gloves and picked up trash off the floor, he expected that staff member to change gloves and perform hand hygiene.

Based on interview and record review, the facility failed to provide the resident representative with written notification of the resident's transfer to the hospital for 1 out of 5 sampled residents, Resident (R) 14. The findings include: Review of R14's Face Sheet revealed the facility admitted the resident on 07/16/2024 with diagnoses of hypertension, type 2 diabetes mellitus with diabetic chronic kidney disease, and hyperlipidemia. Review of R14's hospital Discharge Summary, dated 01/08/2025, revealed she had been hospitalized on [DATE] for vomiting blood and was diagnosed with a pyloric obstruction and a urinary tract infection. Review of R14's Nursing Notes, dated 01/08/2025, revealed R14 returned to the facility via the Emergency Medical Technicians (EMT) after being seen at the Emergency Room, on 01/08/2025, for coffee ground emesis and abdominal pain. Further review revealed the emergency room (ER) had removed 1000 milliliters of gastric contents via a nasogastric (NG) tube, gave her intravenous (IV) Rocephin (to treat her urinary tract infection), and gave two doses of morphine for pain. Review of R14's Transfer/Discharge and Bed Hold Policy Notification, dated 01/08/2025, revealed it was the facility's form for notifying R14 and her Responsible Party (RP) she had a bed hold for the facility for 14 days while she was hospitalized or on therapeutic leave. Further review of the Transfer/Discharge and Bed Hold Policy Notification, revealed it was not signed by the resident or the RP. Instead, written on the signature line was verbal consent via a phone call with RP (Family, F3). It was dated 01/08/2025 and signed by the Director of Health Services (DHS). In an interview on 06/26/2025 at 8:29 AM, R14's RP/F3 stated the facility called her and told her R14 had been experiencing bloody emesis, and the facility was going to send R14 to the ER. RP/F3 further stated the facility verbally told her of the transfer; however, she had not received written documentation of R14's bed hold or the transfer. In an interview on 06/25/2025 at 1:54 PM with the Business Office Manager (BOM), she stated she was unsure if anyone sent a copy of Transfer/Discharge and Bed Hold Policy Notification via mail to the RP for a resident when the resident went to the hospital. She stated a letter was sent to the Ombudsman. In an interview on 06/25/2025 at 1:55 PM with the Social Services Director (SSD), she stated Admissions took care of the bed hold policy. She stated she sent an email to the Ombudsman when a resident was sent to the hospital, and a formal letter was sent once per month to the Ombudsman listing all the residents that went to the hospital for that month. In an interview on 06/25/2025 at 2:02 PM with the admission Coordinator (AC), she stated they asked the resident or RP upon admission if they wished to sign the bed hold policy to hold the resident's bed if they were to be sent out to the hospital. She stated the facility contacted the RP via phone to notify them of the transfer and to remind them about the bed hold policy. She stated, if the RP was in the facility, they would give them a copy of the Transfer/Discharge and Bed Hold Policy Notification. The AC stated the facility never sent the Transfer/Discharge and Bed Hold Policy Notification via mail to the RP but did send a copy of it with the resident to the hospital. She stated the Ombudsman received an email when there was a transfer or discharge of a resident from the facility, and a printed list was sent to the Ombudsman at the end of each month listing those residents that were transferred or discharged from the facility. In an interview on 06/26/2025 at 10:09 AM with the Assistant Director of Health Services (ADHS), she stated the facility did not mail Transfer/Discharge and Bed Hold Policy Notification to residents' RPs when a resident was transferred to the hospital. She stated the RP was called as a form of notification. She stated residents or their RPs signed a bed hold policy upon admission and could change their election at anytime during the resident's stay at the facility. In an interview on 06/26/2025 at 10:50 AM with the Director of Health Services (DHS), she stated the facility did not mail Transfer/Discharge and Bed Hold Policy Notification to residents' RPs when a resident was transferred to the hospital. In an interview on 06/26/2025 at 12:07 PM with the Executive Director (ED), he said the facility did not send out Transfer/Discharge and Bed Hold Policy Notification letters in the mail. He stated the facility did give a copy of the Transfer/Discharge and Bed Hold Policy Notification to the resident when they were transferred from the facility to the hospital. He stated it was the facility's process to call the RP and notify them of the transfer and remind them of the bed hold.

Based on observation, interview, and review of facility's policy, it was determined the facility failed to ensure drugs and biologicals stored in the facility were not expired, labeled, and stored in accordance with currently excepted professional principles; and failed to store medications according to appropriate environmental controls to preserve their integrity for two (2) out of two (2) medication storage rooms, and one (1) out of three (3) medication carts. Observation of the [NAME] hall medication room refrigerator revealed the refrigerator's temperature was thirty-two (32) degrees Fahrenheit. Continued observation of the refrigerator's temperature revealed the temperature was thirty-four (34) degrees Fahrenheit (F). There was no covering for the freezer compartment to keep cold air from escaping into the refrigerator portion of the unit. Additionally, there was not a separate thermometer for the freezer compartment. Further observation revealed there were four (4) boxes of Influenza [MEDICATION(S)] stacked on top of each other directly below the open freezer compartment. The refrigerator was crowded, not allowing for proper air flow. In addition, Acetaminophen suppositories were stored in the door on a shelf. Observation of the Secretariat hall medication room refrigerator revealed the temperature was 48 degrees Fahrenheit. Furthermore, an approximately two (2) inch thick layer of ice had accumulated on the inside of the freezer compartment. Observation of the 300 hall medication cart revealed two (2) loose [MEDICATION(S)] tablets without resident identifying information. One (1) tablet was found on the bottom of the medication cart drawer, and the other was found sticking out of a package of another medication labeled for Resident #21. Further observation revealed an open bottle of liquid [MEDICATION(S)] 20 milliequivalents/15 milliliters, prescribed to Resident #41, had been discontinued on 10/20/2021. Further observation revealed an undated, opened bottle of Pro-stat liquid protein supplement. The findings include: Review of the facility policy, Medication Storage in the Facility, revised October 2019, revealed the purpose of the policy was to ensure medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations. Continued review revealed all medication dispensed by the pharmacy should be stored in a container with the pharmacy label. Furthermore, the policy revealed medications requiring refrigeration must be kept in a refrigerator at temperatures between thirty-six (36) degrees Fahrenheit and forty-six (46) degrees Fahrenheit. Medications requiring freezing should be kept at fourteen (14) degrees Fahrenheit to negative twenty (-20) degrees Fahrenheit. Additionally, the refrigerator in which vaccines are stored should be checked at least twice daily, per Centers for Disease Control and Prevention (CDC). Review of the Centers for Disease Control and Prevention's (CDC) Vaccine Storage and Handling, updated 09/29/2021, revealed best practices for storage of vaccines include: 1) do not over-pack the refrigeration unit; 2) place vaccine packages in such a way that air can circulate around the compartment to promote air flow; 3) leave two (2) to three (3) inches between vaccine containers, and the refrigerator's walls; 4) do not use the top shelf, floor, or door for vaccine storage as the temperature in these areas may differ significantly from the temperature in the body of the unit. 1. Observation of [NAME] hall medication room refrigerator, on 11/04/2021 at 10:52 AM, revealed the temperature was thirty-two (32) degrees F. Furthermore, observation revealed there was no covering for the freezer compartment to keep cold air from escaping into the refrigerator portion of the unit. Additionally, observation revealed no thermometer for the freezer compartment. Observation also revealed there were four (4) boxes of Influenza [MEDICATION(S)] stacked on top of each other directly below the open freezer compartment. The medication refrigerator was over-packed in such a way that the refrigerator was filled, with insufficient room for proper air flow to occur. Continued observation of the [NAME] hall medication refrigerator temperature, on 11/04/21 at 11:35 AM, revealed the temperature was thirty-four (34) degrees Fahrenheit. 2. Observation of the medication refrigerator in the Secretariat hall medication storage room, on11/04/21 at 11:05 AM, revealed the temperature was forty-eight (48) degrees Fahrenheit. There was not a separate thermometer for the freezer. Additionally, an approximately two (2) inch thick layer of ice had accumulated on the inside of the freezer compartment. Review of the facility's temperature logs for the [NAME] and Secretariat hall refrigerators, dated September 2021, October 2021, and November 2021, revealed the medication refrigerator range should be between thirty-four (34) degrees Fahrenheit and forty-six (46) degrees Fahrenheit. The freezer range should be between zero (0) degrees Fahrenheit and thirty (30) degrees Fahrenheit. Continued review of the temperature logs, dated September 2021, October 2021, and November 2021, revealed the facility was monitoring refrigerator/freezer temperatures once daily, on the evening shift. Furthermore, both medication refrigerators' temperatures dropped below the CDC's, and the facility policy's, recommended low temperature range of thirty-six (36) degrees Fahrenheit on thirteen (13) out of thirty (30) days in September. The [NAME] medication refrigerator was monitored at thirty-four (34) degrees Fahrenheit on September 26 and 27. The Secretariat medication refrigerator was monitored at thirty-four (34) degrees Fahrenheit on September 8, 9, 10, 11, 12, 14, 15, 16, 20, 23, 24. Review of the operating instructions for the Haier HNSE045BB 4.5 Cubic Foot Compact Refrigerator's operating instructions revealed the freezer compartment should be defrosted whenever frost on the wall of the freezer compartment becomes on-eighth (1/8) inch thick. 3. Observation of the 300 hall medication cart, on 11/04/21 at 1:31 PM, revealed two (2) loose [MEDICATION(S)] tablets without resident identification information. One (1) tablet was found on the bottom of the medication cart drawer, and the other was found sticking out of a package of another medication labeled for Resident #21. Further inspection revealed an open bottle of liquid [MEDICATION(S)] 20 milliequivalents/15 milliliters, prescribed to Resident #41, had been discontinued on 10/20/2021. In addition, there was an undated, opened bottle of Pro-Stat liquid protein supplement. Interview with Licensed Practical Nurse (LPN) #4, on 11/04/2021 at 1:38 PM, revealed she was assigned to the [NAME] hall medication cart. LPN #4 assisted SSA Surveyor with observation of the medication cart and medication storage room. When SSA Surveyor observed two (2) loose [MEDICATION(S)] tablets without resident identification information, one (1) tablet was sticking out of a box of Resident #21's medication. LPN #4 stated that the [MEDICATION(S)] tablets were prescribed to Resident #21's. Further interview revealed that the open bottle of liquid [MEDICATION(S)] 20 milliequivalents/15 milliliters, prescribed to Resident #41, had been discontinued on 10/20/2021. LPN #4 stated it should have been removed from the medication cart and returned to the pharmacy for disposal. LPN #4 further stated that the nursing staff is responsible for ensuring medications are labeled according to facility process, which is to record the date opened on the medication package when the medication has been opened. Furthermore, LPN #4 stated if an item is found to be expired, labeled, and or stored improperly, the nursing staff is responsible to discard the medication according to policy. LPN #4 stated that the importance was to prevent medication errors and ensure the safety of all residents. Interview with LPN #1, on 11/04/2021 at 1:50 PM, revealed it is the responsibility of the nursing staff to ensure medications are stored according to facility policy and procedure. Any expired medications are discarded according to facility policy to ensure the safety of all residents. All medications and supplements were to be dated when opened. LPN #1 further stated that labeling and storing medication properly was important to ensure the resident's safety. Interview with the Assistant Director of Health Services (ADHS), on 11/04/2021 at 10:52 AM, revealed it is the responsibility of the nursing staff to ensure the medication cart was clean, medications were in the proper place. Any expired scheduled medications should be discarded according to facility policy. Further interview revealed it was the responsibility of the night shift nurses to monitor temperatures for the medication refrigerators nightly. ADHS stated temperature are not monitored by the day-shift nurses. Further interview revealed she was not aware that facility's Medication Storage in the Facility, policy stated that medications requiring refrigeration must be kept in a refrigerator at temperatures between thirty-six (36) degrees Fahrenheit and forty-six (46) degrees Fahrenheit. Medications requiring freezing should be kept at fourteen (14) degrees Fahrenheit to negative twenty (-20) degrees Fahrenheit. Additionally, she was not aware refrigerated vaccines should be monitored, to ensure proper temperature ranges, at least twice daily, per facility policy, and CDC guidelines. The ADHS stated that storing medications and vaccines according to policy and the CDC's recommendations was important for resident safety and the efficacy of the medication. Interview with Director of Health Service (DHS), on 11/04/2021 at 2:30 PM, revealed the nursing staff was responsible to ensure medications are stored properly. She stated that medication carts are randomly checked for proper storage to ensure the facility's policy is followed; however, the DHS stated she had no documentation related to these random audit checks. Additional interview revealed she was unaware there was a discrepancy between the facility policy and the temperature log ranges for refrigeration of medications and vaccines. Furthermore, the DHS stated she was not sure if the medication storage policy given to SSA Surveyor, was current. SSA Surveyor requested an update policy, however, it was not provided by the facility. The DHS revealed that after consult with the facility's pharmacist, it was determined the temperature ranges on the temperature log were incorrect. According to the DHS, she was not aware of facility protocols and CDC guidelines to monitor refrigerated vaccines at least twice daily. Continued interview, on 11/04/2021 at 4:10 PM, with the DHS, revealed it is her expectation that all nursing staff follows facility policy and procedures related to medication storage and labeling. Furthermore, the DHS stated if an item is found to be expired, labeled, and or stored improperly, it is her expectation that nursing staff return or discard the medication according to facility policy. The DHS further stated that the importance was to ensure the integrity of medications and vaccines and to provide safe, quality care for all residents. Interview with the Executive Director (ED), on 11/04/2021 at 6:30 PM, revealed it was her expectation for medication to be stored and labeled appropriately according to facility policy and CDC guidelines. Further interview revealed that it is her expectation that the nursing staff follow current policies and protocols for medication storage. ED further stated that the importance was to ensure the efficacy of all medications and vaccines, and to keep residents safe. 4. Review of facility's policy titled, Medication Storage in the Facility, revised on 10/2019, revealed medication supplies should only be accessible to licensed facility personnel, pharmacy personnel or facility personnel lawfully authorized to administer medications. Further, the policy revealed all medications dispensed by the pharmacy would be stored in the container with the pharmacy label. Review of facility's policy titled, Preparation and General Guidelines: Medication Administration, General Guidelines, revised 11/2018, revealed the policy did not outline procedures related to medication(s) left at the resident's bedside. Review of Resident #145's medical record revealed the facility admitted the resident on 11/02/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no Minimum Data Set (MDS) Assessment to review because of the resident's recent admission on 11/02/2021. Observation of Resident #145's medication administration, on 11/04/2021 at 9:01 AM, with Licensed Practical Nurse (LPN) #5, revealed she prepared the resident's medications, which included [MEDICATION(S)] (blood pressure medication). Per active Physician's Orders, [MEDICATION(S)] was held if the systolic blood pressure (top number) was less than one hundred (100); which required the nurse to obtain a blood pressure prior to administration of the medication, to ensure the residents blood pressure was within safe parameters (not to low) for the resident to receive the medication. Further observations revealed LPN #5, left the resident's prepared medications at bedside unattended, within the resident's reach, in medication cups. Further observations revealed LPN #5 left the resident's room and entered the hallway, to get the vital sign machine. The nurse was unable to see the resident or the medications sitting at bedside. Interview with LPN #5, on 11/04/2021 at 9:01 AM, revealed it was not common practice for her to leave medications at the bedside unattended. She further revealed leaving medications unattended at bedside was not a good idea because a resident might take the medication(s) prior to blood pressure measurement. Interview with Director of Health Services (DHS), on 11/04/2021 at 4:25 PM, revealed she expected medication to not be left at the bedside when the nurse was not present in the room. Interview further revealed it was important not to leave medications at bedside because another resident might take them and the resident could take the medication before his/her vital signs were measured. Interview with Executive Director, on 11/04/2021 at 6:14 PM, revealed nurses should not leave medication(s) at the bedside and step out of the room. Interview further revealed her expectation was staff would follow the facility policy on medication administration and storage.

Based on observation and interview, it was determined the facility failed to ensure proper sanitation procedures to prevent the outbreak of foodborne illness. Observation during the initial kitchen tour revealed two (2) large steam table pans stored wet, leading to the potential for bacterial growth. The findings include: Observation, on 11/02/2021 at 9:00 AM, revealed two (2) steam table preparation pans stored wet on a shelf near the steam table, stacked among five (5) other steam table preparation pans. Other serving ware on the shelf was observed to be dry. Interview with the Dietary Manager (DM), on 11/02/2021 at 2:56 PM, revealed normally, all dishes were placed onto a cart to air dry; but, there was limited space and the line had to keep moving. She stated dietary staff panicked when surveyors came in and did not place the pans on the cart to air dry as they were supposed to, and the dietary aides currently working were new. She stated she had been checking all day long to ensure it had not happened again. The DM stated the concern for leaving pans wet was that it created an opportunity for bacterial growth because bacteria grew best in dark, moist places. She stated there was no policy regarding drying of dishes. Interview with the Director of Health Services (DHS), on 11/04/2021 at 9:58 AM revealed her expectation was that any type of serving ware used in the kitchen would be stored dry. She revealed the concern would be for bacteria or mold to grow if items were stored wet. Interview with the Executive Director (ED), on 11/04/2021 at 6:05 PM revealed she was uncertain what the danger would be for pans and utensils to be stored wet. The ED stated she would expect dietary to practice safe storage and serving of food.

Based on observation, interview, record review, and review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to develop and/or implement a person centered Comprehensive Care Plan (CCP) for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for three (3) of eighteen (18) residents; Resident #38, Resident #29, and Resident #12. 1. Review of the CCP for Resident #29 revealed the resident demonstrated exit seeking behaviors and a wander guard would be applied as appropriate. Review of Progress Notes in October 2021, revealed ongoing assessment of need for wander guard; however observations on 11/02/2021 and 11/03/2021 revealed the resident did not have a wander guard. 2.Review of the CCP for Resident #38 revealed his/her preferred activity (s) were music, news via television, and religious services; however observations on 11/02/2021 and 11/03/2021 and review of the medical record revealed the resident's preferred activities based on the comprehensive assessment and care plan were not consistently provided to the resident. 3. Reivew of the CCP for Resident #12 revealed the resident had chronic wounds to his/her bilateral feet. Additionally, the resident's wound would be treated per physician orders. However review of the medical record and observation revealed the resident's dressings were not changed as ordered. The findings include: Review of the facility's policy titled Comprehensive Care Plan Guidelines, dated 05/22/2018 revealed the purpose of the document was to ensure appropriate services and communication to meet the resident's needs, severity/stability of conditions, impairment, disability, or disease in accordance with state and federal guidelines. Additional review revealed the care plan interventions would reflect risk areas that impact the individual resident. Further review revealed pertinent care plan approaches would be communicated to nursing staff. 1. Review of Resident #29's Electronic Medical Record (EMR) revealed the facility admitted the resident, on 06/13/2014, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #29's Elopement Risk Assessment, dated 05/15/2021, revealed the resident was at risk for elopement related to verbalized statements of leaving; exhibited periods of pacing, agitation or wandering towards an exit; and wandering when agitated. Further, the resident required an exit seeking alarm bracelet/device on the resident which required monitoring for placement and function every shift. Review of Resident #29's CCP, initiated on 05/17/2021, revealed the resident demonstrated exit-seeking behaviors. Additional review revealed the goal was the resident would not elope from the facility. Further review revealed interventions included the resident would be assessed for the need for a wander guard; apply as appropriate. Continued review revealed an additional interventions to evaluate the resident's need for a secure unit and to monitor wandering triggers. Review of Resident #29's Quarterly MDS Assessment, dated 09/18/2021, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of seven (7) out of fifteen (15), which indicated the resident had severely impaired cognition. Additional review revealed the resident had no behavior of wandering present. Further, the resident required an elopement wander alarm which was used daily. Review of Resident #29's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #29's Progress Notes/Clinically at Risk Individual Monitoring, dated 10/09/2021; 10/17/2021; 10/24/2021; and 10/31/202, completed by the Director of Health Services (DHS), revealed the resident had agitated behaviors, especially after 4:00 PM. Further review revealed the resident had no attempts to go to exit doors. However, a wander-guard was in place due to wandering. Review of Resident #29's MAR, dated 11/01/2021 through 11/04/2021, revealed an order to check placement of wandering system bracelet/device every shift; twice daily. However observations, on 11/02/2021 and 11/03/2021, revealed no evidence the resident wore a wander guard on the his/her wrists, ankles or wheelchair. Interview with State Registered Nursing Assistant (SRNA) #2, and SRNA #3, on 11/03/2021 at 4:43 PM, revealed they used the CCP to know if a resident required a wander guard. Per interview, Resident #29 had worn a wander guard on his/her wrist for several years related to wandering around the facility, in the evenings. Additional interview revealed it was important the CCP was followed and the resident always had the device on to ensure he/she was safe and did not leave the facility and wander off. Further, it was all staff's responsibility to ensure interventions were implemented for residents. Interview with Licensed Practical Nurse (LPN) #2, on 11/03/2021 at 5:05 PM, revealed she was assigned to Resident #29 on 11/02/2021 and 11/03/2021 day shift. Per interview, it was her responsibility to ensure resident's care plans were followed. Additionally she ensured care plans were followed by making observations of care and reviewing the care plan for residents she was assigned. Continued interview revealed Resident #29 had wandering behaviors and required a wander guard. Additional interview revealed she was responsibility to ensure placement and function of the wander guard during her shift. Further, it was important the CCP was implemented for residents who were at risk for elopement, to ensure their devices were in place and monitored to keep the residents safe. 2. Review of Resident #38 EMR, revealed the facility admitted the resident on 07/30/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #38's CCP, dated 08/05/2020, revealed it was important to the resident to have opportunities to engage in activities, meaningful to the resident. Additional review revealed a goal that staff would take necessary actions to accommodate the resident's routines and preferences to satisfy and engage the resident in activity opportunities. Further review revealed interventions included but were not limited to provide the resident with opportunities to hear/listen to music; ensure the resident keeps up with the news/preferred avenue via television; engage in religious services or practices allowing access to Christian music and broadcasted sermons; and check with the resident on a regular basis to ensure the resident was satisfied with how he/she spent their day. Review of Resident #38's Significant Change MDS Assessment, dated 07/01/2021, revealed the facility assessed the resident to have a BIMS score of three (3), indicating severely impaired cognitive abilities. Further review of the Assessment revealed preferences for Activities that were somewhat important to the resident included listening to music; doing things with groups of people; and participating in religious services or practices. Review of Resident #38's Plan of Care (POC) History Report/Activities, dated August 2021, revealed the resident attended and participated in seven (7) activities during the month. However, there was no documented evidence the resident was offered, attended, or participated music activities, group activities, news, or religious services or practices, per the resident's CCP. Continued review of Resident #38's POC History Report/Activities, dated September 2021, revealed the resident attended and participated in seven (7) activities during the month. However review revealed only once, on 09/30/2021, the resident participated in room music, for fifteen (15) minutes. There was no documented evidence the resident was offered, attended, or participated in group activities, news, or religious services or practices, per the resident's CCP. Additional review of Resident #38's POC History Report/Activities, dated October 2021, revealed the resident attended and participated in six (6) activities during the month. However, all there was no documented evidence the resident was offered, attended, or participated music activities, group activities, news, or religious services or practices, per the resident's CCP. Observations on 11/02/2021, 11/03/2021 and 11/04/2021 revealed the resident was lying in bed. Additional observations revealed the resident's television (TV) was turned off. Further, there was no radio or iPod in the resident's room. Review of Activities Documentation on the EMR for November 2021, with the Life Enrichment Director (LED), on 11/03/2021 at 2:23 PM, revealed no documented evidence the resident was offered, attended, or participated in music activities, group activities, news or religious services or practices, per the resident's CCP. Interview with the LED, on 11/03/2021 at 2:23 PM, revealed he reviewed resident's activity preference with the MDS schedule and ensure the CCP was accurate. Per interview, the IDT worked together to ensure residents engaged in activities of preference per their CCP. Additional interview revealed the LED was familiar with Resident #38's activity preference of music (gospel), and reading the Bible; however review of the POC activity documentation on the EMR, for Resident #38 revealed no documented evidence of those activities for the last three (3) months. The LED stated staff were expected to follow up the CCP and encourage participation in activity. He stated it was important to implement the CCP related to residents choice of activities to enrich their lives and increased their quality of life/care. Resident #38 should be provided opportunities to engage in activities of his/her preference. Interview with SRNA #2, and SRNA #3, on 11/04/2021 at 4:43 PM, revealed Resident #38 loved gospel music and talking with staff; however there were not aware of the residents activity CCP and preferred approaches/interventions. Further, they stated they could not say activities staff did not engage with the resident; however, the only activities they were aware of that activities staff provided were the Daily Chronical and the monthly calendar. Interview with the DHS, on 11/04/2021 at 4:03 PM, revealed it was the responsible of the Interdisciplinary Team (IDT) to ensure the CCP was implemented to meet the needs and goals of all residents. Per the DHS, she reviewed care plans weekly to ensure interventions were implemented for residents. Continued interview revealed she specifically did spot checks herself, to ensure residents were provide care per their CCP. The DHS stated she had not identified an issue with implementation of care plans for residents who required a wander guard or related to residents being provided preferred activities per their CCP. Further, it was important that the CCP was implemented by the IDT to ensure quality of care, quality of life and resident safety. Interview with the Executive Director, on 11/04/2021 at 6:20 PM, revealed she expected a person centered care plan to be implemented by the IDT for all residents. Additionally residents who required wander guards should have wander guards in place to ensure resident safety. Continued interview revealed residents preferred/care planned activities should be honored. Further, it was important for the care plan to be followed to ensure resident needs were met and provided. 3. Review of Resident #12's medical record revealed the facility readmitted the resident on 02/17/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #12's Physician Order's, dated 07/02/2021, revealed an order to clean surgical wound sites (bilateral feet) with wound cleanser or normal saline. Apply [MEDICATION(S)] gauze to area on left foot fifth (5th) metatarsal and to right ankle; wrap with well-padded gauze bandage roll, and apply light cohesive bandage; Change daily on Monday, Wednesday, Friday. Foam dressing to left ankle only. Light/loose application of offloading boots; with no stop date. Review of Resident #12's Quarterly Minimum Data Set (MDS) Assessment, dated 08/03/2021, revealed the resident was assessed to have a Brief Interview of Mental Status (BIMS) score of eleven (11), indicating moderate cognitive impairment. Additional review revealed the resident was assessed to be at risk for pressure ulcers and had pressure reducing devices for his/her bed and chair. Continued review revealed the resident required extensive assist with bed mobility and personal hygiene. The resident and required total assistance for transfers. Record review of Resident #12's CCP, dated 08/17/2020, revealed the resident had chronic wounds to bilateral feet related to [CONDITION(S)]. The goal was the resident's wound will heal without complications. Further interventions included treat per physician orders, notify physician if treatment is not effective and pressure reducing mattress and chair cushion. However, observation on 11/03/2021 at 11:37 AM, of Resident #12's dressing changes, to bilateral feet, with Licensed Practical Nurse (LPN) #1, revealed resident had bilateral offloading boots on, bilateral feet wrapped with cohesive dressings, with gauze bandage underneath, with no date, time, or nurses initials to indicate last dressing change. Additionally, the resident also had an intact foam dressing on his/her left ankle, under gauze wrapping, dated 10/27. There was no documented evidence on the dressing of a year, nurses initials, or time, noted. Interview with LPN #1, on 11/03/2021 at 11:45 AM, who was assigned to Resident #12 on this date, revealed bilateral dressing changes were done every Monday, Wednesday, and Friday. Interview further revealed Resident #12's foam dressing to the left ankle was changed weekly and bilateral boots were on at all times. However, continued interview with LPN #1, on 11/04/2021 at 2:10 PM, revealed she worked on Tuesday, Wednesday and Thursday, therefore she only changed the resident's dressing once a week. Interview with Director of Health Services (DHS), on 11/04/2021 at 4:03 PM, revealed it was her expectation nurses and Minimum Data Set (MDS) Coordinator developed the CCP. Further, it was her expectation the Interdisciplinary Team (IDT) implemented and followed the CCP to meet the needs and goals of each resident. Interview with Executive Director, on 11/04/2021 at 6:20 PM, revealed it was her expectation the person centered care plans were implemented by facility staff for all residents. Additionally, it was important the CCP was implemented to ensure resident care needs were met. Further, she stated the facility Quality Assurance (QA) had not identified any concerns with implementation of the CCP specific to following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Surveyor: [NAME], [NAME]

