Every finding on record at Three Rivers Health and Rehabilitation Center

Based on observation and staff interviews, the facility failed to clean 1 of 1 deep fryer, 1 of 1 steamer, 1 of 1 tray line cooler, 1 of 4 kitchen walls, the floor of 1 of 1 walk-in refrigerator and 2 of 5 meal carts. These practices had the potential to affect food served to residents. The findings included: A continuous observation of the kitchen and interview with the Dietary Manager and Dietary Aide #1 was conducted on 1/28/26 from 10:25 AM through 10:48 AM. A white residue was observed on the tops and on the bottom inner surfaces of two meal carts. The Dietary Manager stated that the meal carts were cleaned weekly. Cloudy (white) oil was observed inside the deep fryer along with food crumbs along all areas surrounding the oil. The Dietary Manager stated that the deep fryer was last cleaned on 1/23/26 by removing all food crumbs and changing the oil. However, shrimp was fried for dinner on 1/27/26 and the deep fryer should have been cleaned after use. [NAME] drip marks were observed covering the wall behind the fryer, steamer and convection oven. The Dietary Manager stated that the wall could not be cleaned because the kitchen equipment was attached to gas and none of the items could be moved. A black substance surrounding the edges of a large plastic bin holding up steamer pans on the clean rack was observed. Also, two full size steamer pans with holes were observed with a black substance on the inner surface. The Dietary Manager stated that the plastic bin and steamer pans with holes were no longer used in the kitchen. However, they should not be dirty. A brown substance was observed on the inner bottom surface of the tray line cooler. Also, a white substance was observed covering the bottom doors of the tray line cooler. The Dietary Manager stated those areas needed to be cleaned. A buildup of a yellow and white flakey substance was observed covering the top of the dishwasher. The Dietary Manager stated that it should be cleaned weekly. A white liquid substance was observed on the floor under the boxes holding up milk cartons inside the walk-in refrigerator. The Dietary Manager stated she did not know how long the white spillage was present because she was late this morning and had not gone in the walk-in refrigerator yet. Dietary Aide #1 stated that he saw the white spillage in the walk-in refrigerator earlier in the morning but did not clean it up. He stated any spillage should be cleaned up but could not provide a reason why he did not clean the white substance on the floor of the walk-in refrigerator. Review of the Kitchen Cleaning Checklist Log for the months of December 2025 through January 2026 (the dates of 1/11/26 - 1/19/26 only) revealed that the log showed a Monday - Sunday table for each task (all items to be cleaned weekly). Some spaces were left blank, some staff members put the date near their name, and some staff wrote the date and signed their name inside the table. According to the Kitchen Cleaning Checklist Logs, the deep fryer had not been cleaned since 12/22/25, the steamer had not been cleaned since December 2025 (no date specified), and the dishwasher had not been cleaned since 1/15/26. An interview was conducted with [NAME] #1 (daytime cook) on 1/29/26 at 11:37 AM. She revealed that all unclean areas observed on 1/28/26 were able to be cleaned. [NAME] #1 stated that she tried to clean as she worked but some days, she was too busy. She stated that the night shift did not complete their cleaning on 1/27/26. As far as the cleaning schedule goes, [NAME] #1 indicated that when she was working and assigned a task, she was expected to complete it. Dietary Aide #2, who worked the evening shift on 1/27/26, was interviewed on 1/29/26 at 11:40 AM. She revealed that she worked with a new employee (hired 1 month ago) during the evening shift of 1/27/26. All tasks fell on her during the shift, and she did not have any time to clean after the shift. During a follow-up interview with the Dietary Manager on 1/29/26 at 11:55 AM, she revealed that all the issues observed in the kitchen on 1/28/26 were cleaned later that day. The Dietary Manager stated all the issues identified in the kitchen were not addressed on 1/28/26 because she did not go behind them (kitchen staff) frequently. When she assigned a cleaning task, she expected staff to make sure it was completed. However, sometimes she was the cook during a shift and could not see everything. The Dietary Manager indicated that training was performed monthly during huddle; however, she did not document these training courses prior to 1/22/26. She planned to document the huddles going forward to ensure all staff were informed of things such as the cleaning checklist log. An interview was conducted with [NAME] #2 (evening cook) on 1/29/26 at 11:59 AM. He revealed that he was asked to come in early on 1/29/26 to help clean the kitchen. Normally, he did not come in early to help clean. Cooks were expected to clean up after themselves and any equipment they used during their shift. [NAME] #2 stated that the cleaning checklist log was only for deep cleaning. [NAME] #2 indicated if he was assigned a task, he would mark it on the log. Some staff members put the date of completion, and some did not. [NAME] #2 indicated that he could not always complete his cleaning during the first shift because there were two meals to prepare. Therefore, the evening shift would have to pick up the slack if cleaning was missed during the day shift. During a follow-up interview with the Dietary Manager on 1/29/26 at 2:05 PM, she revealed that each task on the Kitchen Cleaning Checklist Log should be completed weekly, and she expected staff to date and sign when completed. The Dietary Manager indicated the cleaning log was supposed to be posted weekly in December 2025 but did not happen due to many holiday events. The cleaning log for 1/1/26 through 1/11/26 could not be found. The Dietary Manager stated that cleaning tasks were rotated each week, but some staff did not do what they were supposed to do. The interview further revealed the deep fryer was broken from 1/4/26 until 1/20/26 or 1/21/26 (unsure of exact date) because it was not reaching the proper temperature and was last cleaned on 1/16/26. The first time it was used was on 1/23/26 and then again on 1/27/26. The Dietary Manager stated that the last training was completed on 1/22/26 for all kitchen staff related to hand hygiene, food contamination, and single use gloves. The Administrator was interviewed on 1/30/26 at 8:34 AM and stated the kitchen cleaning schedules should be followed.

Based on record review, observation and staff interviews, the facility failed to position a urinary drainage bag from touching the floor to reduce the risk of infection for 1 of 2 residents reviewed with urinary catheters (Resident #49).The findings included:Resident #49 was admitted to the facility on [DATE] with diagnoses which included suprapubic catheter due to neuromuscular dysfunction of the bladder.Resident #49's care plan revised on 9/10/2025 identified the suprapubic catheter with interventions including: keeping the catheter bag covered to maintain dignity and positioning the catheter bag and catheter tubing below the level of the bladder and away from the entrance door.Resident #49's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 was severely cognitively impaired. Resident #49 was coded for an indwelling / (suprapubic) catheter.An initial observation was conducted on 1/28/2026 at 11:30 AM of Resident #49 as he was lying in his bed. The bed was noted to be in the lowest position with the catheter bag lying on the floor wedged between the floor and the bed frame. There was no tension noted on the catheter tubing.Additional observation on 1/28/2026 at 1:45 PM revealed Resident #49 was still lying in his bed. The bed had been raised approximately 3 inches off the floor and the catheter bag remained on the floor with no barrier between the floor and the catheter bag.An interview was conducted with Nurse Aide (NA) #2 on 1/29/2026 at 9:18 AM. She confirmed she had been assigned to Resident #49 on 1/28/2026. NA #2 stated Resident #49's catheter bag was secured on the right side of the bedframe and below the bladder. NA #2 stated the catheter bag may have fallen on the floor when they lowered the bed to feed him. NA #2 stated the catheter bag was not supposed to touch the floor and she would position the bag back onto the bedframe, so it did not touch the floor. She explained she had checked on Resident #49 before lunch and again around 2:30 to 3:00 pm and stated Resident #49's catheter bag was not touching the floor during those times. NA #2 also stated education was provided during orientation on caring catheters.On 1/29/2026 at 11:18 AM an interview was conducted with Nurse #1. She stated when she came in yesterday (1/28/2026 at 7:00 am) Resident #49's catheter bag was on the floor. Nurse #1 stated she picked up the catheter bag and placed it on the bed frame. Nurse #1 stated she did not assess if the catheter bag was on the floor at any other time on 1/28/26. She stated catheter bags were to be off the floor to prevent possible infection. Nurse #1 revealed she received annual education on catheter bag placement which included keeping the catheter bag from touching the floor.An interview was conducted with the Director of Nursing (DON) / Infection Preventionist on 01/29/2026 at 11:27 AM. The DON stated the staff most likely did not understand that lowering the bed would cause the catheter bag to be on the floor. The DON explained the staff should raise the bed so the catheter bag would be at least 2 to 3 inches off the floor to prevent possible infections and to check behind themselves prior to leaving the room regarding the position of catheter bag. The DON stated the facility provided education regarding catheter care and placement during orientation to new staff and annually.On 01/29/2026 at 12:29 PM an interview was conducted with the Administrator. The Administrator stated everyone should know the catheter bag should not be touching the floor. She did not know why the NA did not identify the catheter bag on the floor.

