Every finding on record at The Woodlands Health and Rehab Center

Based on clinical record review, the facility staff failed to obtain physician orders for the care of an implanted cardiac defibrillator for one of 21 residents, Resident #153. Findings were: Resident #153 was admitted to the facility with the following diagnoses, including but not limited to: Acute respiratory failure with hypoxia cardiomegaly, atherosclerotic heart disease, mitral valve insufficiency, presence of automatic implantable cardiac defibrillator (AICD), heart failure, dysphagia, and hypertensive heart disease. The admission MDS (minimum data set) with an ARD (assessment reference date) of 01/27/2023 assessed Resident #153 as cognitively intact, with a summary score of 13 out of 15. The clinical record was reviewed on 04/12/2023, beginning at approximately 11:00 a.m. Review of the physician orders did not contain orders regarding the care and or monitoring of the implanted cardiac defibrillator. The Nursing Admission/Readmission assessment dated [DATE] included the following information in section O. Immediate Needs Plan of Care were the following: Cardiovascular Concerns: Focus: Has impaired cardiovascular status as related to multiple cardiac arrest and placement of AICD while hospitalized .Goal: Patient will experience stable cardiovascular status through the next review. Interventions were: Assess for/report complaints of heart jumping or fluttering, radiating arm and/or jaw pain, new onset of nausea or other potential signs/symptoms of cardiac/health complications. Encourage patient to pace activities to level of comfort. Observe for signs and symptoms of shortness of breath, chest pain, lethargy. Report for further assessment and intervention. Take vital signs as ordered, per protocol, or clinically indicated. Promptly report unusual findings or changes for further assessment. The comprehensive care plan was reviewed, a focus area included .has altered cardiovascular status which impacts function and tolerance to activity r/t arrythmia, s/p AICD placement, s/p NSTEMI with the goal, .free from s/sx of complications of cardiac problems through the review date. Interventions included: Observe/report to MD PRN s/sx of CAD, chest pain or pressure especially with activity, heartburn, nausea and vomiting, shortness of breath, excessive sweating, dependent edema, changes in cap refill, color/warmth of extremities; oxygen as ordered; and vital signs per MD orders and as indicated by s/s. Notify physician of significant deviations/abnormalities. No additional information was received prior to the exit conference on 04/13/2023.

Based on medication pass and pour observation, staff interview, and facility document review, the facility staff failed to follow professional standards of nursing practice during medication pass on the back hall. Findings were: A medication pass and pour observation was conducted on the back hall of the facility on 04/12/2023 at approximately 8:00 a.m. with LPN (licensed practical nurse) #1. LPN #1 removed two plastic bags from the medication cart and explained that the pharmacy packed the medication for each resident in separate labeled bags. The bags were labeled with the resident name, room number and time of day for the medications to be administered. Listed on each bag were the blister packs of medication that were in the bag and the resident was to receive. LPN #1 removed the bags for Resident #45 and compared the medications listed on the outside of the bag to the electronic MAR (medication administration record). then opened the bags and placed the blister packs on the top of the medication cart. LPN #1 popped each pill from the blister packs into the medication cup. LPN #1 them administered the medications, a total of twelve pills in all to Resident #45. After the medications were administered LPN #1 was asked if she ever compared the medications in the bag to what was written on the outside or to the MAR to ascertain if the medications in the bags were correct. LPN #1 stated, I check the bag to the MAR. When asked how she knew what was in the bag was accurate, LPN #1 stated, I glance at them, I know what my people are supposed to get .nobody ever trained me to take the pills and compare them to the bag or the MAR. The DON and the ADON were interviewed at approximately 9:00 a.m. and were asked if the medications should be compared to the EMAR. They both stated, Yes. The facility policy on Medication Administration contained the following, Verify that the following information on the bag matches the information on the MAR .name, room number, administration date and time .Verify that the following information for each mediation in the bag (1st med check) matches the information on the MAR: med name, med strength, med quantity .if there are no discrepancies between the MAR and the bag, tear open the bag .remove all of the blisters from the bag. Reread each order on the resident's MAR and locate the blister(s) that contains the specified medication to verify the matching for (2nd med check): med name, med strength, med quantity. Proceed through the resident' s MAR, checking each order with the blister and popping the blister into a medication cup . The above finding was discussed during an end of the day meeting on 04/12/2023. No further information was obtained prior to the exit conference on 04/13/2023.

Based on observation, staff interview, and clinical record review, the facility staff failed to review and revise the comprehensive care plan for one of 21 residents. Resident # 14's care plan was not updated to include the use of a specialty mattress. Findings were: Resident #14 was admitted to the facility with the following diagnoses, including but not limited to: Vascular dementia, urine retention, hypertension, Parkinson's disease, and cerebrovascular disease. The most recent MDS (minimum data set) was an annual assessment with an ARD (assessment reference date of 01/23/2023. Resident #14 was assessed as having problems with both long and short term memory, as well as daily decision making skills. ON 04/11/2023 at approximately 10:00 a.m., during initial tour of the facility, Resident #14 was observed sitting in a geri chair in his room. Resident #14 was non verbal except for the repetitive sound of la la la la. The sides of the mattress on Resident #14's bed were higher than the rest of the mattress. The clinical record was reviewed on 04/12/2023 at approximately 10:00 a.m. There was no mention of a specialty mattress on his physician orders or his care plan. The DON was interviewed at approximately 11:30 a.m., and asked what type of mattress was on Resident #14's bed. The DON stated she would look. At approximately 11:55 a.m., the DON stated, It is a concave mattress. She was asked why he had the specialty mattress. She stated, He's wiggle worm. She was asked if it should be on the care plan. She stated, Yes, we are adding it now. The above findings were discussed during an end of the day meeting on 04/12/2023 with the DON and the administrator. No further information was obtained prior to the exit conference on 04/13/2023.