Based on observation, interview, record review and review of facility's policy, it was determined the facility failed to ensure an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, for one (1) of eighteen (18) residents, Resident #38. There was no documented evidence Resident #38 participated in his/her preferred activities in August, September, October or November of 2021. Record review revealed the resident attended and participated in minimal activities during the last four (4) months at the facility and he/she had not been consistently offered news via television, music, religous or group activities even though the activity(s) were assessed as his/her preferred activities, and were offered on the facility's monthly activity calendar. In addition, observation of Resident #38, on 11/02/2021, 11/03/2021, and 11/04/2021, revealed the resident was in his/her room, in bed with the lights dimmed and no television or music on his his/her room. The findings include: Interview with the Executive Director, on 11/04/2021 at 8:30 AM, revealed the facility did not have a written policy or protocol related to the activities department programming. Review of the Activity Calendar, dated August 2021 through November 2021, revealed each Sunday at 10:00 AM there were Church Services and at 1:30 PM there was Gospel Music. Continued review of the calendars revealed each day at 10:00 AM there was an activity Broadcast on the facility's television channel. Additionally, Hymn Sing was each Wednesday at 6:00 PM. Further, review revealed weekly activities included but were not limited to music, trivia, bingo, socials, and exercise. Review of Resident #38 Electronic Medical Record (EMR), revealed the facility admitted the resident on 07/30/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #38's Comprehensive Care Plan (CCP), dated 08/05/2020, revealed it was important to the resident to have opportunities to engage in activities, meaningful to the resident. The goal was the staff would take necessary actions to accommodate the resident's routines and preferences to satisfy and engage the resident in activity opportunities. The interventions included but were not limited to provide the resident with opportunities to hear/listen to music; ensure the resident keeps up with the news/preferred avenue via television; engage in religious services or practices allowing access to Christian music and broadcasted sermons; and check with the resident on a regular basis to ensure the resident was satisfied with how he/she spent their day. Review of Resident #38's Significant Change Minimum Data Set (MDS) Assessment, dated 07/01/2021, revealed the resident had adequate hearing and vision and had the ability to make him/herself understood and usually could understand others. Continued review revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (3), indicating severely impaired cognitive abilities. Additional review revealed preferences for Activities that were somewhat important to the resident included listening to music; doing things with groups of people; and participating in religious services or practices. Further, the resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #38's Plan of Care (POC) History Report/Activities, dated August 2021, revealed the resident attended and participated in seven (7) activities during the month. On 08/03/2021 at 11:19 AM, for thirty (30) minutes; on 08/06/2021 at 2:08 PM, for thirty (30) minute; on 08/12/2021 at 3:49 PM, for thirty (30) minutes; on 08/19/2021 at 3:53 PM, for twenty (20) minutes; on 08/23/2021 at 3:46 PM, for thirty (30) minutes; on 08/27/2021 at 10:46 AM, for thirty (30) minutes; on 08/28/2021 at 9:49 AM, for thirty (30) minutes; and on 08/29/2021 at 9:55 AM, for thirty (30) minutes. However, all seven (7) activities were categorized as the Daily Chronical. There was no documented evidence the resident was offered, attended, or participated music activities, group activities or religious services or practices, per the resident's choice/preference of activities. Review of Resident #38's POC History Report/Activities, dated September 2021, revealed the resident attended and participated in seven (7) activities during the month, on 09/02/2021 at 4:41 PM, calendar and newsletter, no time/duration noted; on 09/03/2021 at 12:14 PM, the Daily Chronical for thirty (30) minutes; on 09/09/2021 at 12:15 PM, the Daily Chronical, for thirty (30) minutes; on 09/19/2021 at 1:03 PM, the Daily Chronical, for thirty (30) minutes; on 09/25/2021 at 10:00 AM, the Daily Chronical, for thirty (30) minutes; on 09/28/2021 at 4:17 PM, October Calendar and Newsletter, no time/duration noted. Further review revealed on 09/30/2021 at 2:16 PM, the resident participated in room music, for fifteen (15) minutes. There was no documented evidence the resident was offered, attended, or participated in group activities or religious services or practices, per the resident's choice/preference of activities. Review of Resident #38's POC History Report/Activities, dated October 2021, revealed the resident attended and participated in six (6) activities during the month. On 10/09/2021 at 11:59 AM, for thirty (30) minutes; on 10/14/2021 at 10:48 AM, for thirty (30) minutes; on 10/17/2021 at 10:29 AM, for thirty (30) minutes; on 10/17/2021 at 10:29 AM, for thirty (30) minutes; on 10/18/2021 at 9:55 AM, for thirty (30) minutes; on 10/23/2021 at 3:28 PM, for thirty (30) minutes; and 10/31/2021 at 11:06 AM, for thirty (30) minutes. However, all six (6) activities were categorized as the Daily Chronical. There was no documented evidence the resident was offered, attended, or participated music activities, group activities or religious services or practices, per the resident's choice/preference of activities. Observations on 11/02/2021 at 9:25 AM, revealed the resident was lying in bed, there were no lights on in the room. A large wooden bookshelf blocked the window, the room was dim. Continued observations revealed the resident's television (TV) was turned off. Additional observations revealed the resident was turned to the right side towards the doorway. Further, the resident's eyes were open; however, he/she did not respond to the State Survey Agency (SSA). Observations on 11/02/2021 at 1:18 PM, revealed the resident lying in bed, on his/her right side. The room was dim and the resident's eyes were closed. Additional observations revealed the TV was turned off. Further, there was no radio or iPod in the resident's room. Observations on 11/02/2021 at 3:15 PM, revealed the resident was lying in bed on his/her left side, facing away from the doorway. The room light was on above the bed and the resident's eyes were closed. Further the TV was turned off and there was no other source of music in the room. Observations on 11/02/2021 at 5:16 PM, revealed the resident was lying in bed on his/her right side. Further the resident's eyes were open and when the SSA spoke to the resident, the resident answered direct questions. Interview with the resident at that time revealed he/she was comfortable, slept a lot and enjoyed music. Observations on 11/03/2021 at 8:20 AM, revealed the resident was in bed lying on his/her back. The resident's eyes were closed. Further, the TV was turned off and there was no other source of music in the room. Observations on 11/03/2021 at 10:55 AM, revealed the resident was in bed lying on his/her left side facing the bookshelf. The resident's eyes were closed and the room was dim. Further, the TV was turned off and there was no other source of music in the room. Observations on 11/03/2021 at 2:20 PM, revealed the resident was lying in bed on his/her right side, towards the door. Additional observation revealed the resident's eyes were close. Further the TV was turned off, and there was no other source of music in the room. Review of Resident #38's Activities Documentation on the EMR for November 2021, with the Life Enrichment Director (LED), on 11/03/2021 at 2:23 PM, revealed no documented evidence the resident was offered, attended, or participated in music activities, group activities or religious services or practices, per the resident's choice/preference of activities. Observations on 11/04/2021 1:14 PM, revealed the resident was lying in bed with his/her eyes closed, on his/her left side towards the bookshelf. The room was dim, the lights were off and the blinds were closed. Further observations revealed the resident's TV was turned on and a screen saver, displayed Christian music; however there was no sound. Interview with the LED, on 11/03/2021 at 2:23 PM, revealed he provided oversight over activities by assessing resident needs related to activities and asking residents what they liked to do for fun, on admission, with significant change, quarterly and as needed. These preferences were noted on the MDS Assessment and the CCP. Per interview, there were Activity Associates (AA) who worked under him to assist/work together to ensure residents engaged in activities of preference. Additional interview revealed each morning activities staff delivered the Daily Chronical, which was a facility newsletter, to each resident, and engaged with the residents prompting and encouraging them to attend and participate in activities offered later in the day. Continued interview revealed AAs approached residents unable or unwilling to participate in activities throughout the day and prompted and encouraged activities per the Activity Calendar and provided individualized one (1) on one (1) activities per the resident's preferences. These activities were documented in the POC EMR. Further, the facility had a broadcast channel, which allowed residents to engage in facility activities from their rooms if they were unable to attend activities. Per interview, music and religious services were on the calendar each month and there were four (4) music channels available on resident's TV's and the facility had radios/boom boxes for residents to utilize for music. Further interview revealed the LED was familiar with Resident #38's activity preference of music (gospel), and reading the Bible; however review of the POC activity documentation on the EMR, for Resident #38 revealed no documented evidence of those activities for November 2021. The LED stated activities staff were expected to follow up with all residents to encourage participation in activity. He stated it was important to engage residents to participate in activities of their preference to enrich their lives, which prevented depression and increased their quality of life/care. Resident #38 should be provided opportunities to engage in activities of his/her preference. Interview with State Registered Nursing Assistant (SRNA) #2, and SRNA #3, on 11/04/2021 at 4:43 PM, revealed Resident #38 loved gospel music and talking with staff. Additional interview revealed they had seen him/her TV on in the past but could not recall what was on the TV. Further, they stated they could not say activities staff did not engage with the resident; however, the only activities they were aware of that activities staff provided were the Daily Chronical and the monthly calendar. Interview with the Director of Health Services (DHS), on 11/04/2021 at 4:03 PM, revealed activities were important for all residents. Per interview, she expected residents would be engaged in preferred activities throughout the day. Continued interview revealed it was the responsibility of the whole Interdisciplinary Team (IDT) to interact and identify what resident needs and preferences were and engage/promote activities. Further, it was the IDT's responsibility to ensure activities were provided through daily rounds. Per interview, engaging residents in activities ensured better quality of life for the resident. Interview with the Executive Director, on 11/04/2021 at 6:20 PM, revealed the facility should offer/provide scheduled activities as well as individualized activities to each resident per their choices and preferences. Further interview revealed it was important to honor resident choices for activities.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed ensure residents received treatment and care in accordance with professional standards of practice, the resident's plan of care and Physicaian's Orders to meet eahc resident's physical, mental and psychosocial needs for one (1) of eighteen (18) sampled resident, Resident #12. The findings include: Review of facility policy titled Guidelines for General Wound and Skin Care, dated 05/23/2018, revealed the purpose of the policy was to provide measures to promote and maintain good skin integrity. Per policy, procedures followed included perform wound treatment and date, time, initial all dressings at time of application. Review of facility policy titled Pressure/Stasis/Diabetic Wound Guidelines, dated 05/10/2016, revealed the policy did not address following physician treatment orders. Interview with the Director of Health Services (DHS), on 11/03/2021 at 11:31 AM, revealed the facility failed to have a written policy or protocol related to following physician treatment orders. However, the DHS stated the facility's Standard of Practice related to clinical practices in the facility was the Lippincott Manual of Nursing Practice, tenth (10th) edition. Review of Resident #12's medical record revealed the facility readmitted the resident on 02/17/2021 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #12's Quarterly Minimum Data Set (MDS) Assessment, dated 08/03/2021, revealed the facility assessed the resident to have a Brief Interview of Mental Status (BIMS) score eleven (11), indicating moderate cognitive impairment. Additional review revealed, the resident was assessed to have surgical wounds and infections on both feet. Treatments included dressing to bilateral feet, surgical wound care, and pressure reducing devices for chair and bed. Further review revealed the resident required extensive assist with bed mobility and was totally dependent for transfers. Review of Resident #12's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Then apply [MEDICATION(S)] gauze to area on left foot fifth (5th) metatarsal and to right ankle; wrap with well-padded gauze bandage roll. Additionally, apply light cohesive bandage; Change daily on Monday, Wednesday, Friday; Foam dressing to left ankle only. Further, light/loose application of offloading boots. There was no documented evidence of a stop date for the order. Record Review of Resident #12's Treatment Administration Record (TAR), dated 10/01/2021 to 10/31/2021, revealed Licensed Practical Nurse (LPN) #9 initialed the TAR, indicating the treatment was completed to his/her bilateral feet, on 10/29/2021 for 6:00 AM - 6:00 PM. Further record review of the resident's TAR, for 11/01/2021 to 11/04/2021, revealed LPN #9 initialed the TAR, indicating the treatment was completed to his/her bilateral feet, on 11/01/2021 for 6:00 AM - 6:00 PM. Further record review of Resident #12's Progress Notes, dated 10/29/2021 through 11/01/2021, revealed no documented evidence treatments to the resident's bilateral feet were not completed per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 11/03/2021 at 11:37 AM, of Resident #12's dressing changes to his/her bilateral feet and ankles, by LPN #1, revealed bilateral feet and ankles were wrapped with cohesive dressings with gauze bandage underneath. Additional observations revealed there were no date, time, or initials noted on the dressings. Further observation revealed the resident had an intact foam dressing to his/her left ankle under gauze bandage, noted with a date of 10/27; however there was no year, initials, or time noted. Resident #12's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . However, two (2) of the dressings in place were not dated and one (1) dressing was dated 10/27; there was no documented evidence the dressing changes were made on 10/29/2021 or 11/01/2021 per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 11/04/2021 at 2:13 PM, State Survey Agency (SSA) attempted to contact LPN #9 via telephone; however, she was not available for interview. Interview with Resident #12, on 11/03/2021 at 11:40 AM, revealed the resident did not know when the foam dressing to his/her left ankle was changed. Interview with LPN #1, on 11/03/2021 at 11:45 AM, revealed bilateral dressing changes were done every Monday, Wednesday, Friday. Additionally, the foam dressing on left ankle was changed weekly and the bilateral boots were on at all times. Further interview with LPN #1, on 11/04/2021 at 2:10 PM, revealed after review of the resident's medical record the foam dressing to Resident #12's left ankle was ordered to be changed every Monday, Wednesday, Friday. Interview with Clinical Support Nurse, on 11/03/21 at 05:15 PM, revealed it was her expectation Resident #12's foam dressing to his/her left ankle would be changed daily on Monday, Wednesday, Friday, per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with Director of Health Services (DHS), on 11/04/2021 at 2:12 PM, revealed it was her expectation that Resident #12's surgical wound sites were cleansed, and dressings changed every Monday, Wednesday, Friday, per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to have an effective system in place to ensure each resident received adequate supervision to prevent elopement for one (1) of eighteen (18) residents; Resident #29. On 05/15/2021, the facility assessed the resident to be an elopement risk and to require a wandering system bracelet/device on his/her body. Review of the resident's Progress Notes, Care Plan and interviews with staff revealed the resident had wandering behaviors present; however, State Survey Agency (SSA) observations on 11/02/2021 and 11/03/2021 revealed the resident did not have a wandering system bracelet/device on his/her body per Physician's Orders. The findings include: Interview with the Executive Director, on 11/04/2021 at 8:30 AM, revealed the facility failed to have a policy to outline the procedure and policy related to accident hazard risk(s) including risk for elopement. Review of Resident #29's Electronic Medical Record (EMR) revealed the facility admitted the resident on 06/13/2014, with diagnoses that included Diabetes Mellitus, Hereditary Motor and Sensory [CONDITION(S)], Anxiety Disorder, Chronic Pain, Open-Angle [CONDITION(S)], Alzheimer's Disease, Dementia with Behavioral Disturbance, Unsteady on Feet, History of Falls, Major Depressive Disorder, and Unspecified [CONDITION(S)]. Review of Resident #29's EMR revealed there was no documented evidence of an Elopement Risk Assessment between January 2021 and 05/15/2021; four (4) months. Review of Resident #29's Physician's Orders, dated May 2021, revealed an order for check placement of wandering system device every shift (twice a day), with a start date of 05/15/2021. Review of Resident #29's Elopement Risk Assessment, dated 05/15/2021, revealed the resident was at risk for elopement because he/she voiced statements of leaving; exhibited periods of pacing, agitation or wandering towards an exit; and wandering when agitated. Further, the resident required an exit seeking alarm bracelet/device on the resident which required monitoring for placement and function every shift. Further review of Resident #29's EMR revealed there was no documented evidence an Elopement Risk Assessment between 05/15/2021 and 11/04/2021; six (6) months. Review of Resident #29's Comprehensive Care Plan (CCP), initiated on 05/17/2021, revealed the resident demonstrated exit-seeking behaviors. The goal was the resident would not elope from the facility. Further review revealed interventions included to assess the need for wander guard and apply as appropriate; evaluate need for secure unit and transfer if needed; and monitor wandering triggers. Review of Resident #29's Quarterly Minimum Data Set (MDS) Assessment, dated 09/18/2021, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of seven (7) out of fifteen (15), which indicated the resident had severely impaired cognition. Additionally, no behavior of wandering was present. Further, the resident had an elopement wander alarm which was used daily. Review of Resident #29's Medication Administration Record (MAR), dated 10/01/2021 through 10/31/2021, revealed an order to check placement of wandering system bracelet/device every shift; twice daily. Further review revealed twice daily nurses initialed the wandering system bracelet/device placement was checked. Review of Resident #29's Progress Notes/Clinically at Risk Individual Monitoring, dated 10/09/2021 at 8:58 PM, completed by the Director of Health Services (DHS), revealed the resident continued to have agitated behaviors, especially after 4:00 PM. Further review revealed the resident had no attempts to go to exit doors. However, a wander-guard was in place due to wandering. Review of Resident #29's Progress Notes/Clinically at Risk Individual Monitoring, dated 10/17/2021 at 8:42 AM, completed by the DHS, revealed the resident continued to have agitated behaviors, especially after 4:00 PM. Further review revealed the resident had no attempts to go to exit doors. However, a wander-guard was in place due to wandering. Review of Resident #29's Progress Notes/Clinically at Risk Individual Monitoring, dated 10/24/2021 at 9:24 PM, completed by the DHS, revealed the resident continued to have agitated behaviors, especially after 4:00 PM. Additional review revealed the resident had no attempts to go to exit doors. However, a wander-guard was in place due to wandering. Further, Psychiatric services suggested and increase in AM dose of antipsychotic medication, which was approved by the Medical Director (MD). Review of Resident #29's Progress Notes/Clinically at Risk Individual Monitoring, dated 10/31/2021 at 9:56 AM, completed by the DHS, revealed the resident continued to have agitated behaviors, especially after 4:00 PM. Further review revealed the resident had no attempts to go to exit doors. However, a wander-guard was in place due to wandering. Further review of Resident #29's Progress Notes revealed no documented evidence of ongoing Risk Monitoring between 11/01/2021 and 11/04/2021. Review of Resident #29's Medication Administration Record (MAR), dated 11/01/2021 through 11/04/2021, revealed an order to check placement of wandering system bracelet/device every shift; twice daily. Further review revealed twice daily nurses initialed the wandering system bracelet/device placement was checked. Observation, on 11/02/2021 at 9:28 AM, revealed staff had just exited the room after assisting the resident to the restroom. Resident #29 was in his/her room sitting in a wheelchair at bedside. Further, a wandering system bracelet/device was not on the resident's wrists, ankles or wheelchair. Observations, on 11/02/2021 at 11:58 PM, revealed the resident was in the main dining room at a table for lunch meal services. Additional observations revealed the resident was in a wheelchair. Further, a wandering system bracelet/device was not on the resident's wrists, ankles or wheelchair. Observations, on 11/02/2021 at 3:16 PM, revealed the resident was in bed watching television; the wheelchair was at bedside. Further, a wandering system bracelet/device was not on the resident's wrists or wheelchair. Observations, on 11/02/2021 at 5:17 PM, revealed the resident was sitting in a wheelchair at bedside. Interview with the resident at this time revealed he/she was unaware of a bracelet or device he/she wore and stated he/she did not wear jewelry. Further observations at this time revealed no wandering system bracelet/device on the resident's wrists, ankles or wheelchair. Observations, on 11/03/2021 at 8:22 AM, revealed the resident sitting in a wheelchair eating breakfast at bedside. Further, a wandering system bracelet/device was not on the resident's wrists, ankles or wheelchair. Observations, on 11/03/2021 at 10:55 AM, revealed the resident continued to sit at bedside in his/her wheelchair. Further, a wandering system bracelet/device was not on the resident's wrists, ankles or wheelchair. Observations, on 11/03/2021 at 2:20 PM, revealed the resident was in bed with his/her eyes closed. Further, a wandering system bracelet/device was not on the resident's wrists or wheelchair. Interview with State Registered Nursing Assistant (SRNA) #2, and SRNA #3, on 11/03/2021 at 4:43 PM, revealed Resident #29 had increased behaviors, agitation and wandered around the facility, in the evenings. Additional interview revealed the resident wore a wandering system bracelet/device on his/her wrist and had worn the device for several years. Further, they had never seen Resident #29 take the wandering system bracelet/device off his/her wrist. Continued interview revealed it was important the resident always had the device on to ensure he/she was safe and did not leave the facility and wander off. Observations, on 11/03/2021 at 5:00 PM, revealed the resident was in the main dining room at a table. Additional observations revealed the resident was in a wheelchair. Further observations revealed a wandering system bracelet/device was not on the resident's wrists, ankles or wheelchair. Interview with Licensed Practical Nurse (LPN) #2, on 11/03/2021 at 5:05 PM, revealed she was assigned to Resident #29 on 11/02/2021 and 11/03/2021 day shift. Per interview, Resident #29 wandered around the facility and required redirection; however she was not certain if the resident wore a wandering system bracelet/device. Additional interview revealed if a resident was assessed to require a wander guard, there would be a Physician's Order for the device. Continued interview revealed the order would populate into the Electronic MAR (EMAR) and would include checking placement and function of the device; which would be the assigned nurse's responsibility to physically check the device before initialing the EMAR. Further, the use of wandering system bracelets/devices for residents at risk for elopement, either actively exit seeking or a history of exit seeking, minimized and/or prevented the resident from going out the exit doors unsupervised. Per interview, it was important for residents who needed the devices to have them on and monitored the device routinely to keep the residents safe and free from injury(s). Continued interview revealed wandering system bracelets/devices were placed by nurses and the common practice in the facility was to place the device on residents above the waist, usually the wrist, to ensure the alarm system caught the bracelet when a resident neared an exit. Devices were never put on ankles or on wheelchairs. On 11/03/2021 at 5:30 PM, the SSA requested LPN #2 point out where Resident #29's wandering system bracelet/device was located. LPN #2 approached Resident #29, while he/she was seated at the dining room table in a wheelchair and spoke with the resident while touching the resident's wrists and ankles. LPN #2 was unable to locate Resident #29's wandering system bracelet/device. Additional interview with LPN #2, on 11/03/2021 at 5:30 PM, revealed LPN #2 and SSA reviewed the current Physician's Orders for Resident #29 on the EMR. An active order for check placement of wandering system bracelet/device twice daily, with a start date of 05/15/2021, was noted. Additional review of Resident #29's EMR, revealed on the November EMAR, LPN #2 had initialed, check placement of wandering system bracelet/device, on 11/02/2021 and 11/03/2021, day shift. Further interview with LPN #2, on 11/03/2021 at 5:35 PM, revealed LPN #2 stated Resident #29 should have a wandering system bracelet/device on, per Physician's Orders. LPN #2 stated it was her responsibility to physically check the resident to ensure the resident was wearing the wandering system bracelet/device and she had inadvertently initialed Resident #29's EMAR that she had checked the wandering system bracelet/device, on 11/02/2021 and 11/03/2021. Further, the LPN stated the resident must have removed the wandering system bracelet/device after she had checked the placement on the resident's wrist. On 11/03/2021 at 5:40 PM, the SSA accompanied LPN #2, to Resident #29's room, and observed LPN #2 as she checked the resident's room for the wandering system bracelet/device. LPN #2 stated she had never known the resident to remove the wandering system bracelet/device; however, she immediately found the wandering system bracelet/device on the room dividing bookshelf, beside the usual place the resident sat in his/her room. The wandering system bracelet/device was behind a house slipper, in the back of the shelf. The bracelet was twisted. LPN #2 stated she would re-apply a wandering system bracelet/device to the resident's wrist. Interview with the DHS, on 11/04/2021 at 4:03 PM, revealed it was the responsible of the Interdisciplinary Team (IDT) to ensure hazards and risk were identified and assessed for all residents. Per interview, residents were initially assessed for risk for elopement on admission and ongoing with the MDS schedule and as needed with any incident. Additionally, residents at risk for elopement would have interventions implemented to reduce the risk for elopement and monitoring in place to ensure compliance with the interventions. Continued interview revealed devices such as wandering system bracelets/devices required a Physician's Order and nurses were expected to lay eyes on the device before initialing off on the order; residents assessed to have a device and ordered to have a device should have a device in place. Per the DHS, she also did spot checks herself to ensure residents with wander system bracelets/devices, in fact had the device on as ordered. Further, the IDT discussed residents clinically at risk, weekly and reviewed their risk and their implemented interventions to determine if any modification were needed. Further interview revealed the DHS had not identified an issue of residents who required a wandering system bracelet/device guard not having them in place or documentation of the device not being accurate. Per interview, it was important to ensure elopement risk interventions, such as a wandering systems bracelet/device was needed and effective to reduce the risk for elopement. Interview with the Executive Director, on 11/04/2021 at 6:20 PM, revealed the facility did not have a written policy or protocol related to outline the procedure and policy related to accident hazard risk(s) including risk for elopement. Additionally, it was her expectation for staff to ensure residents were safe. She expected residents with physician's orders for wandering system bracelet/device to have those devices in place. Further the Executive Director stated nursing staff should to monitor and document placement of those devices accurately. Continued interview revealed the facility had not identified any concerns with elopement risk and wandering system bracelet/devices. Per interview, ensuring wandering devices were in place was important for the residents protection.