Based on observation, consulting Pharmacist and staff interviews, the facility failed to date an opened multi-dose pen injector of insulin medication in 1 of 2 medication administration carts reviewed for medication storage (200 hall medication cart).The findings include:Per manufacturer's recommendations insulin isophane human/insulin regular human 70/30 insulin pen can be stored at room temperature (59 to 86 degrees Fahrenheit) for 31 days.On 1/28/2026 at 2:58 PM, an observation of the 200-hall medication administration cart with Nurse #1 revealed one opened and undated multi-dose insulin isophane human/insulin regular human 70/30 insulin pen. The insulin pen was assigned to Resident #55. An interview conducted on 1/28/2026 at 3:00 PM with Nurse #1, who was working from the 200-hall medication cart, revealed insulin pens should be dated when opened and she was not aware the insulin isophane human/insulin regular human 70/30 insulin pen was not dated. Nurse #1 stated nurses were supposed to check their medication administration carts daily, but she did not check it that day (1/28/2026). Nurse #1 did not offer an explanation as to why she had not checked the medication administration cart.On 1/29/2026 at 3:16 PM an interview was conducted with the consulting Pharmacist. The consulting Pharmacist revealed she reviewed at a minimum two medication administration carts every two months that included reviewing the medications inside the cart for labels and open dates on insulin bottles and pens. She stated there should be a label with an open date on any open insulin and the facility should inspect their medication administration carts monthly.On 1/29/2026 at 3:31 PM an interview was completed with the Director of Nursing (DON). The DON indicated nurses were responsible for checking the medication administration carts they were assigned to daily and the Nurse Managers were responsible for inspecting medication carts monthly. During these inspections the nurse's and Nurse Managers were observing for the date of opened medications and expired medications. The DON was not certain why Nurse #1 had not checked her cart.On 1/29/2026 at 4:18 PM during an interview, the Administrator stated the nurses completed the labeling and dating of insulin pens. She stated an insulin pen should be removed from the refrigerator and labeled when opened. The Administrator stated the responsibility of checking medication administration carts included the Pharmacy Consultant who completed random checks monthly, the Nursing Administration Manager completed random checks monthly, and the nurses should check prior to administering medications.