Based on observation, staff interview, and clinical record review, the facility staff failed to develop comprehensive care plans for two of 21 residents. Resident # 153 did not have a care plan in place for nutrition and a physician ordered treatment was not listed on the care plan for pressure ulcers. Resident #119 did not have a care plan for the use of a life vest. Findings were: 1. Resident #153 was admitted to the facility with the following diagnoses, including but not limited to: Acute respiratory failure with hypoxia cardiomegaly, atherosclerotic heart disease, mitral valve insufficiency, presence of automatic implantable cardiac defibrillator (AICD), heart failure, dysphagia, and hypertensive heart disease. The admission MDS (minimum data set) with an ARD (assessment reference date) of 01/27/2023 assessed Resident #153 as cognitive intact with a summary score of 13 out of 15. The clinical record was reviewed on 04/12/2023 beginning at approximately 11:00 a.m. Review of the admission MDS Section V indicated that Resident #153 had triggered for nutrition and should be care planned. The care plan was reviewed and there was not a focused area for nutrition or interventions listed to address his nutritional status. Review of the physician orders showed that Resident #153's diet had been downgraded after a speech therapy evaluation, from regular texture to soft and bite size texture. Also, included were orders for house supplement twice a day and prostat 30 ml twice a day as a supplement. A Nutrition Deficiencies/Risk for Malnutrition form was observed in the clinical record. Per the documentation Resident #153 was S/p (status post) hospitalization for NSTEMI (non ST elevated myocardial infarction - a heart attack), Acute hypoxia, Resp failure, AICD placement, CAD (coronary artery disease), Mitral valve regurgitation, Anemia Myasthenia Gravis Base on the clinical indicators and comorbidities and your medical judgement, please indicate any of the following diagnoses associated with these findings in the medical record that apply: At risk for malnutrition [was the choice checked by the nurse practitioner]. The form was completed at the time of Resident #153's admission. The physician orders also contained : Apply foam overlay to coccyx for preventative care. Daily and PRN (as needed) as becomes soiled or dislodged. The care plan contained a focus area for .at risk for skin breakdown . Interventions listed in the care plan did not include the use of a protective dressing. The DON was interviewed on 04/13/2023 regarding care plans. She stated, MDS does the care plans, but the nurses can add to them or change them as needed. The above findings was discussed during a meeting with the administrator, the DON, the ADON and two corporate nurses on 04/23/2023 at approximately 2:00 p.m. No further information was obtained prior to the exit conference on 04/23/2023. 28106 3. The Findings Include: Resident #19 did not have a care plan for the use and monitoring of a life vest (apparatus that is worn to detect and shock a person if an abnormal heart rhythm is detected). Diagnoses for Resident #19 included; Respiratory failure, pleural effusion, obstructive pulmonary disease, coronary artery disease. The most current MDS (minimum data set) was a 5 day assessment with an ARD (assessment reference date) of 4/1/23. Resident #19 was assessed with a cognitive score of 12out of 15, indicating cognitively intact. On 4/11/23 at 11:08 AM, an interview was conducted with Resident #19's family member. During the conversation, Resident #19 was noted to be wearing a vest. When asked what it was for, Resident #19's family member verbalized that it was a life vest and it was to be worn due to an unstable heart condition. On 4/12/23 review of Resident #19's physician orders indicated that Resident #19 should wear the life vest at all times. Review of the Care plan did not evidence that a care plan had been completed regarding the use or monitoring of the life vest. On 4/12/23 at 3:18 PM, registered nurse (RN #1, MDS coordinator) was interviewed. RN #1 reviewed Resident #19's care plan and verbalized a care plan should have been in place and would look into it. On 4/12/23 at 4:07 PM the above findings were presented to the director of nursing and administrator. No other information was presented prior to exit conference on 4/13/23.

Based on staff interview and clinical record review, the facility staff failed to provide a baseline care plan for one of 21 residents in the survey sample. Resident #53 was not presented with a completed copy of the baseline care plan. This was a closed record review. The Findings Include: Diagnoses for Resident #53 included; Dementia, anxiety, depression, epilepsy, insomnia, and muscle wasting. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 11/19/21. Resident #53 was assessed with a cognitive score of 15 indicating cognitively intact. On 4/12/23 review of Resident #53's clinical record evidenced that a baseline care plan was completed on 8/14/21 after the admission on 8/13/21. A form titled Safe Transition Meeting dated 8/16/21 documented a meeting with the facility staff and Resident #53, and indicated that the baseline care plan was reviewed during the meeting. The form was electronically signed by the social worker, however there was not a place for Resident #53 to sign indicating presence during the meeting. On 4/12/23 at 8:50 AM the director of nursing (DON) was asked if residents are provided with a copy of the baseline care plan. The DON verbalized if a resident requests a copy then the facility will provide a copy of the care plan. On 4/12/23 at 9:00 AM the social worker (other staff, OS #5) was also asked if baseline care plan is provided to residents. OS #5 verbalized, if a resident request a copy then one will be provided. OS #5 was then asked if Resident #53 had received a copy of the baseline care plan. OS #5 said that there was a meeting with Resident #53 to discuss the baseline care plan, but was unsure if a copy had been provided to Resident #53 and would look into it. On 4/12/23 at 11:15 AM OS #5 verbalized after reviewing Resident #53's clinical record she was unable to find documentation of a baseline care plan was provided to Resident #53. On 4/12/23 at 4:07 PM the above information was presented to the director of nursing and administrator. No other information was presented prior to exit conference on 4/13/23.