Based on observation, interview, record review and review of the facility's polciy, it was determined the facility failed to ensure respiratory care was provided consistent with professional standards of practice and the comprehensive care plan for two (2) of eighteen (18) residents. Observations of Resident #35 and Resident #42 on 11/02/2021 and 11/04/2021 revealed their oxygen tubing was unlabeled and there was no signage in place indicating oxygen was in use in accordance with the facility's policy. Further observation of Resident #42 revealed the tubing was crimped and the humidifier was without moisture. The findings include: Review of the facility's policy, Guidelines for properly Administering Oxygen and any Respiratory procedure, revealed that the steps for the initial application of oxygen include placing a No Smoking/Oxygen in Use sign on the outside of the room entrance door. Further review of the policy revealed that the tubing should be dated for the date it was initiated, then should be changed monthly and as needed. Review of the policy additionally revealed that a humidifier should be used for residents receiving oxygen at 4L or above and to re-check water level in humidifying jar. Interview with the Director of Health Services/Infection Preventionist (DHS/IP) on 11/04/2021 at 04:03 PM revealed that the facility did not use oxygen signage outside resident rooms because it was a non-smoking facility. She further stated that oxygen use should not be a problem in that environment. She additionally stated she would have to look at the facility's oxygen administration policy for how often tubing was changed but stated that the oxygen tubing was not labeled. The DHS/IP stated she would have to check to be sure of details, but the oxygen company came to the facility weekly to change tubing and service the concentrators. Additional interview revealed that the facility relied on the Lippincott Manual of Nursing Practice for guidance on practice issues. Review of oxygen administration practice in Lippincott's Manual of Nursing Practice revealed the standard of practice includes posting No Smoking signs on the patient's door. 1. Record review revealed the facility admitted Resident #35 on 12/30/2012 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of Resident #35 on 11/02/2021 at 9:44 AM revealed he/she was sitting in a wheelchair in a common area with supplemental oxygen applied at 2.5 Liters (L) via portable concentrator. Further observation revealed that tubing was not dated or labeled in any way. Observation of Resident #35 on 11/02/2021 at 4:25 PM revealed he/she was resting in his/her room with oxygen applied per nasal cannula (NC) at 3L, but there was no labeling on the tubing and no signage outside room that indicated oxygen in use. Observation of Resident #35 on 11/03/2021 at 9:37 AM, in his/her room revealed his/her oxygen applied per NC at 3L, and continued lack of label on the tubing, nor signage indicating oxygen use outside the room. Observation of oxygen administration for Resident #35 on 11/04/21 at 2:52 PM in his/her room at 2.5 lpm from concentrator without labeling or signage. Further observation revealed that there continued to be no date or other label on the tubing. Interview with Licensed Practical Nurse ( LPN) #6 on 11/04/2021 at 2:52 PM revealed oxygen tubing should be changed periodically and that she has seen tubing labeled and dated. Further interview revealed she was not aware of policy for changing and dating, or when oxygen tubing and humidifiers were changed. Record review revealed the facility admitted Resident #42 on 07/10/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of Resident #42 on 11/04/2021 at 3:25 PM revealed the resident was resting in room with oxygen applied at 4L with humidification per NC. Further observation revealed no signage that indicated oxygen was in use. Additional observation revealed the humidifier bottle was empty, no date or other label on tubing or humidifier bottle. Still further observation revealed tubing lying on floor and a porton of the tubing was looped inside closed bedside table drawer and two areas on tubing were crimped. Interview with LPN #4 on 11/04/2021 at 03:32 PM revealed oxygen tubing was changed regularly but that she was not aware of the particular details about timing as this taskwas carried out on night shift. She also stated that the facility typically did not post oxygen signage but would have to look up the specific policy for the details. Interview with Executive Director on 11/04/2021 at 6:09 PM revealed there ws no need for oxygen in use signage as the entire campus was smoke free. Further interview revealed that oxygen tubing changes should be documented in Matrix and signed by the nurse. She further stated she would always refer to documentation in Matrix care and was not sure about labeling tubing.

Based on observation, record review, staff interview, review of Sanitizer Wipes Manufacturer's Product Information, and review of the facility policies entitled Enhanced Prevention and Control Program for COVID-19 and Guidelines for Donning and Doffing Personal Protective Equipment (PPE), the facility failed to 1) implement their policy to follow CDC (Centers for Disease Control and Prevention) guidelines to ensure disposable face shields were dedicated to one staff member when caring for two (2) of two (2) new admission sample residents on isolation precautions for unknown COVID-19 status (Resident #1 and #4). The facility did not have a procedure for sanitizing the foam headband or the securing strap of the disposable face shield between uses; which had the potential for cross contamination. The facility also failed to 2) ensure a staff member wore eye protection and performed hand hygiene when providing care to one (1) of two (2) new admission sample residents on isolation precautions for unknown COVID-19 status (Resident # 4). These failures occurred during a COVID-19 Pandemic. The findings include: 1. During an interview with the Director of Nursing on 9/8/20 at 3:15 p.m., she indicated that newly admitted residents, without COVID-19 symptoms, were placed on transmission based precautions in a private room for a 14 day observation period due to unknown COVID-19 status. Resident #1 was admitted on [DATE] and had unknown COVID-19 status. Review of the Physician Orders dated 9/1/20 revealed Resident #1 was on contact and droplet precautions. Resident #4 was admitted on [DATE] and had unknown COVID-19 status. Review of the Physician Orders dated 9/4/20 revealed Resident #4 was on contact and droplet precautions. Observation of the multi-drawer isolation cart, located in the hallway outside the entrance to Resident #1's room on 9/8/20 at 4:00 p.m., revealed two (2) unlabeled face shields stored on the handrail just above the isolation cart. Further observation revealed the face shields were made of a clear flexible plastic looking material, with a foam head band that would rest on the wearers forehead and an elastic looking strap that snapped onto each side of the top of the face shield to secure it to the wearers head. Observation of the multi-drawer isolation cart, located in the hallway outside the entrance to Resident #4's room on 9/8/20 at 4:01 p.m., revealed three (3) unlabeled face shields stored on the handrail just above the isolation cart. On 9/9/20 at 10:44 a.m. Therapy Staff Member #1 was observed wearing a face shield while standing in the doorway of Resident #4's room, with his back to the room's inside and facing out into the hallway. He then exited Resident #4's doorway, approached the isolation cart, located in the hallway just outside Resident #4's room, and with his back to the Federal Surveyor, he was observed placing the face shield inside the bottom drawer of the isolation cart without cleaning or sanitizing it. The face shield was not labeled with the wearer's name or date and was stacked on top of other face shields in the drawer. During an interview with Therapy Staff Member #1 on 9/9/20 at 10:45 a.m., he stated that he had sanitized the face shield while inside Resident #4's room. He indicated that he did not have a dedicated face shield to use and confirmed the shield area was supposed to be sanitized with a wipe before and after use. When informed that the Federal Surveyor observed him wearing and then placing the face shield in the drawer, without sanitizing, he maintained that he had previously sanitized the face shield. Further observation of the face shield revealed it did not appear wet. Therapy Staff Member #1 was then observed sanitizing the face shield. Review of the Manufacture's information for the sanitizing wipes used to disinfect the face shields revealed, May be used on hard nonporous surfaces. On 9/9/20 at 11:30 a.m., observation of the bottom drawer of isolation cart, located in the hallway outside Resident #1's room, with the Director of Nursing (DON), revealed multiple face shields stacked on top of each other. Further inspection of two (2) of the face shields revealed the plastic shield area appeared unclear with one of the two obscured by a cloudy residue/film. The DON acknowledged the face shield with residue was not useable and needed replacement. The DON further revealed that staff did not have dedicated face shields due to the difficulty in storing them if each staff member had their own. During an interview with the DON on 9/11/20 at 8:00 a.m., she acknowledged that the facility did not have a method to adequately sanitize the foam head band on the disposable face shields between uses by more than one staff member. Review of the facility policy entitled, Enhanced Prevention and Control Program for COVID-19 revealed Refer to CDC updated guidance for Optimizing Strategies for PPE (Personal Protective Equipment) https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html. Review of the above referenced CDC document dated July 16, 2020 entitled, Optimizing Supply of PPE and Other Equipment during Shortages revealed a link to specific guidance regarding face shields in a document, dated June 28, 2020 entitled, Strategies for Optimizing the Supply of Eye Protection. Review of this guidance revealed, If a disposable face shield is reprocessed, it should be dedicated to one HCP (Health Care Professional) and reprocessed whenever it is visibly soiled or removed (e.g., when leaving the isolation area) prior to putting it back on. 2. On 9/9/20 at 9:00 a.m. Licensed Practical Nurse #1 (LPN #1) was observed in Resident #4's room wearing a gown, gloves, and a KN95 mask. She was not wearing eye protection. LPN #1 was standing approximately two feet in front of the resident and administering medication. Upon exiting Resident #4's room, LPN #1 did not perform hand hygiene after doffing her personal protective equipment (PPE) or before donning clean gloves and sanitizing the vital sign machine, she had been using in the room. Observation of the Droplet Precautions signage on the door to Resident #4's room revealed eye protection was required. During an interview with LPN #1 on 9/9/20 at 9:04 a.m., she stated that she should have worn a face shield when she went in Resident #4's room and a surgical mask over her KN95 but didn't because there were none available on the isolation cart. Observation of the isolation cart outside Resident #4's room on 9/9/20 at 9:05 a.m., revealed there was a stack of surgical masks in the top drawer and approximately five (5) face shields stacked on top of each other in the bottom drawer. The face shields were unlabeled and appeared previously used. During an interview with the Director of Nursing (DON) on 9/10/20 at 9:00 a.m., the DON stated that LPN #1 should have worn eye protection when in Resident #4's room providing medications and should have performed hand hygiene immediately after removing her gown and gloves. Review of the facility document entitled, Guidelines for Donning and Doffing Personal Protective Equipment (PPE) revealed Immediately perform hand hygiene after removing any PPE.

Based on the observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure food safety was maintained in accordance with professional standards for food services safety related, to food temperature logs. Review of the kitchen temperature logs for (MONTH) (YEAR), (MONTH) 2019, and (MONTH) 2019 revealed no documented evidence of daily temperature logs of all foods on the serving line at every meal. Findings include: Review of the facility's Food Temperature Serving line Standard Operating Procedure (SOP) for Dining Services policy, dated 03/30/18, revealed the temperature of all foods on the serving line would be measured and recorded at every meal, and at every service point. Review of the facility's Daily Data Sheet for food temperatures for (MONTH) (YEAR) revealed there was no documented evidence a Daily Data Sheet for food temperatures was completed for 12/31/18. Review of the Daily Data Sheets for (MONTH) 2019 revealed the form was completed for 01/02/19 and 01/30/18; however, there is no documented evidence the form was completed or food temperatures obtained for other days in January. Review of the Daily Data Sheets for (MONTH) 2019 revealed no documented evidence the form was completed or food temperatures were obtained for 02/01/19 and 02/02/19. Additional review of the Daily Data Sheet Food Temperature forms revealed the form was not consistently completed with the temperature obtained and documented for each food for each meal. Interview with Cook #1, on 02/07/19 at 2:27 PM, revealed thermometers were used to check food temperatures. Per interview, the food temperatures were written down on a worksheet in the Food Temperature notebook. Additionally, the temperatures should be obtained every day after the food was cooked and during holding the food before serving to the resident. Further interview revealed the plates with pureed foods temperatures were to be obtained before being served. Per interview, failure to monitor food temperatures per policy placed residents at risk of getting sick. Interview with Cook #2, on 02/07/19 at 2:31 PM, revealed food temperatures were to be obtained directly after cooking. Continued interview revealed the cooks were responsible for obtaining the temperatures and documenting them in the log. He further stated he was unaware of the location of the missing (MONTH) logs. Further interview revealed the kitchen staff had mandatory Emerge training courses related to food temperatures ranges, reheating temperatures and holding temperatures several times a year. Per interview, the reason for strict temperature monitoring was to decrease risk for bacteria. Interview with the Facility's Director of Food Services (DFS), on 02/07/19 at 2:02 PM, revealed it was the responsibility of the DFS to ensure all data in the Food Temperature log was accurate and complete. Continued interview with the DFS revealed he was very active in ensuring the Food Temperature log entries were accurate and complete per protocol. Additional interview with the DFS revealed foods temperatures should be obtained after the initial cooking and additionally at Point of Service and this documented in the Food Temperature log binder by the cook who was responsible for obtaining and documenting the temperatures. Further interview revealed there were missing temperature log sheets and he was not aware of the location of the missing Food Temperature logs. Per the DFS, the missing Food Temperatures logs were a result of the recent change in DFS position. Continued interview revealed potential consequence of not recording food temperatures was resident safety related to food borne illness, and resident happiness. Additional interview revealed recording food temperatures was a facility policy, Standard Operating Procedure (SOP) for Dining Services and he expected this to be maintained. Per interview, failure to record food temperatures was in violation of the Food Temperature Operating Policy. Interview with facility's Executive Director (ED), on 02/07/19 at 2:02 PM, revealed she was unaware of when foods temperatures were obtained or logged per the facility policy or how long the logs were to be maintained in the kitchen. She stated the importance to maintain Food Temperatures logs per policy was to ensure foods are served at a safe temperature so residents don't get sick. Additionally, she stated it was her expectation that temperatures will be done for each meal daily and to maintain the logs annually, per policy.

Based on observation, interview, record review, and review of the facility policy and protocol, it was determined the facility failed to meet professional standard of quality as outlined by the comprehensive care plan (CCP). Observation of Resident #6, on 02/06/19 at 5:45 PM, revealed three (3) medication cups sitting on the over bed table: however, there was no nursing staff present. Continued observation revealed a family administer the medication to Resident #6. The findings include: Review of the facility's (YEAR) Mandatory Training- Mandatory Med Pass competency, dated 03/26/18 revealed the Certified Resident Medication Aide (CRMA) would observe the resident consuming medication per the Six rights of Medication Administration. Review of the CRMA Medication Training course, dated 4/13/18, revealed the (CRMA) would observe the resident consuming the medication per the Six Rights of Medication administration. Continued review revealed the Six Rights of medication administration were right medication, right route, right resident, right dose, right time and right documentation. Review of the facility's Policy and Procedure for Guidelines for Medication Orders, dated 05/23/18 revealed, the CRMA would observe the resident consuming the medication per the Six Rights of Medication Administration. Review of Resident Assessment Instrument Version 3.0 Manual, dated (MONTH) (YEAR), revealed the CCP is an interdisciplinary communication too and must include measurable objectives and time frames and must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review revealed the services provided or arranged must be consistent with each resident's written Plan of Care. Review of Resident #6's Electronic Health Record (EHR) revealed he/she was admitted by the facility on 03/06/15 and readmitted by the facility on 01/14/18, with [DIAGNOSES REDACTED]. Review of Resident #6's Quarterly Minimum Data Set (MDS) assessment, dated 12/24/18, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of zero (00), indicating the resident was unable to complete the interview. Additional review revealed Resident #6 requires extensive assist of one staff for means of oral intake. Further review revealed the Resident had functional imitations in functional Range of Motion (ROM): impairment on two sides both upper extremities. Review of Resident #6's CCP, dated 07/15/18, revealed the resident had a history of [REDACTED]. Further interventions included providing supplements, vitamins and minerals as ordered, encouraging fluids, and treatment per physician orders. However, there was no documented evidence Resident #6 had been care planned to have the medications at the bedside. In addition, there was no documented evidence Resident #6 or family had been assessed by the facility to self medicate. Continued review of the CCP, dated 06/26/18, revealed the Resident #6 had the potential for alteration in nutrition and fluid status related to diagnosis, medications, physical activity, and metabolic demands with a goal to be free from any unfavorable nutrition outcomes. Further review revealed interventions included providing medications as ordered. Additional review of CCP plan, dated 07/17/17 revealed Resident #6 had potential for constipation with a goal to have regular soft formed stools. Further review revealed an intervention to administer medications as ordered. However, there was no documented evidence Resident #6 had been care planned to have the medications at the bedside. In addition, there was no documented evidence Resident #6 or family had been assessed by the facility to self medicate. Review of Resident #6's Physician's Orders, dated 02/01/18 through 02/07/19, revealed an order dated 01/14/18 for [MEDICATION NAME] solution (laxative), thirty (30) milliliters to be administered orally for constipation, once per day. Continued review revealed an order, dated 01/14/18 for Polyethylene [MEDICATION NAME] powder (stool softener), seventeen (17) grams, to be administered orally once per day. Additional review revealed an order, dated 01/14/18 for Arginad powder packet to be administered orally twice per day for wound healing. There was no documented evidence there was a physician order for [REDACTED]. Review of (MONTH) (YEAR) Medication Administration Record [REDACTED]. Observation of Resident #6, on 02/06/2019 at 12:15 PM, during lunch services in the restorative dining room, revealed that the Resident required total assistance of one staff for meal consumption. Additional observation revealed the Resident did not attempt to use his/ her arms to independently eat and their hands at rest were closed. Further, the Resident indicated desire for more food by grunting and opening his/ her mouth. Additional observation of Resident #6, on 02/06/19 at 5:45 PM in the Resident's room revealed the Resident's mother assisted him/her with the evening meal. Additional observation revealed the Resident's mother provided total assistance with eating. The Resident was lying in bed, opening his/ her mouth, grunting occasionally, looking at his/ her mother. Further observation revealed the mother picked up each cup of medication, mixed it with the Resident's drinks, and offered fluids to resident. The resident drank each cup of fluid with medications mixed into the fluid. Interview with Resident #6's mother, on 02/06/19 at 5:45 PM, revealed that the cups of medication were frequently left for her to mix with fluids during evening meals related to the Resident's frequent refusal to accept the medications. Further interview revealed while the mother was aware of medications and their indications, she had not been assessed for safe medication administration. Interview with CRMA #1, on 02/06/19 at 6:05 PM, revealed she had been a CRMA for twenty (20) years, and with this facility for a year and a half. Additional interview revealed CRMA initially had denied leaving the medication at bedside unattended, but later recanted and stated Resident #6's mother had requested the CRMA to leave the [MEDICATION NAME], Polyethylene [MEDICATION NAME], and Arginad at the bedside. Continued interview revealed she knew leaving the medications at the bedside was an improper practice. Further interview revealed a possible negative consequence would be another Resident coming into the room and consuming the medications. Interview with Licensed Practical Nurse (LPN) #3, on 02/06/19 at 5:58 PM, revealed CRMA #1 was responsible for administering medications to Resident #6. Additionally, LPN #3 stated that medications should not be left at bedside unattended unless the Resident or Resident representative has been assessed and care planned for safe self- administration of medications. Continued interview revealed it was important to observe medication consumption to ensure that the correct Resident received the correct medication. Per interview, LPN #3's expectation of CRMA was to administer medication per the facility policy and standard of practice and maintaining the Six rights of medication administration. Further interview revealed it was common practice that Resident #6's mother would administer the medication due to the Resident's reluctance to consume medications; however, she should be assessed to do so and Resident #6 should be care planned for this. Interview with the Director of Health Services (DHS), on 02/07/19 at 3:45 PM, revealed the practice of leaving [MEDICATION NAME], Polyethylene [MEDICATION NAME], and Arginad at the bedside unattended, in a Resident room, was against facility policy and procedure. Continued interview revealed the possible negative consequence was another Resident would consume the medications. Per DHS, the Resident's mother had not been assessed for safe self administration, and the Resident had not been care planned for self administration. Additionally, the DHS reported that annual training of the six (6) Rights of medication administration reinforced this standard of practice. Interview with the Executive Director (ED), on 02/07/19 at 3:45 PM, revealed the practice of leaving [MEDICATION NAME], Polyethylene [MEDICATION NAME], and Arginad at bedside, unattended in a Resident room was against facility policy and procedure. The ED further acknowledged another Resident entering the room and consuming the medication would have a negative consequence. Continued interview revealed it was her expectation for staff to follow the facility's policy and procedure for medication administration.