Based on record review, staff interview, Medical Director/Physician interview, and Pharmacist interview the facility failed to have effective safeguards and systems in place to account for, and periodically reconcile controlled medications to protect the residents right to be free from potential drug diversion. This was for 7 of 14 residents reviewed for pharmacy services for controlled medication (Resident #9, Resident #205, Resident #210, Resident #211, Resident #212, Resident #213 and Resident #221). Findings included: a. Resident #205 was admitted to the facility on [DATE] with diagnoses that included aftercare for joint replacement surgery. Documentation on the [DATE] Medication Administration Record (MAR) revealed Resident #205 had an active physician's order for Oxycodone 5 milligrams (mg) tablets to be administered as 1 tablet by mouth every 4 hours as needed for pain. The MAR further revealed Oxycodone 5 mg tablets were discontinued on [DATE] when the resident discharged home. Resident #205 was administered 4 doses of Oxycodone 5 mg tablets during her stay. Documentation on the Packing Slip Proof of Delivery from the Pharmacy revealed 28 tablets of Oxycodone 5 mg were delivered on [DATE]. Documentation provided by the facility on [DATE] revealed there was no narcotic count sheet, or card of Oxycodone 5 mg capsules found when DON #1 and Nurse #2 attempted to reconcile the discontinued controlled medications for Resident #205 to return to the pharmacy for disposal. This left 24 doses of Oxycodone 5mg tablets unaccounted for. b. Resident #9 was admitted to the facility on [DATE] with diagnoses including dementia, osteoarthritis and osteoporosis. Documentation on the [DATE] MAR revealed Resident #9 had an active physician's order for Oxycodone 5 mg capsules to be administered as 1 tablet by mouth every 4 hours as needed for moderate to severe pain. The MAR further revealed Oxycodone 5 mg capsules were discontinued on [DATE]. Resident #9 was administered 28 doses of Oxycodone 5 mg capsules. Documentation on the Packing Slip Proof of Delivery from the Pharmacy revealed 90 capsules of Oxycodone 5 mg were delivered on [DATE]. Documentation provided by the facility on [DATE] revealed there was no narcotic count sheet, or card of Oxycodone 5 mg capsules found when DON #1 and Nurse #2 attempted to reconcile the discontinued controlled medications for Resident #9 to return to the pharmacy for disposal. This left 62 capsules of Oxycodone 5 mg capsules unaccounted for. c. Resident #210 was admitted to the facility on [DATE] with a diagnosis of aftercare following right knee replacement surgery. Documentation on the [DATE] MAR revealed Resident #210 had an active physician's order for Hydrocodone-Acetaminophen ,d+[DATE] mg to be administered as 1 tablet by mouth every 6 hours as needed for pain. The MAR further revealed Hydrocodone-Acetaminophen ,d+[DATE] mg were discontinued on [DATE]. Resident #210 had been administered 17 doses. Documentation on the Packing Slip Proof of Delivery from the Pharmacy revealed 60 tablets of Hydrocodone-Acetaminophen ,d+[DATE] mg were delivered on [DATE] for Resident #210. Documentation provided by the facility on [DATE] revealed there was no narcotic count sheet, or card of Hydrocodone-Acetaminophen ,d+[DATE] mg found when DON #1 and Nurse #2 attempted to reconcile the discontinued controlled medications for Resident #210 to return to the pharmacy for disposal, leaving 43 tablets unaccounted for. d. Resident #211 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of ovary (ovarian cancer). Documentation on the [DATE] MAR revealed Resident #211 had an active physician's order for Oxycodone 5 mg to be administered as 1 tablet by mouth every 4 hours as needed for severe pain. The MAR further revealed Oxycodone 5 mg were discontinued on [DATE]. Resident #211 had been administered 1 dose. Documentation on the Packing Slip Proof of Delivery from the Pharmacy revealed 10 tablets of Oxycodone 5 mg were delivered on [DATE] for Resident #211. Documentation provided by the facility on [DATE] revealed there was no narcotic count sheet, or card of Oxycodone 5 mg found when DON #1 and Nurse #2 attempted to reconcile the discontinued controlled medications for Resident #211 to return to the pharmacy for disposal, leaving 9 tablets unaccounted for. e. Resident #212 was admitted to the facility on [DATE] with a diagnosis of aftercare following right knee replacement surgery. Documentation on the [DATE] MAR revealed Resident #212 did not have an active physician's order for Hydrocodone-Acetaminophen ,d+[DATE] mg. Documentation on the Packing Slip Proof of Delivery from the Pharmacy revealed 120 tablets of Hydrocodone-Acetaminophen ,d+[DATE] mg were delivered on [DATE] for Resident #212. Documentation provided by the facility on [DATE] revealed there was no narcotic count sheet, or card of Hydrocodone-Acetaminophen ,d+[DATE] mg found when DON #1 and Nurse #2 attempted to reconcile the discontinued controlled medications for Resident #212 to return to the pharmacy for disposal, leaving 117 tablets unaccounted for. f. Resident #213 was admitted to the facility on [DATE] with a diagnosis of aftercare for joint replacement surgery. Documentation on the [DATE] MAR revealed Resident #213 had an active physician's order for Oxycodone 5 mg to be administered as 1 tablet by mouth every 6 hours as needed for pain level between ,d+[DATE] (mild to moderate pain). The MAR further revealed Oxycodone 5 mg were discontinued on [DATE]. Resident #213 had been administered 5 doses. Documentation on the Packing Slip Proof of Delivery from the Pharmacy revealed 120 tablets of Oxycodone 5 mg were delivered on [DATE] for Resident #213. Documentation provided by the facility on [DATE] revealed there was no narcotic count sheet, or card of Oxycodone 5 mg found when DON #1 and Nurse #2 attempted to reconcile the discontinued controlled medications for Resident #213 to return to the pharmacy for disposal, leaving 115 tablets unaccounted for. g. Resident #221 was admitted to the facility on [DATE] with a diagnosis of dementia. Documentation on the [DATE] MAR revealed Resident #221 had an active physician's order for Ativan 0.5 mg (Lorazepam) to be administered as 1 tablet by mouth every 8 hours as needed for anxiety for 7 days. The MAR further revealed Ativan 0.5 mg was discontinued on [DATE] when the Resident died . Resident #221 had been administered 14 doses. Documentation on the Packing Slip Proof of Delivery from the Pharmacy revealed 90 tablets of Ativan 0.5 mg were delivered for Resident #221 with no delivery date noted. Documentation provided by the facility on [DATE] revealed there was no narcotic count sheet, or card of Ativan 0.5 mg found when DON #1 and Nurse #2 attempted to reconcile the discontinued controlled medications for Resident #221 to return to the pharmacy for disposal, leaving 76 tablets unaccounted for. Nurse #3, a witness named during the facility investigation, was interviewed on [DATE] at 3:03 PM. She stated DON #2 came into the facility at approximately 6:00 PM on [DATE]. Nurse #3 stated she thought it was unusual as it was after her working hours and she thought DON #2 was on Family Medical Leave (FMLA) and did not expect her to be in the building. Nurse #3 further stated DON #2 approached her at the medication cart and asked if she had any controlled medication that needed to be returned to pharmacy and she gave DON #2 two cards of Oxycodone 5 mg prescribed to Resident #205 that had been discontinued. Nurse #3 revealed she held both cards up separately so the cameras could see what she was giving DON #2. Nurse #3 indicated DON #2 went to the medication storage room where the controlled medication return box was kept, she then came out with something under her arm, went to her office and then left. Nurse #3 stated a short time later the Administrator called her to ask what DON #2 was doing in the building so she explained that DON #2 had taken two cards of discontinued Oxycodone #5 out of her cart to put in the controlled medication return box and that DON #2 was the only person who had the keys to do this. An interview with the Administrator and Director of Clinical Services on [DATE] at 4:15 PM revealed DON #2 had a Doctors appointment on [DATE] for documentation to take FMLA. The Administrator asked her to bring her keys into her after her appointment. DON #2 had the only keys to the controlled medication return box. DON #2 couldn't come into the facility until after 5:00 PM and asked if she could put the keys in the Administrators office, to which she agreed. At about 6:15 PM on [DATE] the Administrator received a call from SW #1 notifying her DON #2 was in the building with her child and had gone onto 400 hall. The Administrator and Director of Clinical Services further stated that up until [DATE] the process for discarding discontinued controlled medications was solely done by DON #2. She would collect the discontinued controlled medications and their count sheets from the medication carts and put them in the double locked controlled medication return box to be reconciled and returned to pharmacy approximately every 6 months, when DON #2 called them to come. Furthermore, there was no tracking of the medication between when it was taken off the medication cart to when it was put in the controlled medication return box. They felt that this system led to the medications being easily misappropriated from the facility. The Administrator revealed DON #2 had been employed at the facility since [DATE] and she resigned on [DATE] after she refused to be involved in the investigation into the missing controlled medications. DON #2 was reported to the North Carolina Board of Nursing on [DATE]. The Administrator and Director of Clinical Services indicated changes had been made to the controlled medication removal system: 1. There are now two keyholders, DON #1 and Nurse #2. 2. Two licensed nurses must sign for the removal of the controlled medication from the medication cart. Documentation of the removal would consist of reconciliation of the number of pills left on the card against the controlled medications card count sheet and a return to pharmacy carbon copy form completed at the time of removal. DON #2 was not able to be reached for interview. In an interview with the Social Worker (SW #1) on [DATE] at 8:54 AM she stated she was working late on [DATE] and saw DON #2 come into the building with one of her children and she called the Administrator to let her know DON #2 was in the building after normal working hours. In an interview with Nurse #2 on [DATE] at 3:41 PM she stated she and DON #1 conducted a reconciliation of controlled medications located in the pharmacy return box on [DATE] at the request of the Administrator. They completed a 100% audit of all discontinued controlled medication from [DATE] to [DATE] to determine if the medications were in the controlled medication return box or if they had been sent home with residents upon discharge. They discovered controlled medications and their count sheets missing from the return box for Resident #9, Resident #205, Resident #210, Resident #211, Resident #212, Resident #213 and Resident #221. All medications had been discontinued when a resident went to the hospital, discharged home, discontinued during the residents stay or died in the facility. An interview was conducted with the facility pharmacist on [DATE] at 9:08 AM. He stated controlled medications needed to be returned to the pharmacy for destruction and could not be destroyed in the facility. He further stated the pharmacy did not know when a medication was discontinued and moved to the controlled medication return box, they only knew what was returned to them. The process was for DON #2 to call the pharmacy for a pickup, the driver would reconcile the controlled medications being returned against the list DON #2 gave him. The Pharmacist indicated that the process the facility had at that time left too many opportunities for diversion. He further indicated that the facility had changed the process after this incident so that when controlled medications were taken off the cart it was now signed off by two licensed nurses. In addition, DON #1 and Nurse #2 have received two separate keys to unlock the controlled medication return box so that they must be together to open it. The Medical Director, who was also the physician for Resident #9, Resident #205, Resident #210, Resident #211, Resident #212, Resident #213 and Resident #221 , was interviewed on [DATE] at 10:30 AM. He stated he was aware that controlled medications were discovered to be missing in October of 2023 and he felt the process of DON #2 having sole control of discontinued medications was part of the problem. The Physician further stated the facility had changed the process so that DON #1 and Nurse #2 had the keys to open the controlled medication return box, one has the key for the inside lock and one for the outside lock so that it is never opened by just one person. Additionally, signatures by two licensed Nurses are needed to remove the controlled medication from the medication cart. The facility provided the following corrective action plan: - On [DATE] the DON and support nurse (Nurse #2) began interviewing all alert and oriented residents asking questions related to medication administration concerns, pain related concerns, or misappropriation of property. This was completed on [DATE] with no concerns voiced. - Non-interviewable residents were assessed by DON #1 and Unit Manager for any acute changes in condition related to pain beginning [DATE] with review of the pain assessments recorded on the MAR. This was completed on [DATE] with no concerns related to changes in pain. - On [DATE] each medication carts narcotics were audited by the interim DON and Nurse #2. No discrepancies were found. A new narcotic count sheet was established for each medication cart. - On [DATE] DON #1, Nurse #2 and Director of clinical services initiated random audits on any discontinued controlled substance between [DATE] and [DATE]. If the discontinued medication was not listed on the destruction sheet on [DATE] return to pharmacy report, the facility attempted to locate the packing slip and the controlled count sheet for the medication to account for the medication. - On [DATE] the Director of Clinical Services, DON #1 and Nurse #2 started a 100% audit of all discontinued controlled medications from [DATE] to [DATE] to determine if the medications were in the controlled medications return cabinet or if the medication was sent with the resident upon discharge. These audits were completed on [DATE]. Facility identified additional missing controlled medication count sheets and unclear disposition of the controlled medication. The audits did not identify missing controlled doses scheduled that impacted the resident. The residents went to the hospital, discharged from the facility or the controlled medication was discontinued during the residents stay. The facility has been unable to locate these missing medications. - On [DATE] Nurse #2 and DON #1 began inservicing all licensed nurses and medication aides/techs, including agency, on the narcotic policy and process. - The facility process to reconcile discontinued controlled substances removed from the medication cart until pharmacy pickup or when given to the resident upon discharge includes: controlled substances requires two licensed nurses to remove and secure the medications being stored until pharmacy pickup for destruction. The disposition of the medications will be indicated on the count sheet and the return to pharmacy carbon copy form. A copy of this form will be placed in the secured box with the count sheet and medication until pharmacy pick up for destruction. The card count sheet will show the change that the card was removed. Controlled substances given to residents upon discharge will be witnessed by two licensed nurses indicating disposition on the controlled substance count sheet and the count sheet will be updated. The carbon copy form indication medication was sent home with the resident will be completed and a copy will be given to the resident and the other copy will be uploaded into the medical record after review by DON #1, Nurse #2 or Administrator. - The two keys required to get into the controlled substances pending pharmacy pickup for destruction will not be kept by the same person. One key is in the possession of DON #1 and one by Nurse #2. - Controlled substances will have to be removed by two nurses from the medication cart, two nurses will have to be present to put the medications in the return to pharmacy locked cabinet along with the narcotic count sheet and the carbon copy of the form titled drugs returned to pharmacy or released to the patient. - Two nurses will have to validate when controlled medications are sent home with the resident by indicating such on the count sheet and carbon copy of the form titled drugs return to pharmacy or released to resident. The card count sheet will reflect the removal of the cards. - The carbon copy form of stored medications will then be given to the Administrator so she can reconcile the controlled drugs are accounted for in the locked return to pharmacy box or were sent home. This will be in partnership with DON #1 or Nurse #2. - The controlled medication card count sheets will be maintained on each medication cart. - DON #1 will ensure that any of the above identified staff who did not complete the inservice training by [DATE] will not be allowed to work until the training is completed. Quality Assurance started [DATE]. - DON #1 and Administrator will monitor the narcotic process weekly for 4 weeks and monthly for 2 months or until compliance is achieved. - The audit tool will include: Audits to ensure the narcotic count sheets and the narcotic card count sheets are being signed off each shift. Audits to show that discontinued controlled substance count sheets, card count sheets and return to pharmacy sheets are completed each time a narcotic is removed from the medication cart. Audits to reconcile controlled substance items that have been discontinued are stored in the controlled substance return to pharmacy box or were returned home with the resident. Audits to interview at least three residents weekly regarding any concerns regarding their medication administration and availability or misappropriation. Quality Assurance Performance and Improvement (QAPI) meeting was held on [DATE] with the Medical Director and QAPI team. Reports will be presented to the weekly Quality Assurance (QA) committee by the Administrator or DON #1 to ensure corrective action is initiated as appropriate. Compliance will be monitored and ongoing auditing program reviewed at the weekly QA meeting. The weekly QA meeting is attended by the Administrator, DON #1, Nurse #2, MDS coordinator, Therapy department and Dietary department manager. Onsite validation of the facility Plan of Correction was completed on [DATE]. Confirmed date of compliance was [DATE]. Staff interviews confirmed the facility provided education on the updated narcotic handling procedures. Record reviews indicated education was initiated on [DATE] regarding implementation of the controlled substance count sheet, regarding the policy on controlled substances and on facility misappropriation/abuse policy. Records further indicated the facility completed the stated QA monitoring. The compliance date of [DATE] was validated.