Based on closed clinical record review, and staff interview, the facility failed to maintain a complete and accurate clinical record for one of 21 residents in the survey sample (Resident # 54). Facility staff failed to document the resident's bathing for the period [DATE] through [DATE]. The findings were: Resident # 54 was admitted to the facility with diagnoses that included Alzheimer's Disease, anemia, coronary artery disease, hypertension, renal insufficiency, diabetes mellitus, anxiety disorder, Non-Alzheimer's Dementia, benign prostatic hyperplasia, urinary retention, chronic prostatitis, gastroesophageal reflux disease, hypertensive chronic kidney disease, and arteriosclerotic heart disease. According to the most recent Minimum Data Set, a Quarterly review with an Assessment Reference Date of [DATE], Resident # 54 was assessed under Section C (Cognitive Patterns) as being severely cognitively impaired, with a Summary Score of 03 out of 15. Under Section G (Functional Status), the resident was assessed as needing supervision with set-up help only for transfer, walking in the room and unit corridor, locomotion on and off the unit, and eating; as needing limited assistance with one-person physical assist for dressing and personal hygiene; and, as needing extensive assistance with one-person physical assist for bathing. Under Section H (Bladder and Bowel), the resident was assessed as occasionally incontinent of bladder, and frequently incontinent of bowel. Resident # 54, who was a Hospice recipient, expired at the facility on [DATE]. According to documentation in the resident's Electronic Health Record (EHR) and confirmed by the Director of Nursing (DON), Resident # 54's bath days were Tuesday and Friday. Review of bathing records revealed the resident refused bathing on [DATE], [DATE], [DATE], [DATE], and [DATE]. The resident accepted showers on [DATE] and [DATE]. There was no bathing documentation for the period [DATE] through [DATE], which neither indicated whether the resident refused or received bathing. The DON was able to determine Resident # 54 did not receive a bath/shower on [DATE], [DATE], and [DATE], but was not able to find documentation indicating if the resident had refused bathing. A thorough review of Resident # 54's EHR failed to reveal any evidence the resident experienced any skin issues as a result of potentially missed baths/showers. No additional information was provided prior to exit conference.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to follow infection control practices to prevent the potential spread of COVID-19 on one of two units, the west unit. Droplet precautions were not implemented at the time of entry for an unvaccinated new admission, facility staff was not aware of the proper PPE (personal protective equipment) to wear while in contact with a resident on droplet precautions, and one staff member was not aware of where to find proper PPE. Findings were: Initial tour of the facility was conducted on 07/26/2021 beginning at approximately 7:00 p.m. Observed outside of Resident #205's room was a white trifold, cloth covered partition. The partition was not around the door but sitting at an angle. RN (registered nurse) #1 was asked what the partition was for. She stated, I don't know why that is there .the resident in the room is a new admission but she was COVID negative when she left the hospital today. There was no signage around the partition or the open door to the room, nor was there an isolation cart observed in the hallway. RN #1 was asked if the resident in the room was on any type of isolation. She stated, No, she's not on anything .when we have someone who's COVID positive we have a hot unit. We put them in the room at the end of this hallway .they are on one to one, and the staff enters the backdoor down here (pointing to the door at the end of the hallway) .but we don't have anyone now that is COVID positive or on any isolation for it. On 07/27/2021 at approximately 8:10 a.m., Resident #205's room was observed with the trifold partition placed directly in front of the room's open door, a yellow sign on the partition read Droplet Precautions Warm Unit -N95 and Eye Protection (Goggles/Face Shield) .gown and gloves. An additional white sign read: Droplet Precautions See Nurse Before Entry. OS (Other staff) #1 was observed outside the room. She was wearing a blue surgical mask and a face shield. She had just walked from behind the partition. She was asked if she had been inside the resident's room. She stated, Yes, I did her therapy. LPN (Licensed Practical Nurse) #1 was in the hallway at the medication cart. She was asked why Resident #205 was on droplet precautions. She stated, I don't know, let me look .she is a new admission, it looks like she came in yesterday afternoon. She was COVID negative when she was tested at the hospital, but it says on her record that she isn't vaccinated so she had to be in a warm unit with isolation here for 14 days. At approximately 10:00 a.m., OS #3 was observed cleaning resident rooms on the west unit. When he got to the Resident #205's room, he donned a gown and gloves and went around the partition into the room. When he came out of the room he was asked why he was not wearing an N95 mask or a face shield/goggles. He stated, I was told I don't have to because I am fully vaccinated. LPN #1 was in the hallway at the medication cart. She was asked what PPE was required to enter Resident #205's room. She stated, Everything .gown, gloves, N95, face shield or goggles. She was asked if those requirements changed if you were fully vaccinated. She stated, I don't think so, I'm vaccinated and I wear everything .I thought you had to wear everything. LPN #1 stopped another staff member in the hallway and asked, Do we still need to wear an N95 and everything in Resident #205's room, even if we are vaccinated? The staff member responded, I don't know, maybe not. At approximately 10:15 a.m., OS #1 was observed coming out of a resident room on the main hallway. She was stopped and interviewed about the PPE worn while in Resident #205's room (warm unit). She stated, I wore a blue mask, a face shield, gown and gloves. She was asked if she had read the sign that directed anyone entering the room to wear an N95 face mask. She stated, Yes, but I didn't know an N95 was available to me .if you find out that they are let me know. At approximately 10:25 a.m., CNA (certified nursing assistant) #1 was asked what was stored on the isolation cart at the door to Resident #205's room. She pulled back the cover over the front of the cart and stated, Everything is on here, gown, gloves, N95 mask, face shields .if you have glasses you don't have to wear the face shield, but you do wear everything when you go in even if you are vaccinated. At approximately 10:30 a.m., OS #1 was informed that there were N95 face masks on the cart. She asked which ones they were. She was told they were white with yellow straps. She then went to her cubical and obtained a green stripped mask. She stated, This is an N95, these are the ones I like, can I wear this one. She was told that she would need to verify what type of N95 was required with the facility. Resident #205 was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no MDS (minimum data set) information, but per her admission assessment, Resident #205 was oriented to self and able to follow directions. The clinical record was reviewed on 07/27/2021 at approximately 10:30 a.m. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission assessment was observed. Under the section IMMUNIZATIONS, section ga The question Has the resident had COVID-19 vaccine (one or both?) was marked no. At 10:35 a.m., the DON (director of nursing), also the Infection Preventionist and the administrator were interviewed. The observations for the initial tour on 07/26/2021 and the observations of that morning (07/27/2021) were discussed. The DON was asked if Resident #205 was vaccinated or had already had COVID. She stated, She has not been vaccinated and has not had COVID .she should have been on isolation from the beginning .(name of RN #1) is fairly new here .we haven't had anyone on the warm unit for awhile. The DON was asked about the timing of the order entry. She stated, I had to reenter that because it wasn't entered correctly. She was asked what should have happened with the Resident #205. She stated, Ideally, they are screened at the the hospital and are COVID negative before their admission .when they get here we screen them for symptoms. The admission nurse sets up the isolation, they are in a private room, and the resident is on 14 days of quarantine with droplet precautions .that's gown, gloves, N95, and a face shield or goggles .everyone wears everything regardless of their vaccination status. If the new admission is at least two weeks post full vaccination they can go to a regular room. The DON was asked about the county positivity rate. She stated, We are currently at 12.9% and testing unvaccinated staff twice a week. The information on the sign going into Resident #205's room compared to the Droplet Precaution policy provided was discussed. Per the droplet policy N95 masks were not required. The DON stated, We are using N95's if it's COVID. At approximately 10:50 a.m., the DON stated (names of OS #1 and OS #2) have both been sent home. (Name of OS #1) should have gone in there last to do the therapy assessment, after she had seen everyone else. The DON was asked if a face shield and a surgical mask were an acceptable substitution for an N95. She stated, No, per the CDC, we are wearing N95 masks, face shields or goggles .here is the sign (printed on yellow paper) I am going to put up that spells it out: 'DROPLET PRECAUTIONS Must Wear PPE Per CDC: 1) Gloves 2) Gown 3) N-95 4) Face Shield or Goggles WASH HANDS BEFORE AND AFTER ENTERING ROOM KEEP DOOR CLOSED AND CURTAINS PULLED IF MORE THAN 1 RESIDENT IN ROOM' The facility policy Novel Coronovirus Prevention and Response was reviewed. The following information was observed on page 5: Considerations for admitting or readmitting residents or resident who may have left the facility for 24 hours or longer: a. Residents with confirmed [CONDITION(S)]-Co-2 [sic] infection who have not met criteria for discontinuation of Transmission-based Precautions should be placed in the designated COVID-19 care unit. b. All other new admissions or readmissions should be placed in a 14-day quarantine, even if they have a negative test upon admission. i. Exceptions include residents within 3 months of [CONDITION(S)]-CoV-2 infection and fully vaccinated residents. ii. If the facility is located within an area with minimal to no community transmission, they might elect to use a risk-based approach for determining quarantining of residents upon admission. The decision should be based on whether the resident had close contact with some one with [CONDITION(S)]-CoV-2 infection while outside the facility and if there was a consistent adherence to IPC practices in healthcare settings, during transportation, or in the community prior to admission. No further information was obtained prior to the exit conference on 07/28/2021.