Based on observation, interview and record review, it was determined the facility failed to provide reasonable accommodation of needs for three (3) of six (6) sampled residents, Resident #1, Resident #2 and Resident #4. Observation on 06/11/18 revealed the call bell was not accessible for Resident #1 and Resident #2 on multiple occasions. Additionally, review of a closed record for Resident #4, revealed an incident documenting the call bell not accessible to the resident. The findings are: Review of the facility policy titled, Guidelines for Answering Call Lights revised on 5/11/16 and reviewed on 5/22/18, revealed staff were to ensure the call lights were plugged in securely to the outlets and in reach of the resident. 1) Review of the medical record revealed, Resident #1 was admitted by the facility, on 11/12/17 and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 05/29/18, revealed Resident #1 was assessed by the facility to have a Brief Interview for Mental Status (BIMS)score of twelve (12) out of fifteen (15), indicating he/she was assessed to be moderately impaired. Continued review revealed, the facility assessed Resident #1 to require extensive assist with two (2) staff for transfers, bed mobility, toileting, hygiene, bathing and extensive assist with one person and a wheelchair for locomotion. The resident was also assessed to have limited range of motion in both upper and lower extremities on one side. Further review of the MDS revealed, the resident had two falls in the review period without injury. Record review revealed, Resident #1 had an event, on 05/15/18 at 1:06 PM, in which he/she was noted to be lying in the floor in front of the recliner with the recliner in an elevated position. Further review revealed, Resident #1 did not have any noted injuries. Continued review revealed Dycem was added to the recliner to prevent sliding and the resident was to have his/her call light in reach. Record Review of Resident #1's care plan revealed, the resident was identified with a problem of Falls, on 11/25/ , with a goal that the resident would remain free of falls with major injury. Continued review revealed, interventions in place included for the resident to keep the call light within reach. Observation of Resident #1, on 06/11/18 at 12:05 PM, revealed the resident sitting in a recliner by the window. Continued observation revealed, Resident #1's call bell was noted to be on the floor beside the bed and not within reach of the resident. Interview with Resident #1, on 06/11/18 at 12:06 PM, revealed Resident #1 was able to push the call bell for any needs if it was accessible. Continued interview revealed, he/she was not given the call bell when he/she transferred to his/her chair that day and he/she did not think to ask for it. Further interview revealed, Resident #1 does use call bell to let staff know of needs. Per interview, staff occasionally do not place the call light within his/her reach and when that happens, he/she has no way to contact staff for assistance. 2. Review of the medical record revealed, Resident #2 was admitted by the facility on 03/21/18 with [DIAGNOSES REDACTED]. Review of the Admission MDS Assessment, dated 03/28/18, revealed the facility assessed Resident #2 to have a BIMS score of fifteen (15) out of fifteen (15), indicating the resident to be cognitively intact. Continued review revealed, the facility assessed the resident to require extensive assist of two staff members for bed mobility, transfers, toileting, dressing, hygiene and bathing and extensive assist of one staff for locomotion. Record review of Resident #2's care plan, dated 03/28/18, revealed the facility identified the resident to be at risk for falls related to weakness. Continued review revealed the goal of the resident was he/she would remain free of falls with major injury. Further review revealed, an intervention was to keep the call light within the resident's reach. Observation of Resident #2, on 06/11/18 at 12:15 PM, revealed the resident in a wheelchair in his/her room with the call bell hanging behind the bed and on the floor and not within reach of the resident. Continued observation, at 2:15 PM, revealed Resident #2 in a wheelchair in his/her room with the call bell hanging behind the bed on the floor and not within reach of the resident. Observation at 3:15 PM, revealed Resident #2 in a wheelchair in his/her room with the call bell hanging behind the bed on the floor and not within reach of the resident. Interview with Resident #2, on 06/11/18 at 2:45 PM, revealed the resident was able to use the call bell for needs if it was accessible. Resident #2 stated, he/she did need staff assistance for help to carry out his/her activities of daily living and the call light was how she notified staff he/she needed help. Resident#2 stated, staff usually came in a timely manner when he/she used the call bell. Per interview, staff occasionally do not place his/her call light within his/her reach and when that happens, he/she has no means to contact staff for assistance. 3) Review of Resident #4's closed medical revealed, he/she was admitted by the facility on 05/02/18 with [DIAGNOSES REDACTED]. Review of Resident #4's Admission MDS Assessment, dated 05/09/18, revealed the facility assessed the resident to have a BIMS of eight (8) out of fifteen (15), indicating the resident was moderately impaired. Continued review revealed, the facility assessed Resident #4 to require extensive assistance of two staff members for transfers, bed mobility, toileting, hygiene, and bathing and one person extensive assistance for locomotion and eating. Further review revealed, Resident #4 was assessed by the facility to have had falls prior to admission to the facility. Per the Care Area Assessment (CAA) the resident was assessed by the facility to trigger for fall risk. Review of Resident #4's incident report, dated 05/13/18, revealed he/she had a call bell attached to his/her gown at rounds at 6:00 AM per staff report. Continued review revealed, when the Resident's daughter arrived at 8:00 AM, the call bell was clipped to the wall. Further review revealed, the resident reported a female staff person had taken the call bell away from her during the night. Interview with Resident #4's daughter, on 06/11/18 at 8:40 AM, revealed on the morning of 05/13/18, during the nightshift (11:00 PM to 7:00 AM), someone came into her parent's room and took his/her call bell off of his/her gown and would not give the call bell back. Continued interview revealed, staff told the resident he/she did not need it. Per the daughter, her parent was visually impaired and could only recognize it was a female staff member. Per interview, he/she did not have the call bell available to him/her that morning at breakfast. Further interview revealed, she notified the facility and initiated an investigation with the facility about what happened and the police were called. The facility was supposed tell her what happened; however, it was handled internally and the resident nor the family were aware of what happened with the investigation. Interview with State Registered Nursing Assistant (SRNA) #1, on 06/11/18 at 5:00 PM, revealed she had been employed by the facility for two years. Per interview, all staff should follow the policy related call bells and make sure the resident's have call bells within arms reach. Continued interview revealed, this was important for the safety and comfort of the resident, so they could have their needs met. Further interview revealed, there could possibly be a negative impact if resident's did not have access to the call bells because it could be a safety concern and their needs might not be met. Per interview, the aides should be making rounds every two hours to ensure the residents have the call lights and their needs were met. Interview with Licensed Practical Nurse (LPN) #1, on 06/11/18 at 5:50 PM, revealed she had been employed by the facility for two (2) years. Per interview, it would be her expectation for all staff to follow the policy and ensure the call bells were accessible to the residents. Continued interview revealed, failure for residents to have call bells available to them could mean the resident might not have their needs met and could have a negative consequence up to and including falls and injury. Per interview, it was important to follow the facility policy related to call bells regardless of resident cognition and physical deficits. She reported, all staff should check for call bell accessibility when rounding or performing tasks in the residents rooms. Interview with the Assistant Director of Health Services, on 06/11/18 at 6:25 PM, revealed she had been employed by the facility for one (1) year. Per interview, it would be her expectation for all staff to follow the facility's policy regarding call lights and make sure call lights were accessible to the residents. Continued interview revealed, this was important for the well being of the resident's to ensure their safety and that the their needs were met. Further interview revealed, if call bells were not accessible to the residents there could be negative consequences for the residents. Interview with the Executive Director, on 06/11/18 at 6:35 PM, revealed she had been employed by the facility for one (1) year. Per interview, it would be her expectation for staff to follow the facility's policy related to call bells and for residents to have call bells accessible to them at all times, regardless of cognitive or physical abilities. Continued interview revealed, this was important so the facility could provide for the resident needs and so the resident would be able to notify the staff regarding those needs. Per interview, there could be negative consequences for the residents as a result of not having access to the call bell system.

Based on interview and record review, it was determined the facility failed to ensure comprehensive care plans that are prepared by an interdisciplinary team involves the participation of the resident and the resident's representative unless the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan for five (5) of nineteen (19) sampled residents (Residents #4, #11, #15, #17, and #32). There was no documented evidence of Care Plan Meetings involving the interdisciplinary team and the resident and the resident's representative after each Assessment including both the Comprehensive and Quarterly review Assessments for Residents #4, #11, #15, #17, and #32. The findings include: Review of the Centers for Medicare and Medicaid Services (CMS) Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.15 dated, (MONTH) (YEAR), revealed chapter 2 section 2.7 page 2-42 stated the resident's care plan must be reviewed after each assessment and revised based on changing goals and preferences and needs of the resident in response to current interventions and resident preferences. Goals change so the facility should have ongoing discussion with the resident and resident representative so that changes can be referred to the comprehensive care plan. Chapter 4 section 4.7 page 4-10 revealed, the care plan should be interdisciplinary and reflect the resident and the resident representative goals and desired outcomes. 1. Review of Resident #4's medical record revealed the facility admitted the resident on 02/21/17 with [DIAGNOSES REDACTED]. Review of the resident's Minimum Data Set (MDS) Assessments revealed Quarterly MDS Assessments were completed on 05/24/17 and 11/09/17. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as severely cognitively impaired and unable to complete a Brief Interview for Mental Status (BIMS). Further review of the medical record revealed there was no documented evidence of Care Plan Meetings by the Interdisciplinary team and no documented record of resident or resident representative input for the Comprehensive Care Plan after these MDS Assessments were completed. In addition, there was no explanation included in the resident's medical record if the participation of the resident and their resident representative was determined not practicable for the development of the resident's care plan. 2. Review of Resident #32's medical record revealed the facility admitted the resident on 03/06/15 and readmitted the resident on 01/14/18 with [DIAGNOSES REDACTED]. Review of the resident's MDS Assessments revealed an Annual MDS assessment dated [DATE]; Significant Change MDS assessment dated [DATE]; and a Quarterly MDS assessment dated [DATE]. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident as severely cognitively impaired. Further review of the medical record revealed there was no documented evidence of Care Plan Meetings by the Interdisciplinary team and no documented record of resident or resident representative input for the Comprehensive Care Plan after these MDS Assessments were completed. In addition, there was no explanation included in the resident's medical record if the participation of the resident and their resident representative was determined not practicable for the development of the resident's care plan. 3. Review of Resident #15's medical record revealed the facility admitted the resident on 09/01/17 with [DIAGNOSES REDACTED]. Review of the resident's MDS Assessments revealed an Admission assessment dated [DATE]. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident as having a BIMS score of thirteen (13) out of fifteen (15) indicating the resident was cognitively intact. Further review of the medical record revealed there was no documented evidence of Care Plan Meetings by the Interdisciplinary team and no documented record of resident or resident representative input for the Comprehensive Care Plan after these MDS Assessments were completed. In addition, there was no explanation included in the resident's medical record if the participation of the resident and their resident representative was determined not practicable for the development of the resident's care plan 4. Review of Resident #17's medical record revealed the facility admitted the resident on 06/13/14 with [DIAGNOSES REDACTED]. Review of the resident's MDS Assessments revealed an Annual MDS assessment dated [DATE]; a Quarterly MDS assessment dated [DATE]; a Quarterly MDS assessment dated [DATE]; and a Quarterly MDS assessment dated [DATE]. Review of the Annual MDS assessment dated [DATE] revealed the facility assessed the resident to have a BIMS score of eleven (11) out of fifteen (15) indicating the resident was moderately cognitively impaired. Further review of the medical record revealed there was no documented evidence of Care Plan Meetings by the Interdisciplinary team and no documented record of resident or resident representative input for the Comprehensive Care Plan after these MDS Assessments were completed. In addition, there was no explanation included in the resident's medical record if the participation of the resident and their resident representative was determined not practicable for the development of the resident's care plan 5. Review of Resident #11's medical record revealed the facility admitted the resident on 06/01/17 with [DIAGNOSES REDACTED]. Review of the resident's MDS Assessments revealed an Admission MDS dated [DATE]; Quarterly MDS assessment dated [DATE]; and a Quarterly MDS assessment dated [DATE]. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident as having a a BIMS score of fifteen (15) out of fifteen (15) indicating no cognitive impairment. The facility was able to produce a letter dated 12/13/17 and a letter dated 03/17/18 addressed to the resident inviting the resident to the care conference or Resident First meeting. However, there was no documented evidence of Care Plan Meetings or facility Resident First Meetings by the Interdisciplinary team and no documented record of resident or resident representative input for the Comprehensive Care Plan after these MDS Assessments were completed in the medical record. In addition, there was no explanation included in the resident's medical record if the participation of the resident and their resident representative was determined not practicable for the development of the resident's care plan Interview on 05/10/18 at 3:00 PM with Resident #11, revealed the resident did not remember ever attending a Care Plan or Resident First Meeting with the staff to discuss his/her care or care plan. Continued interview revealed the resident did not remember receiving any letters with an invitation to a Care Plan or Resident First Meeting. Per interview, nurses and other staff would come to his/her room to talk at times, but there was never any meeting. Interview with the Social Service Director (SSD) on 05/10/18 at 5:45 PM, revealed she had been employed by the facility for one (1) year and four (4) months. Continued interview revealed the facility followed the CMS RAI Manual as the guide for the care planning process and care plan meetings. Per interview, the facility documented care plan meetings as Resident First meetings in the Electronic Medical Record. She stated there were Resident First Care Plan meetings after each MDS Assessment with the Interdisciplinary Team to review the care plan and to discuss resident care even if the resident or resident representative chose not to come. She stated there should have been documentation in the EMR related to these Resident First Care Plan meetings as proof the facility held the meetings. Continued interview revealed the missing documentation may be because the facility switched from paper charting to Electronic Medical Record in (YEAR) and all the records may have not been carried over properly. Per interview, it was important to have resident and resident representative input into the Care Plan and to document their involvement in the medical record. Interview with the MDS Coordinator, on 05/10/18 at 4:30 PM, revealed it was important to have Interdisciplinary meetings involving the staff and the resident and/or the resident representative for continuity of care and to ensure the facility was following a team approach. Further interview revealed these meetings should be documented as per the CMS RAI guidelines. Interview with Assistant Director of Health Services, on 05/10/18 at 4:38 PM, revealed it was important to have care plan meetings with the Interdisciplinary team and the resident and/or resident representative to make sure the resident was receiving appropriate care. make sure everyone was on the same page and to make any appropriate changes to the plan of care. Further interview revealed the care plan should be an accurate picture of the resident and should be updated to reflect any changes which was a team approach. Per interview, documentation of this process was important to provide an accurate medical record. Continued interview revealed it was important the facility follow CMA RAI guidelines related to the care planning process and documentation. Interview with the Director of Health Services, on 05/10/18 at 5:00 PM, revealed staff were to follow the RAI manual, related to the care planning process and to document care plan meetings in the Electronic Medical Record. Per interview, care plan meetings were important to ensure staff were meeting the needs of the residents. She further stated it was important to involve the resident and the resident's representative in the meetings to ensure they were aware of exactly what the care plan entailed. Interview with Executive Director on 05/10/18 at 5:45 PM, revealed there should be documentation of Care Plan Meetings or facility Resident First Meetings held by the Interdisciplinary team along with documentation of the resident's or resident representatives involvement with Care Planning after MDS Assessments were completed for Comprehensive and Quarterly MDS Assessments to ensure proper development and revision of the Care Plan. Per interview, the Resident First Meetings were to be documented in the EMR with the names of who attended and the date and time of the meeting.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to establish mechanisms for documenting and communicating the resident's choices to the interdisciplinary team and to the staff responsible for the resident's care for one (1) of nineteen (19) sampled residents (Resident #7). Resident #7 was admitted to the facility on [DATE] as Full Code Status, and on [DATE] physician's orders [REDACTED]. However, a printed Face-Sheet for the resident, available at the nursing station in a Binder with information used by staff to provide care, revealed the resident's Code Status was Full Code. The findings include: Review the facility's Guidelines for Advance Directives Policy, revised [DATE], revealed Advanced Directives will be reviewed with resident and/or surrogate by the Director of Resident Services or designee at the time of admission, with the annual comprehensive assessment and as needed to ensure the facility staff obtain and follow resident's Advance Directives regarding end of life care. Review of Resident #7's Electronic Medical Record (EMR) revealed the facility admitted the Resident on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #7's EMR Face-Sheet, revealed the Resident's Advance Directive included Do Not Resuscitate (DNR), with a copy on file. Additional review revealed the resident's Responsible Party/Legal Oversight Guardian was his/her granddaughter. Further review of Resident #7's EMR, revealed a Consent for Cardiopulmonary Resuscitation (CPR), dated [DATE], stating It is my desire that I be given CPR, signed by the resident's granddaughter. Review of Resident #7's EMR Physician Documents, revealed a Progress Note for Skilled Nursing Facility (SNF) Evaluation, dated [DATE], noting Full Code Status. Review of the EMR physician's orders [REDACTED]. Review of Resident #7's Kentucky Emergency Medical Services DNR Order Form, dated [DATE], revealed this document is my authentic wish not to be resuscitated, signed by the resident's granddaughter. Review of Resident #7's EMR Physician Documents, revealed Physician Assessments dated [DATE], and [DATE], which stated Code Status DNR. Review of Resident #7's documents, in the tabbed Binder on the nursing desk, revealed a printed Kentucky Emergency Medical Services DNR Form, dated [DATE]. However, the binder also included a printed Face-Sheet noting Full Code. Interview with Customer Service Specialist (CSS), on [DATE] at 02:23 PM, revealed on admission any Advance Directives documents, including Code Status were obtained from the Resident and/or Resident representatives. Per interview, those documents were given to the Minimum Data Set (MDS) Nurse who was responsible to update the Advance Directives Care Plan; and nursing staff was responsible for updating the printed Face-Sheet at the nurse's desk Binder, and obtaining a physician's orders [REDACTED]. The CSS further stated the Director of Social Services (DSS) was responsible for updating the Face-Sheet in the EMR; and Medical Records was responsible for scanning documents into the Electronic Medical Records (EMR). Further interview revealed the DSS was responsible for all changes to a Resident's Advance Directives or code status after admission. The CSS stated he recalled Resident #7's Code Status was Full Code on admission, and after guardianship was established, his/her code status changed to DNR. Interview with the Director of Social Services (DSS), on [DATE] at 02:30 PM, revealed nursing was responsible to change the Resident Face-Sheet related to Advance Directives including updating the Face-Sheets in the Binder at the nurses desk. Interview with Medical Records staff member, on [DATE] at 2:40 PM, revealed she was responsible for scanning Advance Directives into the EMR. She stated Resident Face-Sheets were updated by nursing on admission and with any change. Additionally, she stated nursing was responsible for updating Face-Sheets in the Binders at the nurse's desk. Interview with Licensed Practical Nurse (LPN) #1, on [DATE] at 2:47 PM, revealed floor nurses were not responsible to ensure the Profile Book and Electronic Medical Record had matching Code Status information for each resident. LPN #1 stated the resident's Code Status was in the EMR; however, the Binder at the nurse's station included Resident Face-Sheets and documents to support Code Status, such as a Cardio [MEDICAL CONDITION] Resuscitation (CPR) Consent, or Do Not Resuscitate (DNR) Forms. Further interview revealed the process for changing a resident's Code Status was to make a copy of the document, place it in the Binder at the nurse's desk, under the appropriate Resident's tab, and call the physician to get a Code Status order. She stated she was unaware of who was responsible for updating the Face Sheets in the Binder related to code status. LPN #1 stated it was important to have accurate knowledge of a resident's requested Advance Directives and Code Status to ensure care was provided to the resident per their wishes. Per interview, Code Status needed to be accurate in all areas of the medical record to ensure residents' Advance Directives were honored. Interview with the Director of Health Services, on [DATE] at 3:10 PM, revealed her understanding of the facilities process related to Advance Directives was that the CSS obtained initial paper work from residents and families on admission to the facility, and nursing staff were responsible for obtaining a physician's orders [REDACTED]. Per interview, Medical Records was responsible for scanning related documents into the EMR. Additionally, the DON stated nursing staff was to check the EMR if there was an emergency and a need to check code status because the Binder at the nurse's desk is a workbook, not source of truth. However, she stated she expected the facility policy related to Advance Directives to be followed and Advance Directives and Face-Sheets to be maintained accurately to ensure residents' wishes related to code status was honored. The DON stated she was unaware of who was responsible for ensuring the Face-Sheets in the Binder at the nurses desk were accurate for code status. Interview with the Executive Director (ED), on [DATE] at 3:39 PM, revealed during the admission process, Code Status and Advance Directives documents were obtained from the Resident or Responsible Party by the CSS, and then given to Medical Records and scanned into the individual Resident's EMR. She stated nursing was responsible for obtaining a physician's orders [REDACTED]. Further interview with the ED, revealed nursing was responsible for maintaining the Binder at the nursing desk that contained Resident Face-Sheets and Code Status forms, and it was important the Face Sheets in the Binder have accurate information related to Code Status because it was a resource for staff in a medical emergency. Per interview, if the medical record was not accurate related to code status, residents may not have their Advance Directives honored.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to consult with the resident's physician when there is a need to alter treatment for one (1) of nineteen (19) sampled residents, (Resident #98). Resident #98 was admitted to the facility on [DATE], post Total Right Knee Replacement, with physician's orders [REDACTED]. New physician's orders [REDACTED]. The findings include: Review the facility's Guidelines for Change in Resident Condition Policy, undated, revealed the clinical team is committed to observe, monitor and track behaviors and address change in needs of each resident. Further review revealed licensed professional nurses will notify the physician and responsible party of resident change of needs and document the resident's change and notification in the Electronic Medical Record. Review of Resident #98's Medical Record revealed the facility admitted the Resident on 04/27/18, with [DIAGNOSES REDACTED]. Review of Resident #98's Admission Minimum Data Set (MDS) Assessment, dated 05/04/18, revealed the facility assessed Resident #98 to have a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15) indicating the resident was cognitively intact. Further review of the MDS, revealed the facility assessed the resident as having a surgical wound with ordered wound care. Review of Resident #98's Physician order [REDACTED]. Additionally, there was a physician's orders [REDACTED]. Review of Resident #98's Comprehensive Care Plan, dated 05/01/18, revealed the resident was at risk for pain related to right total knee arthroplasty. The approaches included administer medications as ordered and notify physician for side effects observed; notify physician of increased pain; and ACE wraps/Ted hose per physician's orders [REDACTED].>Review of Resident #98's Treatment Administration History, dated 05/01/18 through 05/09/18, revealed documentation indicating daily administration of Bilateral ACE wraps/Ted hose. However, observation on 05/07/18 at 06:54 PM; 05/08/18 at 09:49 AM and 3:30 PM, and 05/09/18 at 08:15 AM; and 05/10/18 at 09:24 AM; revealed there were no ACE wraps or Ted hose on the resident's lower extremities. Review of Resident #98's Progress Notes, revealed no documented evidence the resident refused, removed, or preferred another treatment to bilateral lower legs. In addition, there was no documented evidence the Physician was notified of the Resident not wearing the ACE wraps or Ted hose to the lower extremities per record review 05/07/18 through 05/09/18. Interview with Resident #98, on 05/08/18 at 3:30 PM, revealed nursing staff had offered to apply ACE wraps to his/her lower legs daily; however, he/she preferred to wear compression hose his/her family had provided. Continued interview revealed the Resident had terrible right ankle pain related to the compression hose the facility provided being too small. Additionally, Resident #98 stated he/she was prescribed pain medication, which did not relieve the right ankle pain, but when he/she had gone for his/her surgery follow up appointment, the first week of May, the compression hose were removed and his/her ankle pain was immediately relieved. Resident further stated ACE wraps or Ted hose had not been applied since Sunday, 05/05/18. Interview with Certified Resident Care Assistant CRCA #1, who was assigned to Resident #98, on 05/10/18 at 2:34 PM, revealed she was aware Resident #98 was supposed to wear Ted hose or wraps to his/her bilateral lower legs. However, she stated Resident #98 always removed the treatment to his/her bilateral lower legs. CRCA stated she had given Resident #98 several pairs of Ted hose from the storage room. Additionally, CRCA stated Resident #98 was alert and oriented and able to verbalize choices and preferences. Further interview revealed Resident #98 told her he/she did not want to wear the Ted hose or ACE wraps related to pain in his/her lower legs. CRCA stated she should have notified the nurse the Resident removed his/her Ted hose or Ace wraps to bilateral lower legs. Interview with Licensed Practical Nurse (LPN) #1, on 05/10/18 at 2:47 PM, revealed when a resident chooses not to follow physician's orders [REDACTED]. Additionally, she stated she was aware Resident #98 had physician ordered treatments to his/her bilateral lower legs; however, the Resident would remove the Ted hose and ACE wraps. Continued interview revealed she should have notified the physician related to Resident #98 removing the Ted hose and ACE wraps routinely and documented the refusal of treatment. LPN stated she was not aware the Resident preferred an alternative treatment related to his/her lower extremities or had pain with treatment. Further interview revealed it was important to notify the physician if an alternate treatment was needed because if physician's orders [REDACTED]. Interview with the Director of Health Services, on 05/10/18 at 3:10 PM, revealed the physician should be notified by nursing staff for any changes in a resident's condition or a need to alter treatment. Per interview, the Physician should have been notified the resident was not wearing the ACE wraps and Ted hose since this was an ordered treatment and this notification should have been documented in the medical record. Interview with the Executive Director (ED), on 05/10/18 at 3:39 PM, revealed any change in a resident's condition requires physician notification, and a related Event Note or Progress Note. Further interview, revealed if physician's orders [REDACTED]. Per interview, it was important to obtain necessary orders, maintain continuity of care, and provide the best care to the Resident.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure each resident receives an accurate Assessment, reflective of the resident's status, for one (1) of nineteen (19) sampled residents (Resident #7). Resident #7 was admitted on [DATE] to the facility with bilateral upper and lower extremity contractures; however, the Admission Minimum Data Set (MDS) assessment, dated 02/16/18, did not identify the resident's impairments and functional limitations in range of motion to the lower extremities. The findings include: Review of the Centers for Medicare and Medicaid Services: Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, version 1.15, dated (MONTH) (YEAR), revealed the primary purpose of the MDS Assessment was to identify resident care problems, address resident problems in individualized care plans, and monitor the quality of care provided to residents. Additional review revealed Functional Limitations in Range of Motion (ROM) were defined as the limited ability to move a joint that interferes with daily functioning (particularly with activities of daily living) or places the resident at risk of injury. Further review revealed the Assessment should be an accurate reflection of the resident's status. Review of Resident #7's medical record revealed the facility admitted the Resident on 02/09/18, with [DIAGNOSES REDACTED]. Review of the Admission Documents included a Monthly Summary, dated (MONTH) (YEAR), from the previous facility, which revealed the resident had leg contractures. Review of the Physician's Progress Note for Skilled Nursing Facility (SNF) Evaluation, dated 02/12/18, revealed the resident was very contracted. Review of Resident #7's Admission Minimum Data Set (MDS) Assessment, dated 02/16/18, revealed the facility assessed the resident as having impaired cognition and as unable to complete a Brief Interview for Mental Status (BIMS). Further review of the MDS Assessment revealed the facility assessed the resident as requiring extensive assistance of two (2) staff for bed mobility, transfers, dressing, and toileting; and total assistance of two (2) staff for bathing; and extensive assistance of one (1) staff for eating. However, further review of the MDS Assessment revealed there were no functional limitations in Range of Motion (ROM) for upper or lower extremities. Review of Resident #7's Occupational Therapy (OT) Plan of Care, start date 02/23/18, revealed OT was necessary for Resident #7 for wheelchair positioning, sensory stimulation, and risk for increased contractures. The Goal was to decrease activity limitations and participation restrictions. Further review revealed the resident was dependent in all Activities of Daily Living and underlying impairments included functional limitations in bilateral upper extremities, and inability to sit unsupported secondary to resident in fetal position. Review of Resident #7's OT Daily Treatment Note, dated 03/01/18, revealed ROM to bilateral upper extremities and lower extremities was tolerated well. Review of Resident #7's OT Progress and Discharge Summary, dated 03/12/18, revealed the resident made good progress over the course of OT treatment and continued to show progress towards sitting tolerance in broad chair and interaction with environment and continued to be totally dependent for functional mobility and fall risk. Per the Summary, Staff training included education on positioning in broad chair and getting up into chair daily for meals and interaction with the environment. Review of Resident #7's Comprehensive Care Plan, dated 03/08/18, revealed Functional Limitations in ROM were not identified as a resident care problem and an individualized care plan was not developed related to the resident's contractures of the lower extremities. Additionally, the Comprehensive Care Plan did not include approaches to monitor and maintain the Resident's limited ROM. Review of Resident #7's Progress Notes, dated 04/01/18 through 05/09/18, revealed no documentation related to Functional Limitations in ROM. Observation of Resident #7, on 05/07/18 at 6:34 PM, revealed the resident had hip flexion, and right hip adduction, knees rotated inward and flexed. The resident's Right knee had greater flexion than left. The resident's Right heel was touching his/her right buttocks. Interview with Minimum Data Set (MDS) Coordinator #1, on 05/10/18 at 3:45 PM, revealed during the Assessment Reference Date (ARD), documentation in the medical record was reviewed, nursing staff familiar with residents were interviewed and a hands on resident assessment was completed for information. Per interview, a true picture of the resident and their needs should be captured in the MDS Assessment. She stated Resident #7's contractures should have been identified and reflected on the MDS assessment. Further interview revealed accurate MDS Assessments were important because they guided Care Plans, referrals, and treatment for [REDACTED]. Further interview revealed Limitations in Functional ROM were to be specifically assessed during the ARD and identified concerns were to be addressed by the interdisciplinary team. Interview with Licensed Practical Nurse (LPN) #1, who was the nurse assigned to Resident #7, on 05/10/18 at 2:47 PM, revealed floor nurses were not involved with MDS process Additionally, she stated she did not know how to access the MDS in the EMR. However, she stated it was important to assess and monitor residents for any decline or worsening condition such as contractures to ensure they received needed care and appropriate services. LPN stated Resident #7's legs had always been contracted. Interview with the Director of Health Services, on 05/10/18 at 3:10 PM, revealed the Resident Assessment Instrument (RAI) Manual was the guideline used by the facility to ensure accurate assessments were completed. Per interview, the MDS Assessment guided the development of the Comprehensive Care Plan and therefore the MDS Assessment was to be an accurate reflection of the resident's status to ensure resident's received appropriate services and individualized care. Further interview, revealed it was important to provided treatment and services for Residents with limited ROM to prevent worsening limitations in mobility. Continued interview revealed the MDS assessment for Resident #7 should have identified his/her contractures. Additionally, she stated the MDS auditing process should have identified the MDS assessment for Resident #7 was inaccurate. Interview with the Executive Director, on 05/10/18 at 3:39 PM, revealed the RAI User Manual and Federal guidelines were the facility resources for guidelines to ensure accurate MDS Assessments. Additional interview revealed it was important for a resident with limited ROM to be assessed accurately to ensure they received the best care and were provided needed services and treatments to maintain current ROM and to prevent pain or worsening contractures. Further interview revealed the facility failed to accurately assess Resident #7's functional limitations in Range of Motion (ROM) on the most recent MDS Assessment.