Based on observations and staff interviews, the facility failed to secure resident medications stored in an unattended medication cart (200 hall medication cart) for 1 of 3 medication carts. Findings included: A continuous observation was conducted of the 200 hall medication cart on 10/31/24 from 5:40 AM to 5:49 AM. The cart was parked between rooms [ROOM NUMBERS], facing out into the hallway. The cart was not visible from the nurses' station. There was one Nurse Aide (NA) working on the hall and one resident sitting next to the medication cart in her wheelchair. The medication cart was observed to have the red dot on the push lock visible, which meant the push lock was not engaged. There was no staff member with the medication cart. Medication Aide #1 came out of room [ROOM NUMBER] at 5:44 AM and prepared the next resident's medications. Medication Aide #1 then left the hall, leaving the cart unlocked and the resident sitting next to it. She returned to the cart at 5:49 AM. During an interview with Medication Aide #1 at 5:50 AM she stated she left the medication cart unlocked both times she had walked away. She further stated the cart should be locked any time she was not using it. An interview with the Administrator on 10/31/24 at 6:45 AM revealed medication carts should not be unlocked unless the Medication Aide was using it. The Administrator stated the Medication Aide assigned to the medication cart was responsible for them for their entire shift. In an interview with the Director of Nursing (DON) on 10/31/24 at 8:11 AM she stated the medication cart should be locked when the Medication Aide was not using it.

Based on record review and staff, Responsible Party (RP), and Physician interviews the facility failed to ensure a resident had an indication and a diagnosis for the use of an anti-psychotic medication. This was for 1 of 5 residents (Resident #157) reviewed for unnecessary medications. Findings included: A review of Resident #157's hospital discharge summary dated 10/23/24 did not reveal a history or a diagnosis of schizophrenia. The list of her discharge medications included Seroquel (an antipsychotic medication) 25 milligrams (mg) give 0.5 tablet by mouth every evening. Resident #157 was admitted to the facility on [DATE] with a diagnosis of schizophrenia (a serious mental health condition that affects how people think, feel, and behave). A review of Resident #157's physician's orders revealed an order initiated on 10/23/24 for Seroquel 25 milligrams (mg) give 0.5 tablet by mouth every evening for schizophrenia. A review of Physician #1's Admission Note for Resident #157 dated 10/25/24 revealed she had been sent to the facility from the hospital on her current medications which included low dose Seroquel for a brief psychotic episode during the hospitalization which was as expected with advanced dementia. Physician #1 indicated he would titrate her off this medication. A review of Resident #157's care plan revealed a focus area dated initiated on 10/28/24 for anti-psychotic medication related to a diagnosis of schizophrenia with risk of adverse side effects. The goal was for Resident #157's risk for adverse reactions related to the use of anti-psychotic medication would be minimized through the next review. An intervention was to discuss possible side effects of the medication with the resident and her RP. Her admission Minimum Data Set (MDS) assessment dated [DATE] was in progress. On 10/29/24 at 2:55 PM in a telephone interview Resident #157's RP stated Resident #157 did not have a history of schizophrenia and he was not aware that she had been given a diagnosis of schizophrenia when she was admitted to the nursing facility. He reported this would not be accurate. He went on to say while she was in the hospital prior to being admitted to the facility Resident #157 did have some delirium. He reported this was not unusual for Resident #157 after she received anesthesia. Resident #157's RP stated he had stayed with Resident #157 in the hospital, and when the delirium had not resolved after a couple of hours, he spoke with her hospital physician. Resident #157's RP reported the hospital physician told him they could start Resident #157 on Seroquel, and he agreed. He stated his understanding was this medication would be used for a short period only. On 10/29/24 at 3:45 PM an interview with Nurse #1 indicated she entered the facility admission medication orders for Resident #157 on 10/23/24. She stated she was being trained to do this, and this was the first admission she had completed. She reported the Director of Nursing (DON) had been helping her with Resident #157's admission process. Nurse #1 stated she used Resident #157's hospital discharge summary dated 10/23/24 to enter Resident #157's admission orders which included Seroquel 25 mg give 0.5 tablet by mouth every evening. She reported the hospital discharge summary didn't have a diagnosis associated with the medication, and the facility medication order entry system asked her for a diagnosis when she entered the order. She went on to say when she asked the DON what Seroquel was used for, the DON told her schizophrenia, so that is the diagnosis she entered into the order system. On 10/31/24 at 10:43 AM an interview with the DON indicated Nurse #1 had been in her office when Nurse #1 was entering Resident #157's admission orders into the system. She stated when Nurse #1 asked her what the medication Seroquel was for, she answered schizophrenia, but she had just taken this as a general question and had not realized Nurse #1 was asking specifically about what diagnosis was associated with Resident #157's use of the medication. The DON went on to say she herself had not looked at Resident #157's hospital discharge summary or anything else because Nurse #1 was sitting right beside her when Nurse #1 was entering Resident #157's admission orders into the order entry system. On 10/29/24 at 4:29 PM an interview with the Corporate Quality Nurse Consultant indicated Physician #1 had been contacted, and Resident #157's diagnosis of schizophrenia had been removed. On 10/31/24 at 10:15 AM an interview with Physician #1 indicated Resident #157 had some delirium (a confused or disoriented mental state) in the hospital and had been started on Seroquel. He stated Resident #157 did not have a diagnosis of schizophrenia. He reported if there had been a question about what the Seroquel for Resident #157 was being used for, someone should have called him. Physician #1 stated when the facility made him aware on 10/29/24 that a diagnosis of schizophrenia had been added as the reason Resident #157 was receiving Seroquel, he corrected this immediately and had discontinued the medication. On 10/31/24 at 10:33 AM an interview with MDS Nurse #1 indicated she had not yet completed Resident #157's Admission MDS assessment. She stated when she did these Admission MDS assessments the facility had a process in place whereby if there was a mental health diagnosis such as schizophrenia for a resident, she would research it thoroughly. She reported she routinely reached out to the mental health provider to obtain supporting historical documentation to ensure that the mental health diagnosis was correct. She went on to say if there had not been any supporting information for Resident #157's schizophrenia diagnosis, she would have contacted Physician #1 immediately. On 11/1/24 at 9:37 AM an interview with the Administrator indicated during the training process the DON had Nurse #1 sitting right next to her in her office when Nurse #1 entered Resident #157's admission orders into the order entry system. She stated Nurse #1 asked the DON what Seroquel was for, and the DON replied to her schizophrenia, but had not realized Nurse #1 was entering this as a diagnosis into Resident #157's medical record. The Administrator reported what should have happened was that the DON and Nurse #1 should have gone back to Resident #157's hospital discharge summary to find out why the hospital had actually been using the medication.

Based on observations, interviews with the Dietary Manager and record review the facility failed to store foods in the refrigerator after opening, failed to discard an expired food item, and failed to maintain pasta salad at or below 41 degrees Fahrenheit during 2 of 3 kitchen observations. This had the potential to affect 43 residents who received meal trays out of 45 total residents. The findings included: 1. On [DATE] at 9:25 AM an opened gallon size container of diced pickles was observed stored in the room temperature storage room. An open date was not observed on the container. The manufacturer label read the product was to be refrigerated after opening. On [DATE] at 9:26 AM an opened gallon size container of Bar B Que sauce was observed stored at room temperature in the storage room. The container had an open date of [DATE]. The label read the product was to be refrigerated after opening. On [DATE] at 9:30 AM an unopened box of pancake mix was observed stored for use on the shelf with other foods. The pancake mix had an expiration date of [DATE]. On [DATE] at 9:25 AM the Dietary Manager stated the diced pickles, the Bar B Que sauce and the pancake mix were not properly stored and needed to be discarded. 2. On [DATE] at 11:45 AM Cook #1 used a calibrated thermometer when she checked the temperature of the large stainless steel bowl of pasta salad. The temperature on the thermometer read 60 degrees Fahrenheit. The cook stated she made the pasta salad earlier that morning and stored it in the walk-in refrigerator. During an interview with the Dietary Manager on [DATE] at 11:50 AM she was unaware the pasta salad was too warm. She added the pasta salad should have been prepared the previous day so it would be properly cooled. A review of the recipe for the pasta salad provided by the Dietary Manager on [DATE] at 3:30 PM read to serve the pasta salad chilled. The critical control point read, Hold or serve cold food at or below 40 degrees Fahrenheit. During an interview with the Administrator on [DATE] at 4:30 PM she indicated she was aware of the food safety concerns. She did not provide any additional information.

Based on record review and facility staff and consultant pharmacist (CP) interviews, the facility failed to act upon pharmacy recommendations for 1 of 5 residents reviewed for unnecessary medications (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses which included [CONDITION(S)]. Review of the electronic health record revealed an Abnormal Involuntary Movement Scale (AIMS) had been completed on Resident #1 on 5/20/21. AIMS is used to assess abnormal body movements in residents taking antipsychotic medications. Resident #1's annual Minimum Data Set, dated dated dated [DATE] indicated she received an antipsychotic medication for 7 days during the look back period. The consultant pharmacist (CP) monthly drug regimen review for Resident #1 dated 12/28/21 included a recommendation for an Abnormal Involuntary Movement Scale (AIMS) to be completed. The CP monthly drug regimen review for Resident #1 dated 1/30/22 included a recommendation for an Abnormal Involuntary Movement Scale (AIMS) to be completed. The CP monthly drug regimen review for Resident #1 dated 2/25/22 included a recommendation for an Abnormal Involuntary Movement Scale (AIMS) to be completed. The CP monthly drug regimen review for Resident #1 dated 3/26/22 included a recommendation for an Abnormal Involuntary Movement Scale (AIMS) to be completed. Review of the electronic health record revealed an AIMS had been completed on Resident #1 on 5/20/21. An interview on 6/03/22 at 10:12 AM with the CP confirmed she had recommended an AIMS be completed for Resident #1 on her Medication Regimen Reviews completed on 12/28/21, 1/30/22, 2/25/22, and 3/26/22. She stated an AIMS should be completed on Resident #1 every 6 months to monitor medication side effects and it should have been completed in November 2021. The CP explained she provided a copy of her recommendations as well as discussed the recommendations with nursing staff during each visit. An interview on 6/02/22 at 8:59 AM with the Director of Nursing (DON) confirmed Resident #1 did not have an AIMS assessment completed every 6 months. She stated she was responsible for ensuring the CP recommendations were completed. She stated she had recently established a process to ensure the pharmacy recommendations were acted on in a timely manner. The DON stated their electronic health record system did not automatically flag the staff to complete an AIMS every 6 months and she had not ensured it was done. An interview on 6/02/22 at 10:45 AM with the Administrator confirmed that Resident #1 should have had an AIMS completed every 6 months and it had just been missed.