Based on observation, staff interview, and clinical record review, the facility staff failed to administer oxygen per physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 29's oxygen was observed being administered above the parameters ordered by the physician. Findings include: Resident # 29 was admitted to the facility 7/11/20 with a readmitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS (minimum data set) was an annual review dated 6/12/21. Resident # 29 was coded as having moderate impairment in cognition with a score of 06 out of 15. On 7/28/21 at 10:30 a.m. Resident # 29 was observed in bed. The oxygen concentrator beside the bed was observed delivering oxygen to the resident via nasal cannula at 4.5 LPM (liters per minute). The clinical record was reviewed at 10:45 a.m. and was noted to include an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was dated 6/17/21. On 7/28/21 at 11:00 a.m. the resident's oxygen gauge was observed to still be set at 4.5 LPM. LPN (licensed practical nurse) # 1 was outside the resident's room and asked if she would verify the reading on the oxygen gauge. LPN # 1 entered the room, looked at the reading and stated it says 4.5 but she's on 3[LPM] and proceeded to turn the oxygen gauge to 3. LPN #1 was asked if she was sure the resident was supposed to be getting 3 LPM, and she stated Yes. On 7/28/21 at 11:35 a.m. LPN # 1 was interviewed about the oxygen for Resident # 29, and informed her the current order was for 4 LPM. She stated Yes, I see that, but the last time I had her she was on 3. I've been working the back hall so I haven't had her in a while . The administrator, DON (director of nursing), and regional nurse consultant were informed of the above findings during a meeting with facility staff at 12:15 p.m. No further information was provided prior to the exit conference.

Based on observation and staff interview, the facility staff failed to post daily staffing in a prominent area visible to all residents and visitors. The facility staff also failed to post correct information on the daily staffing sheet. Findings include: The initial tour of the facility was conducted 7/26/21 beginning at 7:00 p.m. There were several posters and pictures observed on the walls of the lobby of the facility. The daily nurse staffing was not located. During the survey process, the daily staffing information was not located. On 7/28/21 at 9:00 a.m. the DON (director of nursing) was asked for assistance in locating the information. The posting was on a corkboard in the front hallway tacked to the board. There other papers/flyers also posted on the board, and the staffing sheet was partially obscured by the other postings; the sheet had the hours worked by each discipline, but did not include specific units, or the resident census. The DON was asked if visitors and residents knew where to find the posting and she stated I don't know. The above information was presented to the administrator, DON, and regional nurse consultant during a meeting with facility staff 7/28/21 at 12:15 p.m. On 7/28/21 at approximately 2:30 p.m. the administrator brought a revised copy of the posting to the conference room and stated We broke up the hours to specific units, and added the resident census. No further information was provided prior to the exit conference.