Based on observation, interview, record review, and review of facility policy, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for each resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for two (2) of nineteen (19) sampled residents (Resident #7 and #32). Resident #32 was assessed in a Significant Change Minimum Data Set (MDS) assessment dated [DATE], and in a Quarterly MDS Assessment, dated 04/09/18, as having Functional Limitations in Range of Motion (ROM) in bilateral upper extremities. However, the Comprehensive Care Plan was not developed to address the resident's Limitations in ROM/contractures. In addition, although Resident #7 was admitted to the facility on [DATE] with Functional Limitations in Range of Motion (ROM) and contractures to bilateral upper and lower extremities; the Admission Minimum Data Set (MDS) Assessment did not identify the contractures and a Comprehensive Care Plan was not developed related to the resident's Limitations in ROM. (Refer to F-641) The findings include: Review of the facility Interdisciplinary Team Care Guideline Policy, revised 06/2015, revealed to ensure appropriateness of services and communication of the resident's needs, severity of conditions, impairments, disability, or disease, a Comprehensive Care Plan will be developed reflective of the individual's needs and risks. Review of the Centers for Medicare and Medicaid Services (CMS) Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.15 dated, (MONTH) (YEAR), Chapter 4 section 4.7, revealed the comprehensive care plan should be interdisciplinary and identify and document the functional and behavioral implications of identified problems, limitations, and maintenance levels. Further review revealed the overall care plan should be oriented towards preventing avoidable declines in functional levels, managing risk factors, and addressing ways to try to preserve resident strengths. Review of the facility Guidelines for Contracture Prevention and Management Program Policy, dated 05/15/16, revealed to prevent or reduce contractures, and/or preserve ROM, resident specific interventions and goals would be implemented and included on the RESTORATIVE/FUNCTIONAL MAINTENANCE PROGRAM PLAN and documented in the Electronic Medical Record (EMR). 1. Review of Resident #32's clinical record revealed the facility admitted the resident on 03/06/15, discharged the resident on 01/12/18, and subsequently readmitted the resident on 01/14/18 with [DIAGNOSES REDACTED]. Review of the Occupational Therapy Notes dated 07/07/17, revealed Resident #32 had a splint to the right hand for wrist in neutral position. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as having bilateral functional limitation on both Upper extremities. Review of the Section O Special Treatments, Procedures, and Programs, revealed the resident received zero (0) number of days of passive range of motion, zero (0) number of days of active range of motion and zero (0) number of days of splint or brace assistance. Review of the Paragon Rehabilitation Screening, dated 01/08/18, revealed Resident #32 was dependent with all activities of daily living and dependent with transfers with no functional change. The form had a space related to assistive device or adaptive equipment, and this space was not marked to indicate this resident had assistive device or equipment. The resident's upper extremity contractures and splint use were not addressed. Review of Resident #32's Therapy Screen dated 04/05/18, revealed the therapist spoke with nursing staff, and there were no changes in functional status, and skilled therapy was not indicated. The form had a space related to assistive device or adaptive equipment, and this space was not marked to indicate this resident had an assistive device or equipment. Further review of the Therapy Screen, revealed the resident's upper extremity contractures and splint use were not addressed. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 04/09/18, revealed the facility assessed the resident as severely cognitively impaired and unable to complete a Brief interview for Mental Status (BIMS). Further review of the MDS, revealed the facility assessed the resident as having bilateral functional limitation of both upper extremities. Continued review of the MDS, revealed revealed Section O Special Treatments, Procedures, and Programs, revealed the resident received zero (0) number of days of passive range of motion, zero (0) number of days of active range of motion and zero (0) number of days of splint or brace assistance. Observation on 5/07/18 at 6:45 PM; on 05/08/18 at 9:00 AM; and on 05/09/18 at 8:35 AM; revealed Resident #32 was lying in bed in on his/her back and appeared to have contractures noted to the bilateral upper extremities at the elbows and hands. Resident #32's right elbow flexion appeared greater than the left. Also, the resident's bilateral elbows were bent toward the torso with the right arm pointing toward upper chest and left arm pointing towards the waist. Further observation revealed the resident's fingers were turned in towards the palms bilateral hands. Review of Resident #32's Comprehensive Care Plan dated 04/17/17, revealed a problem category labeled Pain with a targeted goal date of 07/23/18 which stated the resident's pain would be at tolerable level with interventions. An intervention initiated 04/17/17, revealed please make sure any splints I have ordered are applied, as they reduce the contractures in my body; however, this intervention was not specific and individualized related to type of splint, when the splint should be used, how long the splint should be used, or where on the body the splint was to be used. Additionally, the Care Plan did not address any further interventions related to the resident's contractures of the upper extremities. Review of Resident #32's physician's orders [REDACTED]. Review of the Profile Book, which was kept at the nurse's station and was a guide for providing resident care, revealed there were no interventions for active range of motion, passive range of motion, splinting, or any interventions to address upper extremity contractures for Resident #32. Interview with Resident #32's Responsible Party (RP), on 05/10/18 at 5:30 PM, revealed she couldn't remember the resident having a splint on the right hand. Continued interview revealed the facility had never spoken to her in a meeting, phone call or in person related to any interventions to increase range of motion or prevent further decrease in range of motion. Additional interview revealed the resident's RP did feel this was an important issue related to the care of the resident and should be addressed. Interview with Certified Resident Care Assistant (CRCA) #3, on 05/10/18 at 4:35 PM, revealed each resident had a CRCA Care Plan in the Profile Book which guided the CRCAs on how to take care of each resident. Per interview, the facility had no specific restorative program, restorative nurse, or restorative aide and each aide was responsible to provide the restorative plan for their individual residents. Continued interview revealed CRCA #3 was familiar with Resident #32 and stated Resident #32's Profile/CRCA Care Plan, did not include any restorative services and did not list specific guidelines related to care for his/her upper extremity contractures to include passive range of motion, active range of motion, or splinting. Interview with Licensed Practical Nurse (LPN) #4, on 05/09/18 at 3:15 PM, revealed each resident had a CRCA Care Plan in the Profile Book which was a guide for the care which was to be provided by the CRCAs. Per interview, the facility had no formal restorative program, restorative nurse or restorative aide in the the facility, and each CRCA was responsible to provide the restorative plan for their assigned individual residents. Further interview revealed LPN #4 was the nurse on the unit assigned to Resident #32 and she was unaware of any Care Plan interventions for the resident's contractures. However, LPN #4 stated it was important to provide appropriate treatments for contractures to increase range of motion or prevent further decrease in range of motion for residents functional well being and as part of standards of care for residents. She stated the resident's Care Plan should have included interventions to prevent further contractures. Per interview, it was important that everyone on the interdisciplinary team provided the resident consistent care and followed the Comprehensive Care Plan; however, she was unaware of any interventions for the resident related to splints. Interview with the Therapy Program Director, on 05/10/18 4:00 PM, revealed she was unable to state why bilateral upper extremity contractures were not addressed on past therapy screens or why there were no recommendations from therapy related to interventions for Resident #32's bilateral upper extremity contractures as she was the therapist who completed these screens. Further interview revealed she did not know what happened to the resident's right hand splint mentioned in the Occupational Therapy Note dated 07/07/17, and did not know why this splint was not mentioned in subsequent therapy screens and notes or Care Planned. Interview with the Assistant Director of Health Services (ADHS), on 05/10/18 at 4:38 PM, revealed, although the facility provided the surveyor with Guidelines for Contracture Prevention and Management Program, the facility didn't have an actual Restorative Program in the facility and the facility did not follow the Guidelines related to contractures. Further interview with the ADHS, revealed all restorative nursing was completed by the CRCAs while performing care, and the CRCAs identified the residents who were to receive restorative nursing or had guidelines related to care for contractures per the Profile book on the unit which was updated daily with any new orders. Per interview, if Resident #32's Profile Page in the Profile Book did not have interventions to address the resident's limited range of motion, or splints, staff would not be performing ROM or implementing other interventions such as hand splints to prevent further decrease in range of motion for this resident. Per interview, care for contractures and limited range of motion should follow accepted standards of practice for the well being of the resident and residents with contractures should have care plan interventions in place to address the contractures. 2. Review of Resident #7's clinical record revealed the facility admitted the resident on 02/09/18, with [DIAGNOSES REDACTED]. Review of the Admission Documents included a Monthly Summary, dated (MONTH) (YEAR), from the previous facility, which stated the resident had leg contractures. Review of the Physician's Progress Note for Skilled Nursing Facility (SNF) Evaluation, dated 02/12/18, revealed Resident #7 was very contracted. Review of Resident #7's Admission Minimum Data Set (MDS) Assessment, dated 02/16/18, revealed the facility assessed the resident as having impaired cognition and unable to complete a BIMS. Continued review of the MDS Assessment, revealed the facility assessed the resident as requiring extensive assistance of two (2) staff for bed mobility, transfers, dressing, and toileting; total assistance of two (2) staff for bathing; and extensive assistance of one (1) staff for eating. Additionally, the facility assessed the resident as having no functional limitations in range of motion for upper or lower extremities; and no therapy or restorative. Review of Resident #7's Occupational Therapy (OT) Plan of Care, with start date of 02/23/18, revealed OT was necessary for Resident #7 related to wheelchair positioning, sensory stimulation, and risk for increased contractures. The Goal stated the resident would have decreased activity limitations and participation restrictions. Further review revealed the resident was dependent in all Activities of Daily Living and underlying impairments included functional limitations in bilateral upper extremities, and inability to sit unsupported secondary to Resident in fetal position. Review of Resident #7's OT Daily Treatment Note, dated 03/01/18, revealed the resident received Range of Motion (ROM) to bilateral upper extremities and lower extremities which was tolerated well. Review of Resident #7's OT Progress and Discharge Summary, dated 03/12/18, revealed Resident #7 made good progress over the course of OT treatment and continued to show progress towards sitting tolerance in broad chair and interaction with environment and continued to be totally dependent related to functional mobility and fall risk. Per review of the Summary, Staff training included education on positioning in broad chair and getting up into chair daily for meals and interaction with the environment. Review of Resident #7's Comprehensive Care Plan, dated 03/08/18, revealed Functional Limitations in ROM were not identified as a care problem and an individualized care plan was not developed related to the resident's contractures. Additionally, the Comprehensive Care Plan did not include interventions to monitor and maintain the resident's limited ROM. There was a new intervention which was added to the Care Plan on 05/10/18, after surveyor intervention, which stated limited range of motion in bilateral upper and lower extremities. Observation of Resident #7, on 05/07/18 at 6:34 PM, revealed he/she had hip flexion, and right hip adduction, with knees rotated inward and flexed. Resident #7's right knee had greater flexion than the left knee. Also, the resident's right heel was touching his/her right buttocks. Interview on 05/10/18 at 3:45 PM, with Minimum Data Set (MDS) Coordinator #1, revealed Limitations in Functional ROM were to be assessed during the assessment look-back period of an MDS Assessment. Per interview, concerns were to be addressed by the interdisciplinary team and an individualized Care Plan was to be developed for a resident with limited ROM. She stated Resident #7's contractures had not been identified on the Admission Minimum Data Set (MDS) Assessment, dated 02/16/18, but should have been identified because the MDS Assessments guided Care Plans, referrals, and treatment. Further interview revealed this resident's Comprehensive Care Plan should have been developed to ensure the resident's individualized care risks related to contractures and limited ROM were addressed. Interview with Certified Resident Care Assistant (CRCA) #1, on 05/10/18 at 2:34 PM, revealed the CRCA Care Plans in the Profile Book at the nurse's station were a reference for providing care for each resident including Restorative /ROM interventions. She further stated Resident #7's Care Plan in the Profile book did not list specific guidelines related to care for his/her contractures. However, she stated she tried to perform range of motion for the resident when dressing him/her and also tried to reposition him/her as much as possible. Interview with LPN #1, on 05/10/18 at 2:47 PM, who was assigned to Resident #7, revealed Resident #7's legs had always been contracted and she was unaware of a specific treatment or plan of care regarding the resident's contractures. However, she stated it was important to monitor residents for any decline or worsening contractures and to ensure residents receive needed care and appropriate services to prevent worsening limitations in mobility. Per interview, Resident #7 should have had a Care Plan developed with interventions to ensure the resident's Limitations in Functional ROM were addressed. Interview with the Director of Health Services, on 05/10/18 3:10 PM; on 05/10/18 at 4:00 PM and on 05/10/18 at 5:00 PM; revealed the facility did not follow the Guidelines for Contracture Prevention and Management Program which was submitted for review. Per interview, the CRCAs completed the restorative nursing while performing care such as during bathing and dressing. However, per interview there should have been a Care Plan developed with interventions to address Resident #32's bilateral upper extremity contractures and if therapy had identified a hand splint was needed, this intervention should have been implemented. Additional interview with the Director of Health Services, revealed Resident #7's Admission MDS should have identified his/her contractures as the MDS was the guide for developing the Care Plan and making referrals. The State Survey Representative requested a copy of the detailed profile page/CRCA Care Plan, in the Profile Book, for Resident #7; however, the DON revealed there was not a detailed CRCA Care Plan in the tabbed Profile Book for this resident and the CRCAs used the Abbreviated Excell Sheet which they carried in their pockets as a guide for reference for care. Review of Resident #7's Abbreviated Excell Sheet revealed no interventions related to the resident's contractures. Per interview, there should have been a Care Plan developed related to Resident #32's contractures. She stated once Care Plans were developed, the information was carried over to the profile page/CRCA Care Plan in order for CRCAs to be aware of the care which needed to be provided related to limited ROM/contractures. Interview with the Executive Director, on 05/10/18 at 3:39 PM, revealed the MDS Coordinator developed the residents' Comprehensive Care Plans and made revisions as necessary. Per interview, each resident's individualized Care Plan should addresses the resident's specific needs and if the Care Plan was not developed related to individual needs, the resident could go without appropriate treatment/care and could have a negative outcome. Further interview revealed Care Plans should be developed and implemented with individualized interventions to address limited ROM for residents with contractures. Continued interview revealed the facility should follow the Guidelines for Contracture Prevention and Management Program Policy.