Based on record review and staff interviews the facility failed to develop a baseline care plan within 48 hours of admission for one of two new admissions reviewed. (Resident #198) Findings included: Resident #198 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #198's medical record did not reveal any evidence a baseline care plan was completed within 48 hours of her admission to the facility. On 06/01/2022 at 3:47 PM an interview with the Social Worker (SW) indicated either the floor nurse or the Minimum Data Set (MDS) Nurse completed resident's baseline care plans. On 06/02/2022 at 2:25 PM an interview with Nurse #1 indicated she was assigned to care for Resident #198 on 05/27/2022 and 05/28/2022 on the 7AM-7PM shift. She stated nurses entered physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She further indicated nurses did not complete residents' baseline care plans. Nurse #1 stated she did not know who did those. On 06/03/2022 at 9:26 AM an interview with Nurse #6 indicated she was assigned to care for Resident #198 on 05/26/2022 when she was admitted to the facility. She stated the MDS Nurse completed residents' baseline care plans. She went on to say based on the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 06/02/2022 at 2:33 PM an interview with MDS Nurse #1 indicated she had been in training since 05/05/2022. She stated she had not completed any residents' baseline care plans. She went on to say MDS Coordinator #2 had been doing what she couldn't do and may have been doing this. On 06/02/2022 at 3:19 PM a telephone interview with MDS Nurse #2 indicated she did not complete residents' baseline care plans. She stated she was a corporate employee working remotely for the facility. She went on to say someone from the facility completed residents' baseline care plans. On 06/02/2022 at 3:50 PM in an interview the Director of Nursing (DON) confirmed Resident #198 had no completed baseline care plan. She stated she thought MDS Nurse #2 was doing them. She went on to say the facility would need to come up with a new process to ensure residents had baseline care plans completed within 48 hours of admission. On 06/03/2022 at 10:23 AM an interview with the Administrator indicated residents should have a baseline care plan completed within 48 hours of admission to the facility. She stated in the past the MDS Nurse had done those. She went on to say the facility would be implementing a new process to ensure they were completed.

Based on observations, record review and staff interviews the facility failed to store an unopened Insulin [MEDICATION(S)] Injection Kwik Pen according to the manufacturer's guidelines and the facility's policy. This was for one (400 Hall) of two medication storage rooms reviewed. Findings included: A review of the manufacturer's instructions for use of the Insulin [MEDICATION(S)] Injection Kwik Pen revealed in part Store unused pens in the refrigerator between 36 degrees Fahrenheit and 46 degrees Fahrenheit. An undated facility policy titled Medication Storage in the Facility, provided by the facility, read in part Medications requiring refrigeration or temperatures between 36 degrees Fahrenheit and 46 degrees Fahrenheit are kept in a refrigerator with a thermometer to allow temperature monitoring. On 06/01/2022 at 9:33 AM an observation of the 400 Hall medication storage room was conducted with Nurse #1. A refrigerator in the medication room which was not plugged in or functioning was observed to contain an unopened Insulin [MEDICATION(S)] Injection Kwik Pen labeled Refrigerate until opened. A pharmacy label on the Kwik Pen indicated it was dispensed on 05/31/2022. An interview with Nurse #1 at that time indicated pharmacy delivery of medication occurred on the 11PM-7AM shift. She stated she did not know why the unopened Kwik Pen was in the non-functional refrigerator. She stated it should have been stored in the 400 Hall medication refrigerator which was plugged in and had temperature monitoring in place. She went on to say she could not say how long the Kwik Pen had been in the non-functional refrigerator. Nurse #1 further indicated the Kwik Pen did not feel cool to the touch. On 06/01/2022 at 9:51 AM observation of the 400 Hall medication storage room was conducted with the Maintenance Director. An interview at that time indicated he did not know why the non-functional refrigerator was in the 400 Hall medication room. He stated it was not plugged in. He went on to say he did not perform any routine maintenance or inspection of medication storage refrigerators. He further indicated he had not received any work orders for the 400 Hall medication room. On 06/01/2022 at 1:01 PM a telephone interview with Nurse #2 indicated she received the Insulin [MEDICATION(S)] Injection Kwik Pen dispensed by the pharmacy on 05/31/2022 on the 11PM-7AM shift on that date. She stated she knew unopened insulin pens required refrigeration. She went on to say the 400 Hall medication storage room had two refrigerators. She further indicated one was plugged in, functional and had a thermometer for monitoring the temperature. She stated the second refrigerator was not plugged in. Nurse #2 went on to say this second refrigerator used to be for storing resident food items but was no longer being used. She further indicated she remembered placing the Kwik Pen in the functional refrigerator. Nurse #2 stated she did not know how it got into the other refrigerator. On 06/01/2022 at 2:16 PM an interview with the Director of Nursing (DON) indicated if the label on the insulin Kwik Pen instructed to refrigerate until it was opened then it should have been refrigerated. She stated she was familiar with the 400 Hall medication room. She went on to say there were two refrigerators but only one was being monitored for temperature and used for storing medications. She further indicated the facility would remove the other refrigerator now to avoid any confusion in the future. On 06/03/2022 an interview with the Administrator indicated the insulin Kwik Pen should not have been in the non-functioning 400 Hall medication room refrigerator.

Based on observations, record review, resident, staff and Physician interviews, the facility failed to assess and document a resident's ability to self-administer medication for 1 of 1 resident (Resident #1) who was observed to have medications at bedside. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's annual Minimum Data Set, dated dated dated [DATE] indicated she was cognitively intact and was independent or supervision only for most activities of daily living. Record review indicated Resident #1 had no self-administration of medication assessment. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] (antipsychotic) - [MEDICATION(S)] (antidepressant) - [MEDICATION(S)] (constipation) - Magnesium (supplement) - Multi-vitamin (supplement) - [MEDICATION(S)] (auto-immune) - [MEDICATION(S)] (diuretic) - [MEDICATION(S)] (diuretic) - [MEDICATION(S)] (antidiabetic) - [MEDICATION(S)] (antirheumatic) - [MEDICATION(S)] (stomach acid suppressant) - [MEDICATION(S)] (anticonvulsant/antimigraine) - [MEDICATION(S)] (antianxiety) - [MEDICATION(S)] (antibiotic) - [MEDICATION(S)] (urinary tract analgesic) - Potassium (supplement) Review of Resident #1's care plan revealed no mention of self-administration of medications. Observation of Resident #1 and an interview were conducted on 5/31/22 at 11:54 AM and revealed 2 medication cups with pills in them on her bedside table by her recliner. Resident #1 stated one cup was her morning medications ([MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], Magnesium, Multi-Vitamin, [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]) and the other was her morning potassium pills. An interview on 5/31/22 at 2:24 PM with Nurse #3 revealed her normal medication administration process for Resident #1 was that she made 3 medication cups for Resident #1's morning medications. She stated she put the narcotic pills in one, potassium pills in one, and all other morning pills in the 3rd. Nurse #3 stated she observed Resident #1 taking the narcotic pills from the cup but left the other 2 medication cups at the resident's bedside for her to take on her own. She stated the resident took a large number of pills and she did this for time management as the resident spent more than 30 minutes taking her morning medications. She also stated that she had not notified the physician or completed a self-administration assessment. An interview on 5/31/22 at 5:51 PM with the Director of Nursing (DON) revealed that residents should be observed while taking medications unless they were assessed for self-administration of medications. She confirmed that Resident #1 did not have a self-administration assessment or a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] An interview on 6/02/22 at 2:57 PM with the Physician revealed that he believed Resident #1 should be observed when she took her medications. An interview on 6/2/22 at 8:56 AM with the Administrator revealed that Resident #1's medications should not have been left in her room and the nurse should have observed her taking her medications to ensure they were taken.