Based on observation and staff interview, the facility staff failed to ensure the wall in one of sixteen rooms was in good repair promoting a homelike environment. The wall in room 169 had two areas of white dry wall patch beside the resident's bed. The rest of the wall and room were painted yellow. Findings were: On 07/27/2021 at approximately 8:00 a.m., Room 169 was observed. The bed beside the door was against the wall with the head of the bed facing the doorway. The wall beside the bed was yellow except for two separate areas of dry wall patches that were white. The resident residing in that room was not interviewable and when asked what had happened to his wall, his response was not understandable, as he pointed at the television. On 07/28/2021 at approximately 9:00 a.m., the wall was observed in the same condition. At approximately 1:00 p.m., LPN (Licensed Practical Nurse) #10 was in the hallway. She was asked to observe the wall in room 169. She was asked what needed to be done to fix the wall. She stated, We would report that to maintenance in [name of system]. I haven't reported it but I am guessing that someone did. She was asked how it could be determined if a report had been made. She stated, I can ask [name of maintenance director]. The maintenance director was interviewed at approximately 1:10 p.m. on 07/28/2021. He was asked if was aware of the damage to the wall in room 169. He stated, Yes. He was asked when he became aware. He stated, About two weeks ago .I patched the areas with dry wall and that needs to dry about 24 hours .they put him [the resident] back in the bed before it was dry and he got into it with his fingers and dug in it, so I had to redo it .He's also a 'spitter' so housekeeping had to clean the wall .it's hard to keep it clean .I just haven't gotten back in there yet to finish it. He was asked when the job should have been completed. He stated, About two weeks ago. He was told that the appearance of the wall did not promote a homelike environment in the room. He stated, I am aware. The above information was discussed with the DON (director of nursing) and the administrator during a meeting on 07/28/2021 at approximately 3:00 p.m. The Administrator stated that the wall was being repaired at that time. At approximately 3:45 p.m. the maintenance director was observed in Room 169, the white patches had been painted as well as the rest of the wall on that side of the room. He stated, This room is slated to be painted to change over to our new color schemes for the rooms. No further information was obtained prior to the exit conference on 07/28/2021.

Based on observation, staff interview, facility document review, and clinical record review, facility staff failed to provide care and services for use of an indwelling catheter for one of 17 residents in the survey sample, Resident #203. Facility staff failed to ensure Resident #203 had an acceptable [DIAGNOSES REDACTED]. Findings included: Resident #203 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #203 did not have a completed MDS (minimum data set) at the time of the survey. According to clnical record progress notes, Resident #203 was assessed as alert and oriented to person, place and time. During initial tour of the facility on 04/02/2019 at 8:08 a.m., Resident #203 was observed lying in bed with his Foley catheter drainage bag hanging from the side of the bed. No privacy bag was observed. Review of Resident #203's clinical record on 04/02/2019 at 2:00 p.m. included a physician order [REDACTED]. The POS included, .Catheter Care q (every) shift, Order Date: 03/21/2019 .D/C (discontinue) cath on 04-04-2019. Monitor output for 4 hours, notify provider if no output .Order Date: 03/29/2019 . An Indwelling Catheter assessment dated [DATE] included the following documentation, .Diagnosis 1. Obtain Resident's reason for Catheter if able: Wound to sacrum and excoriation . No documentation was located in the clinical record of any staged pressure ulcer. On 04/03/2019 at 08:21 a.m. the DON (director of nursing) was interviewed regarding Resident #203's Foley catheter. The DON stated, He came from the hospital with it. I try hard to stay on top of the catheters. I guess I missed changing his bag. The Administrator was informed of the above information during a meeting with the survey team on 04/03/2019 at 10:45 a.m. No further information was received by the survey team prior to the exit conference on 04/03/2019.

Based on observation, staff interview and facility document review, the facility staff failed to ensure [MEDICATION NAME] PPD (purified protein derivative) solution was dated when opened and stored per pharmacy recommendation in the refrigerator of the facility's medication room. One multi-dose vial of PPD solution was observed opened and stored in the top of a medication cart on the front hall of the facility. The vial was not labeled with the date that it had been opened. Findings were: On 04/03/2019 at approximately 9:45 a.m., the refrigerator in the facility's medication room was inspected with LPN (licensed practical nurse) # 1. There were no vials of [MEDICATION NAME] PPD solution observed in the refrigerator. LPN #1 was asked what was used for [MEDICAL CONDITION] testing for newly admitted residents. She stated, We use PPD solution .I used it this morning, it's still in the top of my cart. The opened vial of PPD solution was located on top of the medication cart and observed. The date the vial was opened was not written on the vial. LPN #1 was asked when the vial had been opened. She stated, I don't know. She was asked how long a multi-dose vial of PPD solution could be opened before it would need to be discarded. She stated that she thought the vial was good until the expiration date. She looked at the vial and stated, It expires (MONTH) 2020. She was asked if the vial would be considered OK to use until that time. She stated, Yes, I think so. LPN #1 was asked how long the vial had been out of the refrigerator. She stated, I got it from (name of another nurse) this morning, I don't know how long it has been out. The vial was not cool to touch. At approximately 10:00 a.m., the DON (director of nursing) was asked for the facility policy on storage of multi-dose vials and their usage. A copy of the facility policy, Medication Storage was presented. Per the facility policy, .Multi-dose vials shall be dated when opened and discarded in accordance with policy . At approximately 10:25 a.m., the DON (director of nursing) also presented was the package insert from the [MEDICATION NAME] ([MEDICATION NAME] Purified Protein Derivative, Diluted (stabilized Solution)). Per the manufacturer's guidelines, [MEDICATION NAME] vials in use for more than 30 days should be discarded . She also presented the bag the solution arrived in from the pharmacy. The bag was labeled with the name of the solution, STORE IN REFRIGERATOR and PROTECT FROM LIGHT. The DON stated, I know what happened, (Name of LPN #2) had the vial this morning and she gave it to (Name of LPN #1) to give to (Resident name) .(Name of LPN #2) said that she opened it this morning but you caught them before she got it labeled. The DON was asked if the nurses should label the vials as soon as they are opened and should know how long the vial should be used after opening. She stated, Yes. The above information was discussed during an end survey meeting with the DON, the administrator and the nurse consultant. No further information was obtained prior to the exit conference on 04/03/2019.