Based on observation, interview, record review, and review of the facility Policies and Procedures, it was determined the facility failed to ensure that a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease of range of motion for two (2) of nineteen (19) sampled residents, (Resident #32 and Resident #7). Resident #32 was assessed in a Significant Change Minimum Data Set (MDS) assessment dated [DATE], and in a Quarterly MDS Assessment, dated 04/09/18, as having Functional Limitations in Range of Motion (ROM) in bilateral upper extremities; however, there was no documented evidence the resident was receiving treatment and services related to the bilateral upper extremity contractures. In addition, Resident #7 was admitted to the facility on [DATE] with Functional Limitations in Range of Motion (ROM) and contractures to bilateral lower extremities; however there was no documented evidence the resident was receiving treatment and services related to the bilateral lower extremity contractures. The findings are: Review of the facility Guidelines for Contracture Prevention and Management Program Policy, dated 05/15/16, revealed to prevent or reduce contractures, and/or preserve ROM, resident specific interventions and goals would be implemented and included on the RESTORATIVE/FUNCTIONAL MAINTENANCE PROGRAM PLAN and documented in the Electronic Medical Record (EMR). Review of the Restorative/Functional Maintenance Plan and Summary dated 05/15/16, revealed the designated restorative nurse shall set an achievement goal for each program, and have approaches to accomplish the goal and a time frame for the goal to be accomplished. Continued review revealed the designated restorative nurse shall observe the resident's function and/or communicate with the restorative aid to assess the progress towards the programs goals. The nurse shall document the response to interventions, progress towards goals and continuation of current program plan or changes to the plan with the plan of care. Further review revealed the program shall be evaluated with a written summary quarterly or as required by regulation and a form filed in the medical record upon completion Review of the Paragon Rehabilitation Restorative Programming Policy, dated (MONTH) 2011, revealed Paragon Rehab services will collaborate with the facility in the implementation and development of a Restorative Program, and provide a Restorative Aide who will document and enter data as developed by the facility for MDS reporting. Restorative Care is mandated by Centers for Medicare and Medicaid Services (CMS) to ensure the resident's highest level of function is maintained and to promote dignity. Additional review revealed Paragon will supervise, and train Restorative Aides. Further review revealed the Restorative Nursing Program was to provide Passive Range of Motion, Active Range of Motion and Splint or Brace Assistance. 1. Review of Resident #32's medical record revealed the facility admitted the resident on 03/06/15, discharged the resident on 01/12/18, and readmitted the resident on 01/14/18 with [DIAGNOSES REDACTED]. Review of the Occupational Therapy Notes dated 07/07/17, revealed the resident had a splint to the right hand for wrist in neutral position. Review of the Paragon Rehabilitation Screening dated 01/08/18, revealed the resident was dependent with all activities of daily living and dependent with transfers with no functional change at this time. The form had a space related to assistive device or adaptive equipment, and this space was not marked to indicate the resident had assistive device or equipment. The resident's upper extremity contractures and splint use were not addressed. Review of the Therapy Screen dated 04/05/18, revealed the therapist spoke with nursing staff, and there were no changes in functional status, and skilled therapy was not indicated. The form had a space related to assistive device or adaptive equipment, and this space was not marked to indicate the resident had an assistive device or equipment. The resident's upper extremity contractures and splint use were not addressed. Review of Resident #32's Quarterly Minimum Data Set (MDS) Assessment, dated 04/09/18, revealed the facility assessed the resident as severely cognitively impaired and unable to complete a Brief interview for Mental Status (BIMS). Further review of the MDS, revealed the facility assessed the resident as having bilateral functional limitation of both upper extremities. Continued review of the MDS, revealed revealed Section O Special Treatments, Procedures, and Programs, revealed the resident received zero (0) number of days of passive range of motion, zero (0) number of days of active range of motion and zero (0) number of days of splint or brace assistance. Observation of Resident #32, on 5/07/18 at 6:45 PM; on 05/08/18 at 9:00 AM; and on 05/09/18 at 8:35 AM; revealed the resident was lying in bed in on his/her back and appeared to have contractures noted to the bilateral upper extremities at the elbows and hands. The resident's right elbow flexion appeared greater than the left. The resident's bilateral elbows were bent toward the torso with the right arm pointing toward upper chest and left arm pointing towards the waist. Further observation revealed the resident's fingers were turned in towards the palms bilateral hands. Review of Resident #32's Comprehensive Care Plan dated 04/17/17, revealed a problem category labeled Pain with a targeted goal date of 07/23/18 stating the resident's pain would be at tolerable level with interventions. An intervention initiated 04/17/17, revealed please make sure any splints I have ordered are applied, as they reduce the contractures in my body; however, this intervention was not specific related to type of splint, when the splint should be used, how long the splint should be used, or where on the body the splint was to be used. In addition, the Care Plan did not address any further interventions related to the resident's contractures of the upper extremities. Review of the Profile Book, which was a guide for providing resident care, revealed there were no interventions for active range of motion, passive range of motion, splinting or any interventions to address upper extremity contractures for Resident #32. Review of Resident #32's Physician's Orders dated (MONTH) (YEAR), revealed orders for the resident to be up and dressed and taken to Restorative dining for lunch at 06:00 AM and 1:00 PM and orders for Speech Therapy to treat the resident three (3) times a week for one (1) week. However, continued review revealed there were no Physician's orders regarding restorative nursing related to the resident's upper extremity contractures and no orders for splints. Interview with Resident #32's Responsible Party (RP), on 05/10/18 at 5:30 PM, revealed she could not remember the resident having a splint to the right hand. Further interview revealed the facility had never spoken to her in a meeting, phone call or in person related to any interventions to increase range of motion or prevent further decrease in range of motion. Continued interview revealed the resident's RP did feel this was an important issue related to the care of the resident and should be addressed. Interview with Certified Resident Care Assistant (CRCA) #3, on 05/10/18 at 4:35 PM, revealed she had been employed by the facility for two (2) years. Further interview revealed each resident had a CRCA Care Plan in the Profile Book which guided the CRCAs on how to take care of each resident and also included restorative interventions. Per interview, the facility had no specific restorative program, restorative nurse, or restorative aide in the the facility, and each aide was responsible to provide the restorative plan for their individual residents. Further interview revealed CRCA #3 was familiar with Resident #32. CRCA #3 stated Resident #32's Profile/CRCA Care Plan, did not include any restorative services or specific guidelines related to the resident's upper extremity contractures to include passive range of motion, active range of motion, or splinting. Interview with Licensed Practical Nurse (LPN) #4, on 05/09/18 at 3:15 PM, revealed she had been employed by the facility for eight (8) months. Per interview, each resident had a CRCA Care Plan in the Profile Book which was a guide for the care which was to be provided by the CRCAs. She stated the facility had no formal restorative program, restorative nurse or restorative aide in the the facility, and each CRCA was responsible to provide the restorative plan for their assigned individual residents. Further interview revealed LPN #4 was the nurse on the unit assigned to Resident #32 and the resident did not have Physician's orders to address passive range of motion, active range of motion, splints, or any interventions for bilateral contractures to the upper extremities. Further interview revealed she was unaware of any Care Plan interventions for ROM or splints for Resident #32. However, LPN #4 stated it was important to provide appropriate treatments for contractures to increase range of motion or prevent further decrease in range of motion for residents functional well being and as part of standards of care for residents. Interview with the Therapy Program Director, on 05/10/18 4:00 PM, revealed therapy screens were done quarterly and as indicated by the referral process, and the therapy staff talked to nursing staff and reviewed the medical record and previous therapy notes to make a decision based on clinical judgement on whether or not to do an evaluation. Per interview, she was unable to state why bilateral upper extremity contractures were not addressed on past therapy screens or why there were no recommendations from therapy related to interventions for Resident #32's bilateral upper extremity contractures as she was the therapist who completed these screens. She further stated she did not know what happened to the resident's right hand splint mentioned in the Occupational Therapy Note dated 7/07/17, and did not know why this splint was not mentioned in subsequent therapy screens and notes. Further interview revealed there was no one in charge of the Restorative Program at the facility and she was unaware of Resident #32 receiving any restorative nursing related to upper extremity contractures. Interview with the Assistant Director of Health Services (ADHS), on 05/10/18 at 4:38 PM, revealed although the facility provided the surveyor with the Restorative/Functional Maintenance Plan and Summary Policy; Guidelines for Contracture Prevention and Management Program; and a Paragon Rehabilitation policy, Restorative Programming, the facility did not have an actual Restorative Program in the facility and the facility Policies and Guidelines which were submitted to the State Agency Representative for review were not followed by the facility. Per interview, there was no Restorative Program in the facility other than restorative dining. Further interview with the ADHS, revealed all restorative nursing was completed by the CRCAs while performing care, and the CRCAs identified the residents who were to receive restorative nursing or care related to limited ROM per the Profile book on the unit which was updated daily with any new orders. Per interview, if Resident #32's Profile Page in the Profile Book did not have interventions to address the resident's limited range of motion, staff would not be performing ROM or implementing other interventions such as hand splints to prevent further decrease in range of motion for this resident. 2. Review of Resident #7's medical record revealed the facility admitted him/her on 02/09/18, with [DIAGNOSES REDACTED]. Review of the Admission Documents included a Monthly Summary, dated (MONTH) (YEAR), from the previous facility, stating the resident had leg contractures. Review of Resident #7's Physician's Progress Note for Skilled Nursing Facility (SNF) Evaluation, dated 02/12/18, revealed the resident was very contracted. Review of Resident #7's Admission Minimum Data Set (MDS) Assessment, dated 02/16/18, revealed the facility assessed the resident as having impaired cognition and unable to complete a Brief Interview for Mental Status (BIMS). Continued review of the MDS Assessment revealed the facility assessed the resident as requiring extensive assistance of two (2) staff for bed mobility, transfers, dressing, and toileting; total assistance of two (2) staff for bathing; and extensive assistance of one (1) staff for eating. In addition, the facility assessed the resident as having no functional limitations in range of motion for upper or lower extremities; and no therapy or restorative. Review of Resident #7's Occupational Therapy (OT) Plan of Care, with start date of 02/23/18, revealed OT was necessary for Resident #7 for wheelchair positioning, sensory stimulation, and risk for increased contractures. The Goal revealed the resident would have decreased activity limitations and participation restrictions. Continued review revealed the resident was dependent in all Activities of Daily Living and underlying impairments included functional limitations in bilateral upper extremities, and inability to sit unsupported secondary to Resident in fetal position. Review of Resident #7's OT Daily Treatment Note, dated 03/01/18, revealed Range of Motion (ROM) to bilateral upper extremities and lower extremities was tolerated well. Review of Resident #7's OT Progress and Discharge Summary, dated 03/12/18, revealed Resident #7 made good progress over the course of OT treatment and continued to show progress towards sitting tolerance in broad chair and interaction with environment and continued to be totally dependent for functional mobility and fall risk. Further review of the Summary, revealed Staff training included education on positioning in broad chair and getting up into chair daily for meals and interaction with the environment. Review of Resident #7's Comprehensive Care Plan, dated 03/08/18, revealed Functional Limitations in ROM were not identified as a care problem and an individualized care plan was not developed related to the resident's contractures of the lower extremities. Also, the Comprehensive Care Plan did not include interventions to monitor and maintain the resident's limited ROM. There was a new intervention added to the Care Plan on 05/10/18, stating limited range of motion in bilateral upper and lower extremities, after surveyor intervention. Observation of Resident #7, on 05/07/18 at 6:34 PM, revealed the resident had hip flexion, and right hip adduction, with knees rotated inward and flexed. The resident's right knee had greater flexion than the left knee. Resident #7's right heel was touching his/her right buttocks. Interview with Minimum Data Set (MDS) Coordinator #1, on 05/10/18 at 3:45 PM, revealed Limitations in Functional ROM were to be assessed during the assessment look-back period of an MDS assessment. Further interview revealed concerns were to be addressed by the interdisciplinary team and an individualized Care Plan was to be developed for a resident with limited ROM. She revealed Resident #7's contractures were not identified on the Admission Minimum Data Set (MDS) Assessment, dated 02/16/18, but should have been identified because the MDS Assessments guided Care Plans, referrals, and treatment. Interview with Occupational Therapist (OT) #1, on 05/10/18 at 9:15 AM, revealed residents with Limitations in Functional ROM/contractures were assessed by Paragon Therapy when a referral was received from nursing. Additional interview revealed all Residents were screened Quarterly for change in functional status. Further interview revealed she had not worked with Resident #7 and was unaware of therapy treatments or goals for this resident. Interview with Certified Resident Care Assistant (CRCA) #1, on 05/10/18 at 2:34 PM, revealed the CRCA Care Plans in the Profile Book at the nurse's station were a reference for how to care for each resident including Restorative /ROM interventions. She stated Resident #7's Care Plan in the Profile book did not list specific guidelines related to care for his/her contractures. However, she stated she tried to perform range of motion for the Resident when dressing him/her and tried to reposition him/her as much as possible. Further interview revealed she did not do ROM on each joint of the upper and lower extremities; and did not document anywhere that ROM was provided, the number of repetition, total minutes ROM was performed, or the specific joint in which she performed ROM. Interview with LPN #1, on 05/10/18 at 2:47 PM, who was the nurse assigned to Resident #7, revealed Resident #7's legs had always been contracted and she was unaware of a specific treatment or plan of care regarding therapy or restorative nursing related to the resident's contractures. Further interview revealed it was important to monitor residents for any decline or worsening contractures and to ensure residents receive needed care and appropriate services to prevent worsening limitations in mobility. Per interview, Resident #7 should have had a Plan of Care in place to ensure the resident received restorative nursing or other interventions related to the contractures. Interview with the Director of Health Services, on 05/10/18 3:10 PM; on 05/10/18 at 4:00 PM and on 05/10/18 at 5:00 PM; revealed the facility did not follow the Restorative/Functional Maintenance Plan and Summary Policy; Guidelines for Contracture Prevention and Management Program; and a Paragon Rehabilitation policy, Restorative Programming which were submitted for review. Per interview, the CRCAs completed the restorative nursing while performing care such as bathing and dressing. However, per interview there was no documented evidence of minutes performed for the restorative care provided and no oversight or evaluation of the restorative care as there was no Restorative Nurse. Further interview with the Director of Health Services, revealed there should have been interventions in place to address Resident #32's bilateral upper extremity contractures and if therapy had identified a hand splint was needed, this intervention should have been implemented. Continued interview with the Director of Health Services, revealed Resident #7's Admission MDS should have identified his/her contractures as the MDS was the guide for the care plan and referrals. The State Survey Representative requested a copy of the detailed profile page/CRCA Care Plan, in the Profile Book, for Resident #7; however, the DON stated there was not a detailed CRCA Care Plan in the tabbed Profile Book for this resident and the CRCAs used the Abbreviated Excell Sheet which they carried in their pockets as a guide for reference for care. Review of Resident #7's Abbreviated Excell Sheet revealed there was no documented evidence of interventions related to the resident's contractures. Continued interview revealed with the Director of Health Services, revealed it was important to ensure residents with limited range of motion receive appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion and worsening of contractures for mobility and quality of life for the residents. Interview with the Executive Director, on 05/10/18 at 3:39 PM, revealed each CRCA was responsible to provide restorative nursing or other interventions for residents with Limitations in Functional ROM/contractures from the instructions in the Profile Book for their individual residents. Per interview, when a resident was admitted to the facility with Limitations in Functional ROM/contractures, an assessment, evaluation, and Comprehensive Care Plan for limitations in ROM was to be completed. She stated CRCAs were to make the nurses aware of changes in a resident's ROM and nurses were to obtain therapy referrals as necessary. Further interview revealed a quarterly functional assessment was provided by therapy for all long term care residents and resident's who required restorative nursing should be identified during this assessment. Per interview, providing services and treatment to residents with limited ROM was important to maintaining their current ROM and to prevent pain or worsening contractures. Further interview, revealed although the facility provided the State Survey Representative with policies and procedures related to restorative services, as well as the Guidelines for Contracture Prevention and Management Program, there was no official Restorative Program, Restorative Nurse, or Restorative Aides in the facility and the facility policies and procedures related to restorative were not being followed.