Based on record review, staff and Physician interviews, the facility failed to provide the specialized services in accordance with Pre-Admission Screening and Resident Review (PASARR) report recommendations for 1 of 1 resident (Resident #9) reviewed for PASARR level II. Findings included: Review of Resident #9's PASARR level II Determination Notification dated 11/12/19 revealed he was assessed to be a PASARR level II resident. It further revealed this PASARR level II determination had no expiration date. The notification indicated Resident #9 was to receive individual/group psychotherapy, follow-up psychiatric services by a psychiatrist, and restorative nursing when not in active Physical Therapy (PT). Resident #9 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #9's quarterly Minimum Data Set (MDS) dated [DATE] indicated he had moderately impaired cognition and required extensive assistance or total dependence for most activities of daily living. Review of Resident #9's electronic health record revealed he was currently receiving psychiatric services by a psychiatrist. Further review revealed he was not receiving any individual or group psychotherapy, restorative nursing or PT. An interview on 6/02/22 at 3:44 PM with the Social Worker (SW) revealed she reviewed the PASARR's for transfer and admission residents. She stated that since this resident was transferred from a sister facility she did not review his PASARR to see if he was supposed to receive specialized services. An interview on 6/02/22 at 2:57 PM with the Physician revealed that the residents should receive the specialized services determined by the PASARR or the facility should have the PASSAR reevaluated. An interview on 6/02/22 at 8:53 AM with the Administrator confirmed that Resident #9 was not currently receiving individual or group psychotherapy, restorative or PT. She stated she was unaware that he required specialized services as determined by the PASARR and they had been missed when he was transferred to the facility.

Based on observation, record review and staff and Physician interviews, the facility failed to have Physician's orders for the use of a urinary catheter for 1 of 2 residents reviewed for urinary catheter (Resident #9). Findings included: Resident #9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #9's quarterly Minimum Data Set (MDS) dated [DATE] indicated he had moderately impaired cognition and required extensive assistance or total dependence for most activities of daily living. Review of nurse's progress noted dated 5/22/22 at 10:27 PM indicated that Resident #9 had no urine output during the shift. Review of nurse's progress note dated 5/23/22 at 6:35 AM indicated the urinary catheter was inserted due to urinary retention. Observation of Resident #9 on 5/31/22 at 11:30 AM revealed he had a urinary catheter. Observation of Resident #9 on 6/02/22 at 9:30 AM revealed he had a urinary catheter. Review of Resident #9's Physician's orders revealed no orders for a urinary catheter. An interview on 6/02/22 at 8:59 AM with the Director of Nursing confirmed Resident #9 did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview on 6/02/22 at 2:57 PM with the Physician revealed that Resident #9 should have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview on 6/02/22 at 9:00 AM with the Administrator confirmed that Resident #9 should have had an order for [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on record review and staff and physician interviews the facility failed to obtain an Abnormal Involuntary Movement Scale (AIMS) prior to the initiation of an antipsychotic medication. This was for one of five residents reviewed for unneccesary medication. (Resident #34) Findings included: Resident #34 was admitted to the facility on [DATE] with diagnoses including dementia with behaviors, [CONDITION(S)] disorder (a mental health disorder) and drug induced subacute dyskinesia (uncontrolled involuntary muscle movements). A review of the quarterly Minimum Data Set (MDS) assessment for Resident #34 dated 04/29/2022 revealed she was moderately cognitively impaired. No antipsychotic medications were used during the seven day look back period of the assessment. A review of a psychiatric follow up note for Resident #34 dated 05/16/2022 revealed Resident #34 was hallucinating and having delusions. This was extremely upsetting to Resident #34. The plan was to begin [MEDICATION(S)] (an antipsychotic medication) 25 milligrams (mg) at bedtime daily for [CONDITION(S)] disorder and dementia with delusions and hallucinations. The note further revealed the recommendations were provided to Resident #34's facility physician (MD) on 05/19/2022 and he agreed with the plan. A review of the May 2022 Medication Administration Record (MAR) for Resident #34 revealed a physician's order dated 05/19/2022 for [MEDICATION(S)] 25 mg at bedtime daily for [CONDITION(S)] disorder. It further revealed Resident #34 received this medication at bedtime on 05/20/2022 through 05/31/2022. Behavior monitoring for delusions and antipsychotic medication side effect monitoring was completed each shift. A review of Resident #34's medical record did not reveal evidence an AIMS test was conducted prior to starting the antipsychotic medication on 05/20/2022. On 06/01/2022 at 4:19 PM an interview with Nurse #5 indicated she entered the physician's order dated 05/19/2022 for [MEDICATION(S)] 25 mg at bedtime daily for Resident #34. She stated she knew she should have completed an AIMS for Resident #34 when the medication was ordered but she missed it. She stated an AIMS should have been done prior to starting this medication to establish a baseline for Resident #34's involuntary movements so if Resident #34 developed any new or worsening symptoms the facility would be aware of them. On 06/02/2022 at 11:03 AM a telephone interview with the facility's Registered Pharmacist (RPh) indicated the purpose of a baseline AIMS was to establish whether the resident had any abnormal involuntary movements prior to starting an antipsychotic medication. She stated she did not think a week or two of Resident #34 receiving the antipsychotic medication prior to a baseline AIMS would have any impact on the accuracy of the testing. On 06/02/2022 at 11:48 AM a follow up telephone interview with the RPh indicated the facility had been monitoring for side effects of the antipsychotic medication since initiating it. She stated typically it would take some time after initiating an antipsychotic medication for any involuntary movement side effects to develop. She went on to say a week or two of receiving antipsychotic medication prior to a baseline AIMS did not put Resident #34 at risk for any harm. She went on to say she would expect the facility to conduct a baseline AIMS as soon as possible after starting an antipsychotic medication and then every 6 months thereafter. On 06/02/2022 at 1:21 PM an interview with the Director of Nursing (DON) indicated the facility should be following it's Antipsychotic Drugs policy which was to obtain an AIMS prior to starting an antipsychotic medication. On 06/02/2022 at 3:04 PM an interview with Resident #34's physician (MD) indicated the facility should be following it's Antipsychotic Drugs policy for obtaining an AIMS prior to starting an antipsychotic medication unless the medication was ordered on an emergent basis. He stated if the medication was ordered emergently, he would expect the AIMS to be done as soon as possible after. He went on to say Resident #34's antipsychotic medication was not ordered emergently. On 06/03/2022 at 10:23 AM an interview with the Administrator indicated the facility should be following it's Antipsychotic Drugs policy for obtaining an AIMS.

Based on record review and staff interview the facility failed to accurately code the Minimum Data Set (MDS) to reflect skin conditions for 1 of 3 residents reviewed for pressure ulcers. (Resident #1) Findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the most recent quarterly comprehensive MDS for Resident #1 dated 10/21/2020 indicated he was moderately impaired for daily decision making, required the extensive assistance of one person for activities of daily living including bathing, dressing and bed mobility, had no pressure ulcer, was assessed for risk of pressure ulcers using a formal assessment tool, was at risk of developing pressure ulcers, had no unhealed pressure ulcers, had no other ulcers, wounds or skin problems, had a pressure relieving device for his bed and was receiving the application of dressings to his feet. A review of a care plan focus area for Resident #1 initiated 07/15/2020 indicated he had a pressure ulcer to his left heel and treatments were ordered. An additional focus area initiated 09/17/2020 and revised on 10/02/2020 indicated Resident #1 had actual skin impairment to his left heel with the potential for further skin impairment. A review of a follow-up note dated 10/14/2020 by Resident #1's facility physician indicated he had a chronic left foot wound. A review of a risk assessment dated [DATE] completed by MDS Nurse #1 indicated Resident #1 had one or more unhealed pressure ulcers or injuries. A review of a medication administration note for Resident #1 dated 10/16/2020 at 6:14 PM indicated wound care was done to his left heel by the wound nurse. On 01/08/2021 at 1:59 PM an interview with Nurse #5 indicated she was currently the facility wound nurse and had been the wound nurse in October 2020. She stated she had done wound care to Resident #1's left heel wound in the past. She stated Resident #1 was admitted to the facility with the left heel pressure wound and although it was improving it had never resolved and was still being treated both in the facility with dressing changes and at the wound clinic. On 01/11/2021 at 12:00 PM a telephone interview with the Administrator indicated it did not sound correct that Resident #1's MDS dated [DATE] indicated he did not have any wounds. She stated he still currently had the left heel wound he was admitted to the facility with and she would expect his MDS to be correct. On 01/11/2021 at 12:36 PM a telephone interview with MDS Nurse #1 indicated she was no longer employed with the facility. She stated she completed the skin portion of the MDS assessment dated [DATE] and the risk assessment dated [DATE] for Resident #1. She further indicated she did not have access to the facility's records and although both could not be correct she could not say which was incorrect. She went on to say she looked back at notes to complete the MDS and if notes didn't mention anything about a wound, she didn't enter any. MDS Nurse #1 indicated she did not do a full body assessment or talk to the facility wound nurse before completing the skin portion of the 10/21/2020 MDS for Resident #1.