Based on observation, resident interview, group interview, staff interview and facility document review, the facility staff failed to ensure an effective pest program. The facility staff failed to ensure the facility was free of 'gnats' and/or 'fruit flies. Findings include: On 03/20/18 at approximately 1:30 p.m., Resident # 2 was interviewed briefly in her room. The resident was lying in her bed, covered. The resident had a small can of soda sitting on the over bed table, in front of her. Multiple gnats/fruit flies were observed flying around the resident and the resident's drink/bed side table . The resident was asked about gnats/fruit flies flying around in the room. Resident # 2 stated that she was getting tired of them (gnats) and that a gnat had landed on her face and she did not appreciate it. An interview was attempted with Resident # 2's roommate, that resident was unable to provide information. On 03/22/18 at approximately 12:15 p.m., the resident was visited again. The gnats/fruits flies were still flying around in the resident's room. On 03/22/18 at approximately 1:55 PM, the ESM (Environmental Service Manager), was interviewed regarding any reports from staff and/or residents regarding gnats/fruit flies. The ESM stated that the reports are sporadic and have come from several different sources. The ESM stated that he may get reports from CNA's (certified nursing assistants) or residents. The ESM stated that their pest control company (Name of company) came on 03/07/18 and documented for the treatment of [REDACTED]. The pest control company usually write on the invoice what chemical they use. The ESM stated that it is usually the same rooms that have issues with the gnats. The ESM stated that they (pest control) come each month. The invoices for pest control for January, February, and (MONTH) all documented that the facility was treated for [REDACTED].e. room numbers, kitchen, common areas, etc). The ESM stated that the last report he got on gnats was in January, but did not state where that report came from and there was no documentation of that report. The ESM also stated that he had treated for [REDACTED]. The ESM stated that the gnats/fruit flies 'usually has something to do with residents dumping food and/or drink down the drains in the rooms'. The ESM stated, I haven't put in a work order for that (gnats/fruit flies), I usually just wait on him (pest control). The ESM looked into the computer system for work orders/concerns and stated that there has not been any work orders since back in August. The ESM that the staff can go into the computer system and document a work order to come to me for specific issues. The administrator and DON (director of nursing) were made aware in a meeting with the survey team on 03/22/18 at approximately 4:30 p.m. No further information and/or documentation was provided prior to the exit conference on 03/22/18 at 6:15 p.m.

Based on staff interview and clinical record review the facility staff failed to implement the policy to ensure pneumococcal vaccine status was accurate upon admission to the facility. Four of five sampled resident records were incomplete for pneumococcal vaccine status. The fifth resident record documented refusal of the vaccine. Findings include: On 3/22/18 beginning at 11:00 a.m. the influenza and pneumococcal immunization status of five sampled residents was conducted. It was noted during the review four of the five sampled resident records the pneumonia vaccine was documented in the electronic medical record (eMAR) as Pneumonia 1 and a date identified as historical indicating the vaccine was not received in the facility. One resident record indicated receipt of two pneumonia vaccines. Further review of the eMAR failed to reveal which pneumonia vaccine had been given to the resident, and if there was a plan to ensure resident's vaccine status would be brought up to date. On 3/22/18 at 1:30 p.m. the DON (director of nursing) was asked for clarification of the pneumonia vaccines as recorded in the eMAR. She was asked to identify which vaccine the resident had received, as well as what was in place to ensure completing the vaccine series. The DON confirmed to this surveyor the facility utilized the CDC (centers for disease control) guidelines for the administration of vaccines. A copy of the policy was provided to this surveyor. The policy Pneumococcal Vaccination was reviewed at that time to reveal Policy: To reduce morbidity and mortality from pneumococcal disease by vaccinating all adults who meet the criteria established by the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices. The attending physician will evaluate the resident/patient vaccination status on admission and will order the appropriate vaccine according to CDC guidelines. The policy further directed to refer to CDC attachments for the recommended vaccination schedule of the pneumococcal vaccine as there are two types of vaccine recommended based on age and vaccine history. The two types of vaccine are identified as Pneumococcal [MEDICATION NAME] Vaccine (PPVS23), and Pneumococcal Conjugate Vaccine (PCV13). The CDC reference also directed Both PCV13 and PPVS23 should be administered routinely in series to all adults aged [AGE] years or older. On 3/22/18 at 1:45 p.m. the DON informed this surveyor Well, I found out that we don't know which pneumococcal vaccine had been given to the residents. They (resident and/or family) are asked on admission if they have had the pneumonia vaccine, and if they are alert and oriented we just write down the date they give us. We don't get the physician's name or where they got the vaccine; I didn't realize the type of vaccine they got wasn't identified until today. We will make sure all new admissions are verified of which vaccine they got so we can then give the vaccine needed to complete the series. The DON further stated the resident with two pneumococcal vaccines had been admitted originally in (YEAR), and readmitted ,[DATE], and both admissions stated he had the pneumococcal vaccine. The DON was asked if the resident had named the same vaccine twice, or had the facility verified the information to determine what the vaccination status actually was for the resident. The DON stated That's a good point; I don't know if he actually had two vaccines, or he just gave a verbal 'yes' to the question on each admission if he had been given the pneumonia vaccine. On 3/22/18 during a meeting with facility staff beginning at 4:30 p.m. the administrator and corporate consultant staff were informed of the above findings. No further information was presented prior to the exit conference.

Based on staff interview, facility document review and clinical record review, facility staff failed to follow physician orders [REDACTED].#28. Facility staff failed to accurately track and record 1000 cc (cubic centimeters) fluid restrictions for Resident #28 from (MONTH) 9, (YEAR) through (MONTH) 21, (YEAR). Findings included: Resident #28 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was an admission assessment with an ARD (assessment reference date) of 02/27/18. Resident #28 was assessed as cognitively intact with a total cognitive score of 15 out of 15. Resident #28's clinical record was reviewed on 03/20/18 at approximately 2:00 p.m. During this review Resident #28's most recent POS (physician order [REDACTED].Renal diet Regular texture, Thin consistency, fluid restriction 1000ml/day (milliliters per day) . Subsequent review of Resident #28's Fluid Intake sheet dated 3/9/2018 through 3/21/2018 included the following: 3/09/18 - 1200 cc 3/10/18 - 1440 cc 3/11/18 - 1900 cc 3/12/18 - 1380 cc 3/13/18 - 1500 cc 3/14/18 - 980 cc 3/15/18 - 1840 cc 3/16/18 - 1640 cc 3/17/18 - 1220 cc 3/18/18 - 1600 cc 3/19/18 - 1320 cc 3/20/18 - 1250 cc 3/21/18 - 1900 cc Resident #28 was over her daily fluid allowance everyday, except 3/14/18. The Dietary Manager (DM) was interviewed regarding Resident #28's diet and fluid order on 03/22/18 at 9:25 a.m. The DM stated, Resident #28 is on a renal diet with 1000cc fluid restriction. I have a sheet that tells me how much fluid we can give her and how much nursing gives her. We give 240cc per tray. At approximately 9:45 a.m. the DM gave copies of the Fluid Restriction Guidelines sheet and Resident #28's Dietary Slips to this surveyor. Registered Nurse #1 (RN) was interviewed at approximately 1:10 p.m. regarding Resident #28's fluid restrictions. RN #1 stated, Yes, she is on 1000cc/day. She gets fluid on her trays. She doesn't have a water pitcher at her bedside. She gets 90cc's of fluid with her meds (medications) and she gets meds three times a day. I do not record her intake. The aides record under tasks. At 1:20 p.m. Certified Nursing Assistant #1 (CNA) was interviewed regarding Resident #28's fluid restrictions. CNA #1 stated, Yes, she is on 1500cc/day. We get the information from the nurse's mostly. We can look it up on their Kardex in the computer too. The Administrator and DON (director of nursing) were informed of the above findings during a meeting with the survey team on 03/22/18 at approximately 4:30 p.m. No further information was received by the survey team prior to the exit conference at 6:15 p.m.