Based on observation, interview and review of facility Policy, it was determined the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principle and include appropriate accessory and cautionary instructions and expiration dates. Observation on 05/08/18, of the Medication Room by the Barbaro Hall, revealed Ensure supplements in the medication refrigerator; and the room also had a bottle of [MEDICATION NAME] 1% Ophthalmic Solution drops with an open date of 02/06/18 accessible for use; and Assure Prism meter test strips which had been opened with no open date. In addition, observation on 05/08/18, of the Medication room by the Secretariat Hall, revealed Ensure supplement in the medication refrigerator. The findings are: Review of the facility policy, Medication Storage In The Facility, revised (MONTH) (YEAR), revealed, outdated medications are to be removed immediately from inventory. Continued review revealed refrigerated medications are to be kept in closed and labeled containers separated and separate from fruit juices, applesauce and other foods used to administer medications. Further review revealed, certain medications or package types, such as multiple dose injectable vials, ophthalmic, blood sugar testing strips, once opened, require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency. Further review of the Policy, revealed medications in multidose packaging will have a beyond use dating of sixty (60) days or the manufacturers expiration date if less than sixty (60) days unless the medication is an ophthalmic medication then it will have an expiration date of thirty (30) days unless the manufacturer recommends another date or regulations require different dating. Further review revealed medication administration staff will check the expiration date of each medication before administration and no expired medication should be administered to a resident. Review of the American Society Of Ophthalmic Registered Nurses Recommended Practice: Use of Multidose Medications, Procedures for Multidose Ophthalmic Drops and Ointments, board approved (MONTH) 2013, revealed medication vials are to be labeled with the date and time opened and the initials of the person opening the vial and the expiration date of the vial, not to exceed twenty-eight (28) days for any ophthalmic solutions. If the manufacturer's expiration date occurs prior to the twenty-eighth (28) day the manufacturer's date must be used. 1. Observation on 05/08/18 at 10:30 AM, of the Medication Room by the Barbaro Hall, revealed two (2) Ensure supplements in the medication refrigerator. The medication room also had a bottle of [MEDICATION NAME] 1% Ophthalmic Solution drops with an open date of 02/06/18; and Assure Prism meter test strips which had been opened with no open date. Interview with Licensed Practical Nurse (LPN) #7, on 05/08/18 at 1:00 PM, revealed she had been working at the facility for about a year and a half and had worked on the 200 Hall by the Barbaro Medication Room. Per interview, Ensure and other food items should not be in the medication refrigerator. Continued interview revealed it was important to follow policy and not use expired medications as they may not be as effective and may cause a negative outcome or decreased effects. Further interview revealed Glucose test strips should be dated when opened so the expiration date would be known. She further stated it was important to follow the policy related to storage of medications and biologicals for the safety of the residents and staff. 2. Observation on 05/09/18 at 10:00 AM of the Medication room by the Secretariat Hall, revealed four (4) containers of Ensure supplement in the medication refrigerator. Interview on 05/09/18 at 10:05 AM, with LPN # 5, revealed she usually worked on the 300 Hallway, but was familiar with each medication room and how they were set up. Per interview, Ensure should not be in the medication refrigerator. Interview with the Assistant Director of Health Services, on 05/09/18 at 4:38 PM, revealed it was important for staff to follow the facility policy regarding storage of medication and biologicals. Continued interview revealed It was important to keep food items out of medication refrigerators. Further interview revealed it was important to date meter test strips when opened to ensure they were not used past the expiration date. Per interview, expired medications should be discarded appropriately and not be accessible for use. Interview with the Director of Health Services, on 05/09/18 at 5:00 PM, revealed it was her expectation for staff to follow the policy related to storage of medication and biologicals based on best practices. Per interview, supplements such as Ensure and food items should not be in the medication refrigerator. In addition, she stated meter test strips should be dated when opened. Interview with the Executive Director, on 05/09/18 at 5:45 PM, revealed per policy, expired medications and biologicals should not be used because they could have a less than desired outcome. Continued interview revealed if supplements were considered food items they should not be stored in the medication room refrigerator. Per interview, Glucose test strips and all medications should be labeled with date opened in order for staff to know the expiration date.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure the residents' environment remained as free from accident hazards as possible which affected three (3) of four (4) units in the facility (Units 100, 200 and 300); three (3) of thirteen (13) sampled residents (Residents #2, #7 and #11) and seven (7) Unsampled residents (Unsampled Residents A, B, D, F, G, H, and M). Observation on 03/14/17 at 5:34 PM, revealed two (2) unattended packages on top of a nurse's desk which was located within thirty (30) feet of the main entrance and the common area for residents. Further observation revealed the packages included six (6) different medications for a total of three hundred (300) tablets, and five (5) schedule II narcotic medication patches which were unsecured. Continued observation revealed the medications remained unsecured with no facility nursing staff present at the nurse's desk or in the surrounding area to secure the medications until 5:40 PM, which was six (6) minutes after the initial observation. Interviews and review of the Pharmacy Delivery Manifest determined the medications had been delivered by the Pharmacy and had been accessible to residents, unauthorized staff and visitors since 4:02 PM on 03/14/17, which was one hour (1 hr) and thirty-eight (38) minutes. Also, observation of Resident #7's room on 03/14/17 during initial tour, revealed an unsecured prescription Ventolin HFA inhaler on the bedside table which was accessible to cognitively impaired residents on the unit. Interview with Resident #7's son, revealed the resident brought the inhaler to the facility with him/her when admitted and used the inhaler as needed. However, review of the resident's medical record revealed [REDACTED]. Additionally, observation on 03/14/17 and 03/15/17 revealed potential hazardous items accessible to cognitively impaired residents. These items included: a sharp paring knife, a flat head screw driver, and a letter opener all in a small plastic tray with no lid; two (2) unlabeled purple spray bottles containing a liquid which was identified as Fabuloso, a cleaning product with adverse side effects if ingested or if prolonged skin contact; a clear see through three (3) drawer plastic container containing a tub of Super Sani-Cloth Germicidal Wipes which per the Safety Data Sheet (SDS) was hazardous if there was eye contact, skin contact, or if ingested; a bottle of nail polish remover which per the SDS was hazardous if eye contact or if inhaled; a bottle of hand sanitizer which per the SDS was hazardous if eye contact or if ingested; and a blender with a blade attached was stored in the unlocked cabinet in the bar area, facing the residents' dining area. The facility reported four (4) residents assessed with [REDACTED]. The facility's failure to have an effective system in place to ensure the residents' environment remained as free of accident hazards as possible, has caused or is likely to cause serious injury, harm, impairment or death. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 03/15/17, and was determined to exist on 03/14/17. The facility provided an acceptable credible Allegation of Compliance (AOC) on 03/23/17 alleging removal of the Immediate Jeopardy on 03/20/17. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 03/23/17, prior to exit on 03/23/17, with remaining non-compliance at a Scope and Severity of an E, while the facility develops and implements a Plan of Correction (POC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: 1. Review of the facility's Policy titled, Medication Storage in the Facility; Storage of Medications, revised January 2017, revealed medications and biologicals were to be stored safely, securely, and properly. Continued review of the policy revealed the medication supply was accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Review of the facility's Policy titled, Medication Storage in the Facility; Controlled Substance Storage, revised January 2017, revealed medications included in the Drug Enforcement Administration (DEA) classification as controlled substances were subject to special handling, storage, disposal and record keeping in the facility in accordance with federal, state and other applicable laws and regulations. Further review of the Policy, revealed only authorized medication administration staff and pharmacy personnel have access to controlled substances. Observation of the Alysheba Way Unit's common area, on 03/14/17 at 5:34 PM, revealed a nurse's desk which was located within thirty (30) feet of the main entrance of the facility and the common area for residents. The top of the nurse's desk had two (2) packages which were unsupervised by nursing staff and in plain sight and accessible to residents, unauthorized staff and visitors. The white plastic package had a label which identified the medication was prescribed to Unsampled Resident H and contained five (5) Fentanyl patches 12 MCG/HR (Micrograms/Hour) which was a schedule II narcotic pain medication. The brown paper bag package had a a total of three hundred (300) tablets. Continued observation, on 03/14/17 at 5:38 PM, revealed Unsampled Resident M was propelled in a wheelchair by a family member, and passed the desk with the prescription medications lying on top of the desk. Further observation revealed there was no nursing staff at the Alysheba Unit nurse's desk or in the area to secure the medications until 5:40 PM, when LPN #2 removed the medication packages from the top of the nurse's desk and locked the medications in the medication cart. Review of the Pharmacy Delivery Manifest, revealed LPN #2 electronically signed for the prescription medications on 03/14/17 at 4:02 PM. Interview, on 03/14/17 at 5:41 PM, and on 03/15/17 at 5:41 PM, with LPN #2, revealed she should not have left the medications unsecured on top of the nurse's desk. LPN #2 stated she received the medications from the pharmacy delivery and signed for the medications; however, she had not had a chance to lock the medications in the medication cart. Per interview, she thought she had left the medications out on the nurse's desk unsecured for approximately thirty (30) to forty (40) minutes. However, interviews and review of the Pharmacy Delivery Manifest revealed the medications had been delivered by the Pharmacy and had been accessible to residents, unauthorized staff and visitors since 4:02 PM on 03/14/17, which was one hour (1 hr) and thirty-eight (38) minutes. Interview, on 03/17/17 at 10:45 PM, with the Director of Nursing (DON), revealed medications should not be left unattended by the nursing staff and were to be stored properly to prevent residents, visitors, or unauthorized staff from having access to the medications. Per the DON, there was the potential for harm as unsecured medications could be hazardous for residents if they were to ingest the medications. Interview on 03/23/17 at 9:00 AM, with the Medical Director, revealed he was aware of the incident involving medications being left unattended at the nurse's desk. Per interview, his understanding was the nurse was called away to attend to a resident; however, the nurse should have ensured the medications were safely stored in the medication room or medication cart, and should not have left the medication unattended at the nurse's desk. Interview, on 03/17/17 at 11:05 PM, with the facility Administrator, revealed it was her expectation after the pharmacy delivers medications to the facility, narcotics and other prescription drugs be secured immediately. She stated this was important to ensure residents, unauthorized staff or visitors did not have access to the medications due to multiple scenarios such as the risk for harm or diversion. Further interview revealed there was a total of four (4) residents with cognitive impairment who were mobile within the facility and had the potential to access the unsecured medications on 03/14/17. 2. Review of the facility's Policy titled, Bedside Storage of Medications, revised 09/17/12, revealed bedside medication storage was permitted for residents who were able to self-administer medications upon the written order of the Prescriber and when it was deemed appropriate in the judgment of the facility's interdisciplinary resident assessment team. Further review of the Policy, revealed all nurses and aides were required to report to the charge nurse on duty if any medications were found at the bedside which were not authorized for bedside storage and the unauthorized medications were to be given to the charge nurse for return to the family or responsible party. Observation during initial tour of the Alysheba Way Unit with LPN #1, on 03/14/17 at 10:10 AM, revealed in Room #11 where Resident #7 resided, a prescription Ventolin inhaler (medication used to treat or prevent Bronchospasm) was lying on top of the bedside table unsecured. Continued observation revealed LPN #1 observed the State Survey Representative pick up the Ventalin inhaler and documented the name of the inhaler; however, the LPN did not comment on the inhaler being in the resident's room. Interview on 03/14/14 at 10:10 AM, with Resident #7's son, in the presence of LPN #1, revealed the resident brought the inhaler in with him/her when he/she was admitted to the facility. Continued interview revealed the resident used the inhaler as needed. Review of Resident #7's medical record revealed the facility admitted the resident on 03/01/17 with multiple [DIAGNOSES REDACTED]. Review of Resident #7's Admission Minimum Data Set ((MDS) dated [DATE], revealed the facility assessed the resident as having a BIMS score of five (5) out of fifteen (15) indicating the resident had severe cognitive impairment. Further review of the resident's medical record revealed [REDACTED]. Interview, on 03/14/17 at 11:15 AM, with LPN #1, who was assigned to Resident #7, revealed the Ventolin inhaler in Resident #7's room was a prescription inhaler and should not have been left in the resident's room because there was no Physician's order for the medication and the resident had not been assessed for self administration of medication. The nurse stated this was the first time she had seen this medication in the resident's room. Continued interview revealed other residents could have had access to the prescription inhaler since it was not securely stored out of sight. LPN #1 further stated she did not immediately take the inhaler from the room after it was identified by the State Survey Representative because she wanted to explain the reason the inhaler needed to be removed to the resident and the resident's family first. Review of the Prescriber's Digital Reference (PDR.net), revealed Adverse Reactions with the usage of the Ventolin HFA Inhaler included: Bronchospasm, Cardiac Arrhythmia Exacerbation, Atrial Fibrillation, Angioedema, Muscle Paralysis, Hypertension (high blood pressure), Chest Pain, Edema (Swelling), Urinary Retention, Hyperglycemia (high blood glucose levels), [DIAGNOSES REDACTED] (low potassium levels), Headache, Nausea, Vomiting, Dizziness, Fever, Cough, Abdominal pain, drowsiness, weakness and rash. Interview on 03/23/17 at 2:06 PM, with SRNA #6, revealed she had worked with Resident #7 on a regular basis. She further stated she was unsure if the resident had an inhaler in his/her room and she stated she might have seen one in the resident's makeup bag. Interview further revealed residents could be injured if an inhaler was in a resident's room unlocked because confused and wandering residents could have gotten the inhaler. Interview on 03/23/17 at 5:55 PM, with the DON, revealed when medications were found in a resident's room the process was to ask if the medication could be removed and explain to the resident why the medication was being removed. She further stated she was not aware Resident #7 had an inhaler at the bedside, prior to the survey. However, she revealed if staff had seen the inhaler they should have reported it because the inhaler was accessible to confused wandering residents in the facility. Interview, on 03/15/17 at 12:15 PM with the facility Administrator, revealed she was made aware by the DON on 03/14/17, an inhaler was found in Resident #7's room. Further interview revealed it was her expectation that staff complete an assessment upon admission or at anytime a resident decided they wanted to self administer a medication to find out if the resident was capable of safely self administering the medication. Further interview revealed if the resident could safely administer the medication, a Physician's order would need to be obtained to keep the medication at the bedside stored in a safe manner and the facility policy related to bedside storage of medication would need to be followed. 3. Review of Unsampled Resident A's medical record revealed the facility admitted the resident on 05/12/15, and readmitted the resident on 08/19/16, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 01/16/17, revealed the facility assessed Unsampled Resident A to have a BIMS score of one (1) out of fifteen (15), indicating severe cognitive impairment. Observation of Unsampled Resident A's room (room 112), located on Alysheba Way, on 03/14/17 at 11:08 AM, with LPN #1, revealed a red handled screw driver was noted to be stored in a plastic container without a lid on a bedside table at the foot of the resident's bed. Further observation revealed LPN #1 removed the screwdriver from the container and discovered a sharp paring knife and a letter opener which had been underneath the screwdriver, in the same container. The container was visible from the door. LPN #1 immediately removed the items from the resident's room. Interview with LPN #1 on 03/14/17 at 11:10 AM, revealed Unsampled Resident A had confusion and his/her behavior consisted of frequently ripping his/her ostomy bag off seven (7) to ten (10) times a day. LPN #1 stated, Unsampled Resident A should not have had the screwdriver, paring knife and letter opener in his/her room and she was unaware the resident had the sharp objects in the room which were accessible to him/her and to other residents. She stated she removed all three (3) of the items due to the resident being very confused and and she would not want the resident to get hurt. LPN #1 further stated the resident would not hurt anyone else; however, she would not want the resident to get hurt possibly using the knife to damage his/her ostomy. Continued interview with LPN #1, revealed there were other confused residents in the facility who could have accessed the items in Unsampled Resident A's room. Interview, on 03/15/17 at 8:42 AM with SRNA #1, revealed Unsampled Resident A, had days when he/she was confused and would take his/her clothes, brief, or ostomy bag off. Further interview revealed the resident had letter openers in his/her room in the past and she, along with other staff, had removed them from the plastic container on the bedside table located at the foot of the resident's bed. The SRNA further stated she had never known of the resident having a screwdriver or a knife. SRNA #1 further stated Unsampled Resident A should not have a knife, screwdriver, or a letter opener because the resident could accidentally hurt himself/herself. Continued interview revealed due to safety concerns, no residents in the facility should have sharp objects such as knives or access to the sharp objects. 4. Observation on 03/15/17 at 11:30 AM, revealed a blender with a blade attached was stored in the unlocked cabinet in the bar area, facing the residents' dining area. Interview with SRNA #2, on 03/15/17 at 11:35 AM, revealed the area was used by staff and residents. Further interview with SRNA #2, revealed activities used the area a lot to make drinks for the residents. SRNA #2 stated the blender, with blade attached, could be a safety concern because a resident could get hurt by the blade. Interview with the Life Enrichment Director (LED), on 03/15/17 at 11:40 AM, revealed the blender was used for happy hour and to make milkshakes. Continued interview revealed storing the blender with the blade attached, in an unlocked cabinet, would not be safe because a resident could cut themselves or a wandering resident could get hold of the blade. 5. Review of Unsampled Resident F's medical record revealed the resident was admitted by the facility on 03/09/17 with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of fifteen (15) out of fifteen (15) which indicated the resident was cognitively intact. Observation on 03/15/17 at 9:45 AM, revealed Unsampled Resident F's closet door in room 311, located on Ruffin Way, was wide open with the contents of the resident's items exposed. The closet contained two (2) unlabeled purple spray bottles which were observed by two (2) State Survey Representatives. The spray bottles were at the bottom of the closet; and one (1) bottle was half full and the other bottle was full. Interview with LPN #6, on 03/15/17 at 9:47 AM, revealed the resident just moved into the room yesterday afternoon at around 2:00 PM or 3:00 PM. LPN #6 revealed housekeeping must have accidentally left the bottles in the resident's room, because they had just cleaned the room prior to the resident moving in. LPN #6 took the bottles out of the room and a few minutes later informed the State Survey Representatives the product was not used by the facility per her conversation with housekeeping. LPN #6 stated the unidentified purple spray bottles must have been brought in by the resident's family. Interview, on 03/15/17 at 10:02 AM, with Unsampled Resident's F granddaughter, revealed she brought in the two (2) bottles of cleaning chemicals on the evening of 03/14/17. Continued interview revealed the cleaning chemical was called Fabuloso. Review of the Safety Data Sheet (SDS) dated 03/25/10, revealed the all-purpose cleaner Fabuloso-lavender, was a purple liquid with potential health effects which included causing skin irritation upon prolonged contact; and may be harmful if swallowed in large quantities. Further review of the SDS sheet, revealed if ingested, medical attention was required. Interview with SRNA #7, on 03/15/17 at 10:35 AM, revealed she was assigned to Unsampled Resident F and was unaware the resident had a household cleaner in his/her room and would have removed it if she had been aware. She stated when she found items, such as household chemicals, hand sanitizers, or sharp objects, in the residents' rooms, she would contact the nurse immediately. Further interview revealed the residents' could not have items such as this because another resident could wander into the residents' rooms and these items may cause harm to the residents. Interview with the DON, on 03/15/17 at 10:00 AM, who was standing outside of Unsampled Resident F's room, revealed she believed the chemical in the bottle to be Fabuloso, a cleaner that must have been brought into the facility by someone. Further interview with the DON, revealed she did not recognize the product as one the facility used. The DON stated to her knowledge, since the resident had a private room, the resident could keep such items as long as they were tucked away out of sight of confused wandering residents. 6. Review of Resident #11's medical record revealed the facility admitted the resident on 02/06/15, and readmitted the resident on 04/23/15, with [DIAGNOSES REDACTED]. Review of Resident #11's Annual MDS Assessment, dated 12/20/16, revealed the facility assessed the resident to have a BIMS score of a nine (9) out of fifteen (15) indicating the resident had moderate cognitive impairment. Observation on 03/15/17 at 10:15 AM, of Resident #11's room (room 217), located on Barbaro Neighborhood, revealed a tub of Super Sani-Cloth Germicidal Wipes in the bottom drawer of a clear see through three (3) drawer plastic container which was on the floor in the middle of the room, visible from the hallway. Review of the Super Sani-Cloth Germicidal Disposable Wipe Safety Data Sheet (SDS), revealed the product was a flammable disinfectant and health hazards included eye damage and eye irritation. If in eyes rinse with water for fifteen (15) to twenty (20) minutes, and if eye irritation persists get medical advice/attention. If skin contact, take off contaminated clothing and rinse skin immediately with plenty of water for fifteen (15) to twenty (20) minutes. Further review of the SDS, revealed if ingested, call poison control center or doctor as the product was harmful if swallowed Interview on 03/15/17 at 10:30 AM, with LPN #3, revealed the plastic three (3) drawer plastic container was not locked and she opened the drawer containing the Sani-Wipes. She further stated Sani-Wipes were not safe to have accessible where confused residents could get to the wipes. Continued interview revealed residents could get the wipes on their skin or in their eyes which could cause harm to the residents. Interview further revealed the nurses and Medication Aides were responsible for checking rooms during rounds and when passing medications and removing hazardous items. Interview on 03/15/17 at 11:15 AM, with SRNA #2, revealed staff should have been removing items such as the Sani-Wipes from the resident's room since the wipes could be dangerous to confused residents. She further stated a resident could have wiped their face and the liquid from the wipe could have gotten in their eyes. Interview further revealed there were three (3) confused residents who self-propelled themselves in a wheelchair and two (2) confused residents who ambulated independently who resided on the 200 Hall where the bleach wipes were found in the resident's room. 7. Review of Unsampled Resident D's medical record revealed the facility admitted the resident on 12/23/16 with [DIAGNOSES REDACTED]. Review of the Admission MDS dated [DATE], revealed the facility assessed the resident as unable to be interviewed for a BIMs score, and as having severe cognitive impairment. Observation during initial tour, on 03/14/17 at 10:10 AM, on the 100 Unit, located on Alysheba Way, with LPN #1, revealed Unsampled Resident D who resided in room 103, had a bottle of nail polish remover on a shelf. Interview with LPN #1 at the time of observation, revealed she did not think the resident was cognitively intact. She further stated the nail polish remover should not have been in the resident's room because if a wandering confused resident ingested it, this could cause harm. The LPN stated the resident's family must have brought it in. 8. Review of Unsampled B's medical record revealed the facility admitted the resident on 03/07/17 with a [DIAGNOSES REDACTED]. Review of the Admission MDS dated [DATE], revealed the facility assessed the resident to have a BIMS score of fourteen (14) out of fifteen (15), indicating the resident was cognitively intact. Observation during initial tour, on 03/14/17 at 10:10 AM, revealed Unsampled Resident B, in room #105-B, located on Alysheba Way, had a bottle with a pump of hand sanitizer on the resident's bedside table. Interview with LPN #1, at the time of observation, revealed Unsampled Resident B was very confused at this time, and the hand sanitizer should not have been in the resident's room. She stated if the resident was to ingest the sanitizer, it could cause harm. LPN #1 revealed she did not know where the hand sanitizer came from. 9. Review of Unsampled Resident G's medical record revealed the resident was admitted by the facility on 03/14/17, with [DIAGNOSES REDACTED]. Review of the resident's Admission's MDS Assessment, dated 03/21/17, revealed the facility assessed the resident to have a BIMS score of eleven (11) out of fifteen (15) which indicated the resident had moderate cognitive impairment. Observation and interview on 03/15/17 at 10:05 AM, with Unsampled Resident G who resided in room 301, located on Ruffin Way, revealed there was a small bottle of hand sanitizer in front of the resident in view of anyone passing by the room. The resident stated it was his/her hand sanitizer which he/she often used. Interview with SRNA #7, on 03/15/17 at 10:35 AM, revealed she often worked the 300 Unit. She stated she was not aware Unsampled Resident G, had a bottle of hand sanitizer. She stated it was important items such as this were not accessible to residents because a confused resident could wander into Unsampled Resident G's room, and ingest the hand sanitizer which could cause harm. Further interview with the DON, on 03/15/17 at 10:00 AM, and 03/17/17 at 10:45 PM, revealed she was not aware of a policy that addressed potentially hazardous items/chemicals such as nail polish remover, hand sanitizer, or cleaning solutions. She stated it was her expectation that the residents who had these potentially hazardous items as well as any sharp objects such as knives or screwdrivers in their possession would be assessed for safety with the items and educated to ensure the items were in a safe place out of sight when not in use. Per interview, if the hazardous items were not put away, a confused resident could have access and there could be the potential for harm. Further interview with the Administrator on 03/17/17 at 11:05 PM, revealed it was important for residents to be assessed for safety and proper storage of potentially hazardous items in their possession in order for the facility to determine if the resident was alert and oriented and able to use and store the items safely. The Administrator stated this was important for resident and staff safety. The facility provided an acceptable credible Allegation of Compliance (AOC) on 03/23/17 that alleged removal of the Immediate Jeopardy (IJ) effective 03/20/17. Review of the AOC revealed the facility implemented the following: 1. A facility nurse removed a knife, letter opener, and screw driver from Resident A's bedside table on 03/14/17. The facility offered to store the items in a locked drawer, and the resident declined. The resident agreed to have the items removed from his/her room. The resident's son was notified and stated he brought the letter opener to the resident at his/her request. On 03/15/17, the Assistant Director of Health Services (ADHS)/(ADON) completed a head-to-toe assessment of the resident and no negative outcome was observed. 2. On 03/14/17, the facility nurse obtained a Physician's order for Resident #7's Albuterol inhaler to be at bedside. A Self-Medication Administration Assessment was completed by the nurse on 03/14/17, and the resident demonstrated safe administration and voiced sound knowledge of the reason for his/her inhaler. On 03/15/17, the ADHS/(ADON) completed an assessment of Resident #7 including vital signs and noted no change from the resident's baseline. 3. On 03/14/17, Fabuloso, a cleaning liquid, was discovered in Resident F's room located in his/her closet. The resident and granddaughter agreed to disposal of the cleaning liquid and the granddaughter took the empty bottles home. On 03/15/17, the ADHS/(ADON) completed a head-to-toe assessment of the resident with no change from base line noted. 4. The blender, located in the bar area, inside a closed cabinet was removed by the Director of Food Services and secured in the kitchen. 5. On 03/14/17, the Director of Health Services (DHS)/(DON), Clinical Campus Support (CCS), ADHS/(ADON), and Medical Records Nurse initiated in-service education with staff. Staff were not permitted to work until education was provided. The facility did not use supplemental staffing (temporary agency). The in-service included all facility staff, which included licensed nurses, State Registered Nurse Aides (SRNA), resident care associates, dietary staff, environmental/laundry staff, department leaders, internal marketing, and therapy staff. The education covered proper medication storage; review of the self-administration of medication Policy; and proper storage of chemicals and hazardous items, which was also added to the (Admission Guide). 6. On 03/19/17, sixty-nine (69) of ninety-two (92) staff members had been in-serviced in person or via the phone. The exam was given by the DHS/(DON), ADHS/(ADON), CCS and Executive Director/(Administrator). 7. On 03/19/17, the DHS/(DON), ADHS/(ADON), ED/Administrator and charge nurses completed a partial (cognition and safety) monthly assessment on all health center residents to re-evaluate their cognitive status that may effect their safety and judgement. Residents A, B, C, D, E, F, and G were noted with various items such as nail polish, hand sanitizer, laundry treatment and sanitation wipes in their drawers and closet. 8. On 03/15/17, the ED/Administrator, DHS/(DON), ADHS/(ADON), Medical Records, MDS Coordinator, MDS Support, Administrator in Training (AIT), Life Enrichment Director (LED), Environmental Service Director (ESD), Customer Service Specialist (CSS), Social Service Director (SSD), Director Plant Operations (DPO), Program Director of Therapy, Director of Food Service (DFS), and Clinical Campus Support (CCS) met to discuss how to deliver the message to the residents and family members related to a necessary one hundred percent (100%) building room sweep. All leaders involved were informed to ask permission from the residents prior to looking through their personal items such as dressers, closets, and bathrooms. Leaders were provided a hand written list of potentially hazardous items, dated 03/15/17. All rooms were checked and three (3) residents were identified to have medication (inhalers) at the bedside. The nurse completed a Self-Administration of Medications Assessment and obtained a Physician's order for may keep at bedside. 9. On 03/15/17, the DHS/(DON), and ADHS/(ADON) educated the residents to secure the medication in an area that was not easily accessible to other residents and they voiced understanding. 10. On 03/15/17, all residents and families of the health center were called or spoken directly to regarding the procedure pertaining to hazardous items. Those who placed the phone calls included the AIT, LED, Human Resource Support, DFS, DFS support, and the Business office Manager. 11. On 03/15/17, the Quality Assurance (QA) committee met to discuss the details of the action items contained in the Allegation of Credible Compliance (AOC). The ED/(Administrator), DHS/(DON), ADHS/(ADON), and CCS were present. The Advanced Practice Registered Nurse (APRN) and Medical Director was involved in the discussion and decision making for the action items put in place. A potentially Hazardous Item List