Based on record review and resident, staff and physician interviews the facility failed to complete a dressing change as ordered for 1 of 3 residents reviewed for pressure ulcers. (Resident #1) Findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the most recent comprehensive minimum data set assessment for Resident #1 dated 10/21/2020 indicated he was moderately impaired for daily decision making, required the extensive assistance of one person for activities of daily living including bathing, dressing and bed mobility, had no pressure ulcer, was assessed for risk of pressure ulcers using a formal assessment tool, was at risk of developing pressure ulcers, had no unhealed pressure ulcers, had no other ulcers, wounds or skin problems, had a pressure relieving device for his bed and was receiving the application of dressings to his feet. A review of a care plan focus area for Resident #1 initiated 07/15/2020 indicated he had a pressure ulcer to his left heel and was at risk of developing additional pressure ulcers due to immobility and incontinence. The care plan goal was the resident's risk for pressure ulcers would be minimized. Interventions included administer treatments as ordered, monitor for effectiveness and notify nurse of any new areas of skin breakdown. An additional focus area initiated 09/17/2020 and revised on 10/02/2020 indicated Resident #1 had actual skin impairment to his left heel with the potential for further skin impairment related to DM and [MEDICAL CONDITION] with a goal of will have no complications from impaired skin integrity through next review. Interventions included monitor and document location, size and treatment of [REDACTED]. On 01/07/2021 at 9:05 AM an interview with Resident #1 indicated he entered the facility with a wound to his left heel. He stated he went to the wound clinic weekly to have his wound treated. He indicated at one point in December 2020, although he could not recall the exact date, he had gone to the wound clinic, the physician changed his heel dressing and told him his heel dressing needed to be changed every other day. According to the resident, after these new instructions were given, the facility staff did not follow them and change his wound dressing as they should have. He stated by the time the nurse changed his heel dressing the wound had seeped fluid and his foam boot was wet. He further indicated since the time the nurse found his foam boot to be wet from wound weeping, he felt his heel dressing had been changed the way it was supposed to be. According to the resident, at his last wound clinic appointment the physician told him his wound was improving. On 01/07/2021 at 10:00 AM a telephone interview with Resident #1's responsible party (RP) indicated in December 2020 Resident #1 called her very upset that his heel wound dressing had not been changed like it was supposed to be. She stated Resident #1 told her he was instructed by the wound clinic physician his heel wound dressing was supposed to be changed every other day, it had not been changed for several days, and it had seeped so much fluid that his protective boot was wet. A review of a wound clinic visit report dated 12/10/2020 obtained from the wound care clinic indicated Resident #1 was seen that day for the treatment of [REDACTED]. It further indicated after that appointment his heel dressing was to be changed on Tuesday, Thursday and Saturday. On 01/07/2021 at 10:50 AM a telephone interview with wound clinic Nurse #1 indicated when Resident #1 was sent back to the facility from the wound clinic on 12/10/2020, physician orders [REDACTED]. She went on to say his next dressing change would have been due 12/12/2020. On 1/07/2021 at 11:35 AM an interview with Med Tech #1 indicated she was administering medication to Resident #1 on 12/12/2020 but did not perform any dressing changes as nurses did that. She stated if there was a dressing change due on a treatment administration record (TAR), she would let the nurse know. On 01/11/2020 at 9:43 AM a telephone interview with Nurse #4 indicated she was the nurse on duty supervising Med Tech #1 on 12/12/2020. She stated she did not recall Med Tech #1 telling her a dressing change was due or doing a heel wound dressing change for Resident #1 that day. A review of the December 2020 TAR for Resident #1 indicated Resident #1's left heel dressing was to be changed Tuesday, Thursday and Saturday at 9:00 AM beginning 12/17/2020. No dressing change was indicated on the TAR as being due on 12/12/2020. On 01/08/2021 at 11:15 AM an interview with the Administrator indicated the facility should have received paperwork back from Resident #1's wound clinic appointment on 12/10/2020. She stated she would check with the facility's medical records department to locate this paperwork. A review of a nursing progress note for Resident #1 dated 12/14/2020 at 11:15 PM written by Nurse #2 indicated Resident #1 was noted to have drainage from his left heel wound, his protective boot was wet with drainage, his heel dressing was changed, and his protective boot was laundered. On 01/08/2021 at 12:59 PM a telephone interview with Nurse #2 indicated on 12/14/2020 she received a call from Resident #1's RP who was very upset because Resident #1's heel wound dressing had not been changed. Nurse #2 stated she observed Resident #1's heel dressing was soiled, and his protective boot wet with drainage, so she provided the dressing change and laundered his protective boot. Nurse #2 went on to say although there had been no order for the dressing change on Resident #1's MAR indicated [REDACTED]. She further indicated she found Resident #1's discharge paperwork with dressing change orders from his latest wound clinic appointment in a manilla envelope and dressing change supplies in his drawer. On 01/11/2020 at 8:17 AM in a follow-up telephone interview Nurse #2 went on to say she documented the dressing change in Resident #1's progress notes but didn't enter his orders into the computer because she was busy. A review of Resident #1's physician orders [REDACTED].#3 on 12/15/2020 to change Resident #1's left heel dressing on Tuesday, Thursday and Saturday. The start date for this order was entered as 12/17/2020. On 01/07/2021 at 12:17 PM an interview with Nurse #3 indicated she was caring for Resident #1 on 12/10/2020 when he returned from the wound clinic. She stated she received written orders from the wound clinic that day for Resident #1's dressing to be changed on Tuesday, Thursday and Saturday, indicating that Resident #1's next heel wound dressing change would have been due on Saturday 12/12/2020. She stated she looked at the orders and then put them in a basket at the nurses station meaning to enter them into the computer that day but got busy and forgot. Nurse #3 stated she left work without ever entering those orders into Resident #1's medical record. She further indicated on 12/14/2020 she received a phone call at home from the Director of Nursing (DON) telling her that Resident #1 was very upset because his left heel wound dressing had not been changed and asking her if she knew anything about that. Nurse #3 stated she then remembered she had forgotten to enter the new wound clinic orders from 12/10/2020 into the computer, was returning to work the following day on 12/15/2020 when Resident #1's left heel wound dressing would next be due, and told the DON she would enter the orders when she returned. She went on to say on 12/15/2020 she returned to work, found the orders from the wound care clinic where she left them in the basket, entered Resident #1's 12/10/2020 wound care orders into the computer and changed his left heel wound dressing to keep him on his schedule. On 01/08/2021 at 1:33 PM an interview with the DON indicated she got a call at home on 12/14/2020 from Resident #1's nurse stating he was upset because his left heel wound dressing had not been changed. She stated she told the nurse to go ahead and change the dressing. The DON went on to say she didn't know at that time that his wound clinic dressing change orders had not been entered into the computer system but became aware when she called Nurse #3 that same evening to see if Nurse #3 knew anything about the situation. She stated Nurse #3 told her she received the dressing change orders for Resident #1, had forgotten to enter them into the computer, was returning to work in the morning on 12/15/2020 and would enter them then. The DON further indicated nurses should be entering physician orders [REDACTED]. On 01/09/2021 at 8:31 PM a telephone interview with Resident #1's facility physician indicated he was not notified of any missed dressing changes for Resident #1. He stated if the order was for Resident #1 to have his dressing change done on Tuesday, Thursday and Saturday than that's what should have been done. On 01/11/2021 at 10:00 AM a telephone interview with Resident #1's wound care clinic physician indicated Resident #1 had a wound clinic appointment on 12/10/2020 and his left heel wound dressing was changed. He stated as Resident #1 left the wound clinic that day with orders to change the dressing on Tuesday, Thursday and Saturday the next dressing change would have been due on Saturday 12/12/2021. He stated the risk of Resident #1 not getting his dressing change done as ordered was for a decline in the wound. He went on to say Resident #1 had no decline in his wound during that period and his wound was improving. On 01/11/2021 at 12:00 PM in follow up interview the Administrator stated the facility medical records department had not been able to locate any paperwork from Resident #1's 12/10/2020 wound clinic appointment so there was no proof the facility received any. She went on to say Nurse #3 could have gotten the wound care orders she entered on 12/15/2020 verbally. She further indicated if there was no documentation to say Resident #1's dressing change was done on 12/12/2020 then it was not done but she did not think the facility would be responsible for a missed dressing change on 12/12/2020 if they hadn't received any orders.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) for 5 or 19 resident records reviewed for MDS accuracy (Residents #49, #28, #15, #11, and #39). Findings included: 1. Resident #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment dated [DATE] indicated that Resident #49 was not coded for a wanderguard and did not exhibit wandering behaviors. A review of the annual MDS assessment dated [DATE] indicated that Resident #49 was coded for a wanderguard and did not exhibit wandering behaviors. A review of the physician's orders [REDACTED]. A review of the (MONTH) Medication Administration Record [REDACTED]. During an interview with the MDS Coordinator on 12/10/19 at 12:57 PM, she revealed that the MDS assessment for Resident #49 dated 11/15/19 was incorrect and should have reflected her wanderguard alarm as being used daily. She stated she must have made a mistake and had not coded it correctly on the quarterly MDS. During an interview with the Administrator on 12/11/19 at 3:08 PM, she stated the MDS for Resident #49 should have been coded correctly and she did not know why it had not been done. 2. Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nurse ' s note dated 10/24/19 revealed Resident #28 displayed behaviors such as yelling, screaming and cursing. Resident #28 ' s minimum data set (MDS) assessment dated [DATE], an admission assessment revealed in Section [NAME] no behaviors. During an interview on 12/11/19 at 2:32 PM the MDS Coordinator reported Resident #28 ' s MDS assessment should have accurately reflected behaviors. She stated Section [NAME] of the MDS assessment was completed by social work. An interview was conducted on 12/12/19 at 9:00 AM with the Social Serviced Assistant who stated she did not review Resident #28 ' s progress notes to complete Section [NAME] of the MDS assessment dated [DATE]. During an interview on 12/12/19 at 11:00 AM the administrator indicated Resident #28 ' s MDS assessment should have accurately reflected exhibited behaviors. 3. Resident #15 was admitted to the facility 6/16/17 with [DIAGNOSES REDACTED]. A doctor ' s order dated 7/7/19 revealed an order to admit Resident #15 to hospice. Resident #15 ' s minimum data set (MDS) assessment dated [DATE] revealed Resident #15 was not coded in Section J as receiving hospice services. During an interview on 12/11/19 at 2:32 PM the MDS Coordinator reported Resident #15 ' s MDS assessment should have accurately reflected hospice services. She indicated this was an error. During an interview on 12/12/19 at 11:00 AM the administrator indicated Resident #15 ' s MDS assessment should have accurately reflected hospice services. 4. Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nurse ' s note dated 11/10/19 revealed Resident #39 displayed behaviors such as agitation and wandering. Resident #39 ' s minimum data set (MDS) assessment dated [DATE], an admission assessment revealed in Section [NAME] no behaviors. During an interview on 12/11/19 at 2:32 PM the MDS Coordinator reported Resident #39 ' s MDS assessment should have accurately reflected behaviors. She stated Section [NAME] of the MDS assessment was completed by social work. An interview was conducted on 12/12/19 at 9:00 AM with the Social Serviced Assistant who stated she did not review Resident #39 ' s progress notes to complete Section [NAME] of the MDS assessment dated [DATE]. During an interview on 12/12/19 at 11:00 AM the administrator indicated Resident #39 ' s MDS assessment should have accurately reflected exhibited behaviors. 6.Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a Minimum Data Set assessment (MDS) for Resident #11 dated 6/28/19 indicated she had no unhealed pressure ulcers or injuries. A review of a nursing progress note dated 6/21/19 at 4:07 PM indicated Resident #11 had a sacral (base of spine) wound and the wound care physician had examined her. A review of a nursing progress note for Resident #11 dated 6/24/19 at 10:26 AM indicated Resident #11 had a stage two (shallow open area) pressure ulcer to her sacrum. A review of a nursing progress note dated 6/25/19 at 9:41 PM indicated Resident #11 had a stage two pressure ulcer to her sacrum. On 12/11/19 at 8:27 AM interview with the MDS Coordinator indicated she completed the 6/28/19 MDS section for Resident #11 regarding pressure ulcers. She indicated the assessment period for this MDS was from 6/21/19 through 6/28/19. The MDS Coordinator went on to say she obtained her information by reviewing progress notes, skin assessments and wound care notes for the assessment period when completing this section of the MDS for residents. She indicated based on the progress notes for Resident #11, her stage 2 pressure ulcer should have been reflected on her MDS assessment but was not. On 12/12/19 at 12:44 PM an interview with the Administrator and Director of Nursing indicated Resident #11's stage two pressure ulcer documented in her progress notes should have been reflected on her MDS dated [DATE] but was not.