Based on staff interview and clinical record review, the facility staff failed to ensure the CCP (Comprehensive Care Plan) for three of 17 residents was reviewed and revised in a timely manner. 1. The facility staff failed to review and revise the CCP regarding dementia interventions for Resident # 51. 2. The facility staff failed to review and revise the CCP regarding [MEDICAL TREATMENT] interventions for Resident # 2. 3. R 43's care plan was not revised to incorporate interventions for individual activities of interest. Findings include: 1. The facility staff failed to review and revise the CCP regarding dementia interventions for Resident # 51. Resident # 51 was admitted to the facility on [DATE] with the most recent readmission on 02/02/18. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was 30 day admission assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 2, indicating the resident was severely impaired in decision making skills. On 03/20/18 at approximately 11:00 a.m., Resident # 51 was observed lying in his bed. The resident had colored construction paper cut out signs outside of his door. Two large signs with the resident's room number, with one also including the resident's last name and a third sign (cut out) of a large arrow pointing toward the nursing station. An interview was attempted with the resident without success. On 03/22/18 at 11:20 AM, Resident # 51's care plan was reviewed and documented that the resident had a 'communication deficit' related to dementia which impact decision making and requires direction from staff. The CCP interventions listed included the use of alternative communication tools as needed and listed signs specifically. Additional interventions were reviewed and documented, that the resident had a sign/picture with Lexington Avenue written on it the hung outside of resident's room for easier identification. The resident and the resident's room was observed multiple times throughout the survey process and there was no sign displayed as indication in the resident's CCP. The interventions listed in the resident's CCP were implemented on 02/15/17. No revisions for this care plan intervention were found. No information was found to indicate that there was a change in signage for Resident # 51. The administrator and DON (director of nursing) were made aware in a meeting with the survey team on 03/22/18 at 4:30 p.m. The DON and administrator were asked why this CCP was not reviewed and revised to indicate the change in signage for the resident. The DON stated that different departments update the care plans and this one must have been missed. 2. The facility staff failed to review and revise the CCP regarding [MEDICAL TREATMENT] interventions for Resident # 2. Resident # 2 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was quarterly assessment date 12/24/17. This MDS assessed the resident as having a cognitive score of 8, indicating the resident had moderate impairment in daily decision making skills. On 03/20/18 at 3:03 PM, Resident # 2 was interviewed and stated that she had [MEDICAL TREATMENT] on MWF (Mondays, Wednesdays and Fridays). The resident's CCP (comprehensive care plan) was reviewed and documented that the resident was 'has nausea and vomiting' related to [MEDICAL TREATMENT] treatments and that the resident is to receive an antiemetic prior to [MEDICAL TREATMENT] treatments. The resident's physician's orders [REDACTED]. The above observations were discussed with the administrator and DON (director of nursing) in a meeting with the survey team on 03/22/18 at 4:30 p.m. The DON stated that she (DON) should have been the one to update this care plan, as she (DON) is often the one who review medication changes with the physician, but additionally stated that she (DON) did know how this change in information was missed and did not get updated on the CCP. No further information was presented prior to the exit conference on 03/22/18 at 6:00 p.m. 3. R 43 care plan was not revised to incorporate interventions for individual activities of interest. R 43 was admitted to the facility originally on 03/7/17 with a readmission on 1/4/18. [DIAGNOSES REDACTED]. The most current MDS (minimum data set) was a quarterly assessment dated [DATE]. R 43 was assessed with [REDACTED]. On 3/20/18 at 1:45 p.m. an interview was conducted with R 43. During the interview R 43 verbalized that he spends most of the time in the dining room or in his bed. R 43 verbalized that the social activities was of no interest and did not participate in the activities mainly due to the age population of the facility (R 43 is younger that most of the other residents). During the conversation R 43 expressed the want for independence and to be able to get out of the facility and go for a ride and do different things then just go from the bed to the dinning room. R 43 expressed depression, being bored and told this surveyor that the highlight of his week is when he goes out to [MEDICAL TREATMENT]. Review of R 43's care plan for activities was reviewed. The care plan was initiated on 3/27/17 and had not been revised since initiated to include any new interventions. Interventions included: Ensure resident is aware of activities via calendar, provide transport to the activity center, and likes watching television shows. On 03/22/18 02:09 PM the Activities Director (OS #1) was interviewed regarding activities for R 43. OS #1 verbalized R 43 has expressed to her that there is nothing in activities that interests him. When asked about if she (OS #1) has ever talked to R 43 in regards to what might interest R 43, OS #1 verbalized that given R 43's age he is not interested in what the population of the facility is doing and would probably benefit from computer activity and being able to go outside more often. When asked about R 43's activity care plan to include interventions that R 43 is interested in, OS #1 verbalized that she has had conversations with R 43 regarding activities, but has not revised the care plan to incorporate any new interventions. On 03/22/18 02:39 PM an interview with the nurse consultant (AS #4) was conducted regarding R 43's activity care plan. AS #4 reviewed R 43's care plan and agreed that the activity care plan should be revised to reflect R 43's interests and interventions to accommodate interests. 03/22/18 05:00 PM The above information was presented to the DON and administrator during an end of day meeting. No other information was presented prior to exit conference on 3/22/18