Based on observation, interview and review of the facility's policies, it determined the facility failed to have an effective system to ensure drugs and biologicals were stored safe and secure in locked compartments. Observation on 03/14/17 at 5:34 PM, revealed two (2) packages, unsecured and unattended lying on top of a nurse's desk, which contained six (6) different medications for a total of three hundred (300) tablets, and five (5) schedule II narcotic medication patches. The nurse's desk was near the main entrance and common area of the facility which was accessible to residents, visitors, and unauthorized staff. Further observation revealed there was no nursing staff present at the nurse's desk or in the surrounding area to secure the medications until 5:40 PM, six (6) minutes after the initial observation. Record review revealed Pharmacy delivered the medications and Licensed Practical Nurse (LPN) #2 signed for the medications at 4:02 PM, indicating the medications were left on the nurse's desk unsecured for one (1) hour and thirty-eight (38) minutes. In addition, observation on 03/17/17 during Medication Pass revealed one (1) Novolog Insulin Flex Pen Prefilled Syringe with an open date of 02/08/17 and an expiration date of 03/08/17, in the medication cart and accessible for use, prescribed for Resident #12. Observation on 03/17/17 of the Barbaro Aly Sheba Unit Medication Refrigerator, revealed one (1) opened vial of Purified Protein Derivative (PPD) (used for Tuberculin skin test), with no open date noted, and available for use. In addition, observation on 03/17/17 of the Ruffian/Secretarial Medication Room Refrigerator Log dated March 2017, revealed temperatures were not logged for the following dates: 03/02/17, 03/04/17, 03/06/17, 03/07/17, 03/08/17, 03/09/17, 03/10/17, 03/12/17, and 03/13/17. The facility's failure to have an effective system to ensure drugs and biologicals were stored safely and securely, has caused or is likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy (IJ) was identified on 03/15/17 and determined to exist on 03/14/17. The facility provided an acceptable credible Allegation of Compliance (AOC) on 03/23/17, alleging removal of the Immediate Jeopardy on 03/20/17. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 03/23/17, prior to exit on 03/23/17, with remaining non-compliance at a Scope and Severity of a E while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: 1. Review of the facility's Policy titled, Medication Storage in the Facility revised 09/17/12, revealed medications and biologicals were to be stored safely, securely, and properly. Continued review revealed the medication supply was accessible only to licensed nursing personnel, pharmacy personnel, or staff member lawfully authorized to administer medications. Further review of the Policy, revealed medication rooms, carts, and medication supplies were locked or attended by persons with authorized access. Per Policy, Schedule II medications must be stored in a separate area. Observation of the Alysheba Way Unit's common area, on 03/14/17 at 5:34 PM, revealed a nurse's desk located within thirty (30) feet of the main entrance and the common area for residents. There were two (2) packages on top of the nurse's desk, and the nurse's desk was unsupervised by nursing staff. Further observation revealed the packages, which were in plain sight and accessible to residents, unauthorized staff, and visitors, contained prescription medications with a total of three hundred (300) tablets and five (5) narcotic pain patches. The white plastic package had a label identifying the medication was prescribed to Unsampled Resident H and contained five (5) Fentanyl patches 12 MCG/HR (Micrograms/Hour) which was a schedule II narcotic pain medication. The other package was a brown paper bag with a manifest identifying the following prescription medications prescribed to the following residents: Unsampled Resident A- Carbidopa/Levodopa 25 MG (milligrams)/100 MG -180 tablets (medication used to treat symptoms of Parkinson's Disease or Parkinson-like symptoms) Resident #2- Paroxetine HCL 20 MG -30 tablets (antidepressant medication) Unsampled Resident D- Hyrochlorothiazide 25 MG -30 tablets (diuretic medication used to treat high blood pressure) Unsampled Resident B- Acetaminophen 325 MG -30 tablets (medication used to treat mild pain and fever) Resident #7- Mirtazapine 15 MG -30 tablets (antidepressant medication, antiemetic, appetite stimulant) Continued observation on 03/14/17 at 5:36 PM, revealed while the State Survey Representative was checking the contents of the packages from the attached manifest, LPN #2 came behind the nurse's desk to get to the medication cart and then left the area without questioning the State Survey Representative. Further observation on 03/14/17 at 5:38 PM, revealed Unsampled Resident M was being propelled in a wheelchair by a family member, and passed the nurse's desk while the packages of prescription medications were on top of the desk. Additional observation revealed there was no nursing staff present at the Alysheba Unit desk or in the area to secure the medications until 5:40 PM, when LPN #2 removed the medication packages from the desk and secured them in the medication cart. Per observation, the medications were left unsecured on top of the nurse's desk for six (6) minutes. Review of the Pharmacy Delivery Manifest, revealed LPN #2 electronically signed for the medications on 03/14/17 at 4:02 PM. However, the medications were left unsecured on top of the medication cart until 5:40 PM, which was one (1) hour and thirty-eight (38) minutes. Interview, on 03/14/17 at 5:41 PM, with LPN #2, revealed she had signed for the medications which were delivered by the pharmacy; however, she failed to appropriately store the medications. She stated after she received and signed for the medication, someone called her to assist with a resident's incontinence care before she had time to lock the medications in the medication cart. Continued interview revealed per the facility's process, when medications were delivered, they were to be locked in the medication cart right away and the Fentanyl medication, which was a narcotic, was to be double locked. Further interview revealed she was responsible for the medications because she had signed for them when they were delivered, and she should have ensured the medications were locked in the medication cart. Interview, on 03/16/17 at 9:55 AM, with the contracted Pharmacy Supervisor, revealed non-controlled medications were delivered to the facility in a sealed paper bag or a plastic tote with a band around it. Continued interview revealed for non-controlled medications the delivery driver did not have to verify that all medications were there when dropped off, and the facility had twenty-four (24) hours in which to verify the medications. Further interview revealed controlled medications were delivered to the facility in a sealed white plastic bag, and the delivery driver was to watch the nurse open the white plastic bag and verify the correct controlled medication was delivered, then the unit nurse was to sign for the medications. The Pharmacy Supervisor stated, once the facility nurse signed for the non-controlled or controlled medications, that ended the chain of custody for the pharmacy. The Pharmacy Supervisor further stated the pharmacy did not have any expectations related to the storage of medications upon delivery of the medications. Interview, on 03/17/17 at 10:45 PM with the Director of Nursing (DON), revealed it was her expectation for nurses to ensure medications delivered from pharmacy were immediately stored in the medication carts or medication rooms; and controlled substances were stored under doubled lock. Interview, on 03/23/17 at 9:00 AM with the Medical Director, revealed he was informed of the incident involving medications being left unattended at the nurse's desk. Per interview, his understanding was the nurse was called away to attend to a resident; however, the nurse should have placed the medications in the medication room or medication cart, and should not have left the medication unattended at the nurse's desk. Further interview revealed he thought it was a judgment call on the nurse as to attend to the resident or put the medications away. Interview, on 03/17/17 at 11:05 PM, with the facility Administrator, revealed it was her expectation for narcotics and other prescription medications to be appropriately stored as per the facility's policy, and to be immediately secured once delivered from pharmacy. 2. Review of the Pharmacy Expiration Dates, document dated February 2016, revealed Novolog Flex Pens should be discarded after twenty-eight (28) days from the date opened. Observation on 03/17/17 at 4:20 PM, during Medication Pass revealed one (1) Novolog Insulin Flex Pen Prefilled Syringe with an open date of 02/08/17 and an expiration date of 03/08/17, prescribed for Resident #12, which LPN #4 identified as expired. Interview with LPN #4 who was passing medication at the time of the observation, revealed all nurses were responsible for removing expired medications from the medication cart; however, third shift nurses were responsible for auditing and cleaning the medication carts. Review of Resident #12's Physician order [REDACTED]. is 301 to 350, give 6 units; if Blood Sugar is 351 to 400 give 8 units; and if Blood Sugar is greater than 400, call Physician, Review of Resident #12's Medication Administration History (MAH) (Medication Administration Record) dated 03/01/17 to 03/17/17, revealed four (4) dates and times which were initialed as the medication being administered between the dates of 03/08/17, when the resident's Novolog Flex Pen expired and 03/17/17 when the expired Novolog Flex Pen was removed from the Medication Cart. Per the MAH, the resident received two (2) doses of insulin on 03/09/17; one (1) dose of insulin on 03/10/17; and one (1) dose of insulin on 03/12/17. Interview on 03/17/17 at 5:15 PM, with the Director of Nursing (DON), revealed pharmacy only delivered one (1) insulin pen from the time the medication was ordered which was delivered on 03/05/17, and was un-opened and in the Medication Refrigerator. Further interview revealed the expired Novolog Flex Pen on the Medication Cart must have come from the Emergency Box. Interview further revealed if the only Novolog Flex Pen received from the pharmacy was in the Medication Refrigerator un-opened, there was no other insulin pen the nurses could have been using except the Novolog Flex Pen on the Medication Cart which expired on 03/08/17. Further interview with the DON, revealed expired insulin was to be removed from the medication cart and discarded. She further stated she was unsure what could happen when insulin was used after the expiration date. Interview on 03/17/17 at 4:55 PM, with the Administrator, revealed the pharmacy audited the medication carts monthly; however, night shift nurses should check the medication carts nightly and remove expired medications. She further stated according to the March 2017 MAH, Resident #12 received four (4) doses of expired Novolog Flex Pen from 03/08/17 till 03/17/17. 3. Review of the facility's policy, titled, Guidelines for Refrigerators, no date, revealed the purpose of the policy was to assure that appropriate temperatures are maintained. Further review revealed temperatures were to be checked and documented on the refrigerator monitoring log daily. The policy further stated it was the responsibility of each department to maintain appropriate temperatures and logs. Observation on 03/17/17 at 3:00 PM, of the Ruffian/Secretarial Medication Room Refrigerator Log dated March 2017, revealed temperatures were not logged for the following dates: 03/02/17, 03/04/17, 03/06/17, 03/07/17, 03/08/17, 03/09/17, 03/10/17, 03/12/17, and 03/13/17. Interview on 03/17/17 at 3:10 PM, with LPN #4, revealed the Medication Refrigerator Log was the responsibility of the third shift nurses. She further stated missing documentation eluded to the fact the Medication Refrigerator Temperatures had not been checked on the dates which were not recorded. Continued interview revealed if staff were not obtaining and recording the medication refrigerator temperatures, staff would be unaware if the refrigerator stopped working properly without staffs knowledge and medications could go bad causing illness to the residents. Interview on 03/17/17 with Registered Nurse (RN) #1, who worked night shift, revealed night shift nurses were responsible for checking Medication Refrigerator Temperatures and logging those temperatures on the Medication Refrigerator Temperature Log Sheet. He further stated missing documentation indicated the temperatures were not checked on the dates they were not logged. Interview further revealed there was no way to know the temperature of the Medication Refrigerator on the dates of the missing documentation. Continued interview revealed if the temperature of the Medication Refrigerator was not kept within manufacturer's recommended range, medications could degrade and no longer be effective. Interview on 03/23/17 at 5:55 PM with the DON, revealed night shift nurses were trained on checking Medication Refrigerator Temperatures nightly and recording the temperatures on the Medication Refrigerator Temperature Log Sheet. She further stated missing documentation could mean the temperature wasn't checked or the temperature wasn't logged for that shift; however, there was no way to determine which occurred. Further interview, revealed the refrigerator temperatures needed to be monitored, and the medication needed to be stored per the manufacturer's recommended range of safe temperatures. She stated this was important to ensure medication was not administered which had been improperly stored, which could cause an adverse reaction to a resident. 4. Review of the Pharmacy's Expiration Dates document, dated February 2016, revealed PPD once opened should be discarded within thirty (30) days from date opened. Observation on 03/17/17 at 3:10 PM of the Barbaro Aly Sheba Unit Medication Refrigerator, revealed one (1) opened vial of Purified Protein Derivative (PPD) (used for Tuberculin skin test), with no open date noted. Interview on 03/17/17 at 3:10 PM, with LPN #4, revealed the Purified Protein Derivative (PPD) should have been dated by the nurse, when the multi-dose vial was opened. She further stated she would have no way of knowing the expiration date of the medication if an open date was missing from the vial. Interview further revealed the medication needed to be removed from the refrigerator and disposed of because the medication could not be used. Interview with the DON, 03/17/17 at 9:15 PM, revealed multi-dose vials of medications were to be dated when opened. She further stated if the medication did not have an open date there would be no way to determine the expiration date. Continued interview revealed the nurses should discard any multi-dose vials which had been opened and not dated with the open date. Interview on 03/17/17 at 10:30 PM, with the Administrator, revealed nurses were to date any multidose vials of medication with an open date and an expiration date as soon as they opened the vial. Further interview with the Administrator revealed the removal of expired medications from the medication refrigerator was the responsibility of all the nurses. Further interview revealed the night shift nurse checked the medication refrigerators nightly for temperatures and should have found opened vials of medication with no open date. The facility provided an acceptable credible Allegation of Compliance (AOC) on 03/23/17 that alleged removal of the Immediate Jeopardy (IJ) effective 03/20/17. Review of the AOC revealed the facility implemented the following: 1. A facility nurse removed a knife, letter opener, and screw driver from Resident A's bedside table on 03/14/17. The facility offered to store the items in a locked drawer, and the resident declined. The resident agreed to have the items removed from his/her room. The resident's son was notified and stated he brought the letter opener to the resident at his/her request. On 03/15/17, the Assistant Director of Health Services (ADHS)/(ADON) completed a head-to-toe assessment of the resident and no negative outcome was observed. 2. On 03/14/17, the facility nurse obtained a physician's orders [REDACTED]. A Self-Medication Administration Assessment was completed by the nurse on 03/14/17, and the resident demonstrated safe administration and voiced sound knowledge of the reason for his/her inhaler. On 03/15/17, the ADHS/(ADON) completed an assessment of Resident #7 including vital signs and noted no change from the resident's baseline. 3. On 03/14/17, Fabuloso, a cleaning liquid, was discovered in Resident F's room located in his/her closet. The resident and granddaughter agreed to disposal of the cleaning liquid and the granddaughter took the empty bottles home. On 03/15/17, the ADHS/(ADON) completed a head-to-toe assessment of the resident with no change from base line noted. 4. The blender, located in the bar area, inside a closed cabinet was removed by the Director of Food Services and secured in the kitchen. 5. On 03/14/17, the Director of Health Services (DHS)/(DON), Clinical Campus Support (CCS), ADHS/(ADON), and Medical Records Nurse initiated in-service education with staff. Staff were not permitted to work until education was provided. The facility did not use supplemental staffing (temporary agency). The in-service included all facility staff, which included licensed nurses, State Registered Nurse Aides (SRNA), resident care associates, dietary staff, environmental/laundry staff, department leaders, internal marketing, and therapy staff. The education covered proper medication storage; review of the self-administration of medication Policy; and proper storage of chemicals and hazardous items, which was also added to the (Admission Guide). 6. On 03/19/17, sixty-nine (69) of ninety-two (92) staff members had been in-serviced in person or via the phone. The exam was given by the DHS/(DON), ADHS/(ADON), CCS and Executive Director/(Administrator). 7. On 03/19/17, the DHS/(DON), ADHS/(ADON), ED/Administrator and charge nurses completed a partial (cognition and safety) monthly assessment on all health center residents to re-evaluate their cognitive status that may effect their safety and judgement. Residents A, B, C, D, E, F, and G were noted with various items such as nail polish, hand sanitizer, laundry treatment and sanitation wipes in their drawers and closet. 8. On 03/15/17, the ED/Administrator, DHS/(DON), ADHS/(ADON), Medical Records, MDS Coordinator, MDS Support, Administrator in Training (AIT), Life Enrichment Director (LED), Environmental Service Director (ESD), Customer Service Specialist (CSS), Social Service Director (SSD), Director Plant Operations (DPO), Program Director of Therapy, Director of Food Service (DFS), and Clinical Campus Support (CCS) met to discuss how to deliver the message to the residents and family members related to a necessary one hundred percent (100%) building room sweep. All leaders involved were informed to ask permission from the residents prior to looking through their personal items such as dressers, closets, and bathrooms. Leaders were provided a hand written list of potentially hazardous items, dated 03/15/17. All rooms were checked and three (3) residents were identified to have medication (inhalers) at the bedside. The nurse completed a Self-Administration of Medications Assessment and obtained a physician's orders [REDACTED]. 9. On 03/15/17, the DHS/(DON), and ADHS/(ADON) educated the residents to secure the medication in an area that was not easily accessible to other residents and they voiced understanding. 10. On 03/15/17, all residents and families of the health center were called or spoken directly to regarding the procedure pertaining to hazardous items. Those who placed the phone calls included the AIT, LED, Human Resource Support, DFS, DFS support, and the Business office Manager. 11. On 03/15/17, the Quality Assurance (QA) committee met to discuss the details of the action items contained in the Allegation of Credible Compliance (AOC). The ED/(Administrator), DHS/(DON), ADHS/(ADON), and CCS were present. The Advanced Practice Registered Nurse (APRN) and Medical Director was involved in the discussion and decision making for the action items put in place. A potentially Hazardous Item List was developed and used for audits completed by the DHS/(DON), ADHS/(ADON), Medical Records Nurse, and/or Charge Nurse/Week Start Manager (weekend department leader). With permission from the resident and/or family, 100% of all current residents' rooms were audited for potentially hazardous items. Audits would consist of all new admissions monthly; resident rooms on each health center neighborhood daily for the next two (2) weeks; weekly for the next two (2) months; and then monthly up to a year. The audits would be reviewed during the monthly QA meetings. 12. The Medical Director, ED/(Administrator), DHS/(DON), ADHS/(ADON), and Medical Records Nurse will review the results of the audits weekly to ensure compliance and make modifications when necessary. The committee will monitor by reviewing the audits for any additional educational needs; effectiveness; compliance with the plan; and revise the plan of action related to any and all problems identified through the audit process. The DHS/(DON), ADHS/(ADON), and/or charge nurse will be responsible to provide additional education as identified during the audit and suggestions made by the QA committee. The results will be tracked and reviewed for trends with follow-up actions taken by the ED/(Administrator), no less than weekly. The Medical Director will review the progress with the ED/(Administrator) on a weekly basis. 13. A facility Nurse left medication out on the nurses' desk. The facility nurse removed the bag of medication and secured it in the medication cart. On 03/14/17, the DHS/(DON) counseled and educated the facility nurse on proper storage of medication. The DHS/(DON), ADHS/(ADON) audited all other nurse's stations to assure medications were secured. No other medications were noted unsecured. 14. On 03/14/17, the DHS/(DON), CCS, ADHS/(ADON), and Medical Records Nurse initiated in-service education. A question and answer competency review was developed to help measure the staff's understanding of the information. No staff returned to work without being in-serviced first. The education and exam was given by Clinical Compliance, DHS/(DON), ADHS/(ADON), CCS, and ED/(Administrator). The facility did not use supplemental staffing (temporary agency). The in-service included licensed nurses and Certified Medication Aides. The in-service included the following: The Storage of Medication Policy with emphasis on immediately securing medications delivered from the pharmacy after the nurse signs for the medication and emphasis placed on chain of custody for the delivery and securement of narcotics. All staff to take a question and answer competency exam before returning to work. The DHS/(DON), ADHS/(ADON), and/or charge nurse utilized an employee roster to track staff for the completion of the in-service. 15. On 03/19/17, seventy (70) out of ninety-two (92) employees were in-serviced in person or via the phone. 16. On 03/15/17, the QA Committee met to discuss the details of the Allegation of Credible Compliance. The ED/(Administrator), DHS/(DON), ADHS/(ADON), Medical Records Nurse and CCS were present. The CCS and APRN were available via phone/text with the Medical Director and discussed the action items. The secured medication audit tool would be completed by DHS/(DON), ADHS/(ADON), Medical Records Nurse, and/or Charge Nurse. The tool would be used to audit proper medication delivery to assure all medications were secured immediately. Once signing off by the receiving nurse, the medications were to be placed into the medication cart. Audits were completed on 03/15/17 and 03/16/17. The audit would be completed daily and as needed (PRN) (admission and stat delivery) for two (2) weeks. Once 100% compliance was found the audit would decrease to daily four (4) times a week, and if 100% compliance remained, then one (1) time monthly up to a year. The facility provided an Acceptable Credible Allegation of Compliance (AOC) on 03/23/17 that alleged removal of the Immediate Jeopardy (IJ) effective 03/20/17. Review of the AOC revealed the facility implemented the following: 1. Review of the facility's documented evidence revealed Resident A received a head-to-toe assessment which was completed by the (ADHS)/(ADON), on 03/15/17. There were no concerns identified on the skin assessment. Interview with the ED/Administrator, on 03/23/17 at 4:55 PM, revealed the resident was offered to store items in a locked drawer and the resident declined; however, was willing to have the items removed from his/her room. Continued interview revealed the facility contacted the resident's son who stated he had brought the letter opener in at the resident's request. 2. Resident #7 was discharged from the facility on 03/18/17; therefore, the resident could not be interviewed. Review of Resident #7's Self-Administration of Medication Assessment, dated 03/14/17 revealed the resident requested he/she would like to administer his/her inhaler; and demonstrated safe administration of the inhaler as well as voiced the reason for the inhaler. Review of Resident #7's physician's orders [REDACTED]. Interview with the ADHS/(ADON), on 03/23/17 at 3:25 PM, revealed the charge nurse completed the Self Medication Administration Assessment for his/her medication on 03/14/17. The ADHS/(ADON) stated she followed up with Resident #7's vital signs and assess the resident for any changes by having the inhaler, with no concerns noted on 03/15/17. 3. Interview with CCS, on 03/23/17 at 11:30 AM, revealed with permission from the granddaughter and the resident, the contents of the Fabuloso (cleaning solution), and what the resident described as lavender and water in the two (2) bottles were discarded by a nurse. Review of the facility's documented evidence, dated 03/15/17, revealed the resident received a head-to-toe skin assessment with no concerns noted. 4. Interview with the DFS on 03/15/17 at 11:45 AM, revealed the blender should be stored in a secure area. Continued interview with the DFS revealed she would place the blender in the kitchen. Observation on 03/23/17 at 3:00 PM revealed the blender was no longer stored in the cabinet of the bar area. 5. Review of the In-Service dated 03/14/17, revealed staff signed off they had received education related to proper medication storage, review of the self administration of medication policy, proper storage of chemicals and hazardous items with no sharp objects, no chemicals, and no knives in resident rooms. Interviews with SRNA #8 on 03/22/17 at 3:10 PM; SRNA#4 on 03/22/17 at 3:30 PM; Kentucky Medical Assistant (KMA) #5 on 03/22/17 at 3:50 PM; SRNA #3 on 03/22/17 at 4:25 PM; LPN #6 on 03/22/17 at 4:45 PM; Licensed Practical Nurse (LPN) #5 on 03/22/17 at 5:10 PM; Registered Nurse (RN) #4 on 03/23/17 at 2:22 PM; LPN #8 on 03/23/17 at 2:28 PM; Environmental Services Director on 03/23/17 at 2:30 PM; MDS Coordinator on 03/23/17 at 2:38 PM; MDS Corporate Support on 03/23/17 at 2:40 PM; Director of Plant Operations on 03/23/17 at 2:53 PM; Customer Service Specialist on 03/23/17 at 3:00 PM; SRNA #9 on 03/23/17 at 3:06 PM; Life Enrichment Director on 03/23/17 at 3:07 PM; Director of Food Service on 03/23/17 at 3:20 PM; SRNA #10 on 03/23/17 at 3:36 PM; Program Director of Therapy at on 03/23/17 at 3:45 PM; Social Service Director on 03/23/17 at 3:57 PM; and SRNA #6 on 03/23/17 at 5:00 PM; revealed they were in-serviced on proper medication storage; the storage of chemicals and hazardous items; and self-administration of medications. All interviewed revealed they were not allowed to work until they received the education and a passing score of 100% was required to pass. 6. Review of the Sign-In list, with dates ranging from 03/14/17 to 03/19/17, revealed sixty-nine (69) staff signed off as in-serviced on proper storage of chemicals and hazardous items, proper medication storage and Self Administration of Medication Policy. Continued review of the in-service signature documentation revealed the in-service was provided by the ED/(Administrator), DHS/(DON), ADHS/(ADON), or designee, with the majority of the in-service sheets signed off by the ADHS/(ADON). Interview with the ADHS/(ADON), on 03/23/17 at 3:25 PM, revealed she was one of the first to be in-serviced on storage of medications, self-administration of medications, and hazardous items. She stated she then in-serviced other staff. 7. Review of documented evidence, titled Monthly Observation and Data Collection, dated 03/19/17, revealed all residents were assessed for safety and mental/neuro checks including residents A, B, C, D, E, F, and G. 8. Interviews with the Environmental Services Director on 03/23/17 at 2:30 PM; MDS Corporate Support on 03/23/17 at 2:40 PM; Customer Service Specialist on 03/23/17 at 3:00 PM; Life Enrichment Director on 03/23/17 at 3:07 PM; Food Services Director on 03/23/17 at 3:20 PM; ADHS/(ADON) on 03/23/17 at 3:25 PM; Clinical Campus Support on 03/23/17 at 3:27 PM; ED/(Administrator) on 03/23/17 at 4:55 PM; and DHS/(DON) on 03/23/17 at 5:17 PM; revealed they met to discuss how to communicate to the residents about items that were potentially hazardous. Continued interviews with staff revealed they asked for permission to go through the residents' items and the facility's policy was explained to the residents. The facility provided a list of potentially hazardous items, which was provided to the residents as well as, staff. Three (3) Residents, were identified to have medication inhalers at the bedside which were Residents #7, #9, and #10. Review of the Self Administration of Medication Forms revealed Residents #7, #9, and #10 were assessed by the DHS/(DON) and the ADHS/(ADON), with a completion date of 03/16/17. Review of the physician's orders [REDACTED]. 9. Interview with the ED/(Administrator) on 03/23/17 at 4:55 PM, revealed she talked to the residents who were assessed to self-administer their medications to secure their medications by locking the medications up or asking staff to assist them. Further interview with the Administrator, revealed the residents expressed understanding when explained it was for the safety of other residents who may wander into their rooms. 10. Review of the Notification List, dated 03/15/17 thru 03/16/17, revealed all residents or residents' Power of Attorney (POA)/families were notified related to the procedure pertaining to hazardous items. Continued review revealed staff signed off on the sheet indicating the residents or residents' Power of Attorney (POA)/families were notified. Interview with the ED/(Administrator) on 03/23/17 at 4:55 PM, revealed different staff members called the residents' POA's/families to notify them of items that were identified as hazardous i