Based on observation, staff interview and clinical record review, facility staff failed to follow physician orders [REDACTED].#46. Resident #46 was never observed with heel protectors in place during the survey conducted 03/20/18 and 03/22/18 as ordered by the physician. Findings included: Resident #46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was an initial assessment with an ARD (assessment reference date) of 03/01/18. Resident #46 was assessed as cognitively intact with a total cognitive score of 12 out of 15. Resident #46's clinical record was reviewed on 03/20/18 at approximately 3:00 p.m. During this review Resident #46's current POS (physician order [REDACTED].Heel Protectors every shift for altered skin integrity . Resident #48 was observed by this surveyor on 03/20/18 at 12:00 noon and again at 3:45 p.m. sitting in his w/c (wheelchair) without heel protectors in place. This resident was observed on 03/22/18 at 9:20 a.m., lying in bed without heel protectors in place. He was observed at 1:00 p.m., sitting up in his w/c without heel protectors in place. Registered Nurse #1 (RN) was interviewed on 03/22/18 at approximately 1:05 p.m. regarding Resident #46's use of heel protectors. RN #1 stated, Yes, I believe he is supposed to have them on when in bed. RN #1 and this surveyor reviewed the physician orders [REDACTED]. RN #1 stated, Oh, he is supposed to have them on all the times. I will find some and have them put on him. The Administrator and DON (director of nursing) were informed of the above findings during a meeting with the survey team on 03/22/18 at approximately 4:30 p.m. No further information was received by the survey team prior to the exit conference at 6:15 p.m.

Based on resident interview, staff interview and clinical record review, the facility staff failed to ensure an ongoing program to support choice of activities for one of 17 residents, Resident #43 (R 43). R 43 did not have a activity program to individualize personal choice of activities. Findings include: R 43 was admitted to the facility originally on 03/7/17 with a readmission on 1/4/18. [DIAGNOSES REDACTED]. The most current MDS (minimum data set) was a quarterly assessment dated [DATE]. R 43 was assessed with [REDACTED]. On 3/20/18 at 1:45 p.m. an interview was conducted with R 43. During the interview R 43 verbalized that he spends most of the time in the dining room or in his bed. R 43 verbalized that the social activities was of no interest and did not participate in the activities mainly due to the age population of the facility (R 43 is 57 younger that most of the residents). During the conversation R 43 expressed the want for independence and to be able to get out of the facility and go for a ride and do different things then just go from the bed to the dinning room. R 43 expressed depression, being bored and told this surveyor that the highlight of his week is when he goes out to [MEDICAL TREATMENT]. Review of R 43's medical record conducted on 3/22/18, documented R 43 has been followed by psychology services and also evidenced that R 43 had [MEDICAL CONDITION] due to his condition and did not want to be at the facility to the point of suicidal thoughts (documentation indicated R 43 had been admitted to psych. services do to suicidal ideation). Review of R 43's care plan for activities was reviewed. The care plan was initiated on 3/27/17 and had not been revised since initiated to include any new interventions. Interventions included: Ensure resident is aware of activities via calendar, provide transport to the activity center, and likes watching television shows. On 03/22/18 02:09 PM the Activities Director (OS #1) was interviewed regarding activities for R 43. OS #1 verbalized R 43 has expressed to her that there is nothing in activities that interests him. When asked about if she (OS #1) has ever talked to R 43 in regards to what might interest R 43, OS #1 verbalized that given R 43's age he is not interested in what the population of the facility is doing and would probably benefit from computer activity and being able to go outside more often. When asked about R 43's activity care plan to include interventions that R 43 is interested in, OS #1 verbalized that she has had conversations with R 43 regarding activities, but has not revised the care plan to incorporate any new interventions. 03/22/18 05:00 PM The above information was presented to the DON and administrator during an end of day meeting. No other information was presented prior to exit conference on 3/22/18

Based on observation, staff interview and clinical record review, the facility staff failed to follow physician's orders for one of 14 residents in the survey sample, Resident #8. Resident #8 was observed without physician ordered hip protectors. Findings include: Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 5/6/17. Resident #8 was assessed as being severely cognitively impaired with long and short-term memory loss. Review of Resident #8's medical chart on 6/13/17 evidenced via physician orders, that Resident #8 had an order for [REDACTED]. An intervention for hip protectors was also noted in Resident #8's fall care plan stating hip protectors to be worn as ordered. The intervention was dated 3/4/17. On 6/13/17 at 11:00 a.m. Resident #8 was observed up in a wheelchair in the dining room without hip protectors in place. At this time, this surveyor asked the certified nursing assistant (CNA #1) to also observe Resident #8 for hip protectors. CNA #8 checked Resident #8's legs and verbalized that she (CNA #1) had forgotten to apply the hip protectors. On 6/13/17 at 3:45 p.m. the above finding was brought to the attention of the director of nursing and administrator. No other information was provided prior to exit conference on 6/14/17.

Based on resident interview the facility staff failed to promote dignity and respect for one of 14 residents in the survey sample: Resident # 1. Resident # 1 stated she had soiled in her diaper waiting for staff to assist her to the bathroom. Findings include: Resident # 1 was admitted to the facility 12/13/13 with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly review dated 3/15/17 and had Resident # 1 coded as cognitively intact. On 6/13/17 beginning at 10:30 a.m. during an interview with Resident # 1, she was asked about call response time, and care provided by staff. Resident # 1 stated Well, they take their sweet time, I can tell you that. I have waited as long as 40 minutes after ringing my call bell. This morning, for example, I put rang my call bell and I tried to wait for staff to come in and help me to the bathroom. I could not wait any longer, and I messed myself in my diaper; I don't like that. I take a pretty big dose of my fluid pill, and I don't mind to pee in my diaper, but I certainly do not like to mess myself! On 6/13/17 at 3:45 p.m. during an end of the day meeting with facility staff, the DON (director of nursing) and administrator were informed of the above findings. No further information was provided prior to the exit conference.