Based on record review, resident and staff interviews the facility failed to provide a summary of the baseline care plan to residents or their representatives for 5 of 6 residents reviewed for baseline care plans (Resident #28, Resident #55, Resident #39, Resident #8 and Resident #34). The findings included: 1. Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the most current Minimum Data Set (MDS) assessment dated [DATE] indicated he was cognitively intact. A review of the most current care plan for Resident #28 dated 10/22/19 indicated focus areas including medication risks, activities of daily living needs such as dressing, bathing and grooming, and fall risk with goals that were measurable and interventions which were individualized. On 12/10/19 at 11:30 AM an interview with Resident #28 indicated he did not recall receiving a written summary of his baseline care plan. He denied having any concerns related to his care. On 12/11/19 at 2:34 PM the MDS Coordinator indicated neither Resident #28 or his representative had received a written summary of his baseline care plan. She stated she normally gave residents or their representatives a written copy of the order summary report which they signed in order to acknowledge receipt, but it was not provided to Resident #28. During an interview with the Administrator on 12/12/19 at 9:13 AM with the Administrator she indicated it was the facility ' s practice to provide residents or their representatives with an order summary report which would include initial goals, physician orders, dietary orders, and therapy services which served as the written summary of the baseline care plan. She continued to state Resident #28 should have received this information. 2. Resident #55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #55 ' s most current Minimum Data Set (MDS) assessment dated [DATE] indicated she was cognitively intact. A review of the most current care plan for Resident #55 dated 12/10/19 indicated focus areas including medication risks, activities of daily living needs such as dressing, bathing and grooming, and fall risk with goals that were measurable and interventions which were individualized. On 12/10/19 at 11:45 AM an interview with Resident #55 indicated she did not recall receiving a written summary of her baseline care plan. She denied having any concerns related to her care. On 12/11/19 at 2:34 PM the MDS Coordinator indicated neither Resident #55 or her representative had received a written summary of his baseline care plan. She stated she normally gave residents or their representatives a written copy of the order summary report which they signed in order to acknowledge receipt, but it was not provided to Resident #55. During an interview with the Administrator on 12/12/19 at 9:13 AM with the Administrator she indicated it was the facility ' s practice to provide residents or their representatives with an order summary report which would include initial goals, physician orders, dietary orders, and therapy services which served as the written summary of the baseline care plan. She continued to state Resident #55 should have received this information. 3. Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the most current Minimum Data Set (MDS) assessment dated [DATE] indicated she was cognitively impaired. A review of the most current care plan for Resident #39 dated 11/4/19 indicated focus areas including medication risks, activities of daily living needs such as dressing, bathing and grooming, and fall risk with goals that were measurable and interventions which were individualized. On 12/11/19 at 2:34 PM the MDS Coordinator indicated neither Resident #39 or her representative had received a written summary of his baseline care plan. She stated she normally gave residents or their representatives a written copy of the order summary report which they signed in order to acknowledge receipt, but it was not provided to Resident #39. During an interview with the Administrator on 12/12/19 at 9:13 AM with the Administrator she indicated it was the facility ' s practice to provide residents or their representatives with an order summary report which would include initial goals, physician orders, dietary orders, and therapy services which served as the written summary of the baseline care plan. She continued to state Resident #39 should have received this information. 4.Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the most current Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #8 was independent with daily decision making. A review of the most current care plan for Resident #8 dated 8/23/19 indicated focus areas including medication risks, activities of daily living needs such as dressing, bathing and grooming, and fall risk with goals that were measurable and interventions which were individualized. On 12/12/19 at 9:00 AM an interview with Resident #8 indicated he did not recall receiving a written summary of his baseline care plan. He further indicated he did not have any concerns or questions regarding his care and was being taken of. On 12/12/19 at 10:34 AM interview with the MDS Coordinator indicated neither Resident #8 or his representative had received a written copy of his baseline care plan. She went on to say she usually gave residents or their representatives a copy of the order summary report which they signed to acknowledge receiving but did not know why she had not provided this information to Resident #8 or his representative. On 12/12/19 at 9:13 AM an interview with the Administrator indicated it was the facility's practice to provide residents or their representatives with an order summary report which would include initial goals, physician orders, dietary orders and therapy services which served as the baseline care plan written summary. The Administrator went on to say this information had not been provided to Resident #8 or his representative. She stated it just got missed. 5.Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the most current Minimum Data Set (MDS) assessment for Resident #34 dated 11/6/19 indicated Resident #34 was independent with daily decision making. A review of the most current care plan for Resident #34 dated 10/31/19 indicated focus areas including medication risks, activities of daily living needs such as dressing, bathing and grooming, and fall risk with goals that were measurable and interventions which were individualized. On 12/10/19 at 10:32 AM an interview with Resident #34 indicated she did not recall receiving a written copy of her baseline care plan but had been in the facility before, understood her condition, was going home on 11/11/19 and did not have any questions regarding her care. On 12/12/19 at 10:34 AM interview with the MDS Coordinator indicated neither Resident #34 or her representative had received a written copy of her baseline care plan before her discharge. She went on to say she usually gave residents or their representatives a copy of the order summary report which they signed to acknowledge receiving but did not know why she had not provided this information to Resident #34 or her representative. On 12/12/19 at 9:13 AM an interview with the Administrator indicated it was the facility's practice to provide residents or their representatives with an order summary report which would include initial goals, physician orders, dietary orders and therapy services which served as the baseline care plan written summary. The Administrator went on to say this information had not been provided to Resident #34 or her representative before her discharge. She stated it just got missed

Based on observations, record review and staff interviews the facility failed to provide a dignified dining experience for one of one residents (Resident #27) reviewed for dignity by standing over him while assisting with his meal. Findings included: Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the most recent Minimum Data Set assessment (MDS) for Resident #27 dated 10/22/19 indicated he was severely impaired for daily decision making, had an altered level of consciousness that fluctuated and was rarely if ever understood. It further indicted Resident #27 needed the total assistance of one person for eating. A review of the most current care plan for Resident #27 revealed a focus area of requires assistance with activities of daily living and at risk for complications related to dependence with a goal of will maintain or improve current level of function through next review and interventions including requires total assistance to eat and encourage me to participate to my fullest extent with every interaction. On 12/9/19 at 12:25 PM Nurse #1 was observed in the dining room assisting Resident #27 with his lunch meal. Resident #27 was seated in a recliner chair and Nurse #1 was standing to his side, feeding him. Resident #27 was wearing a baseball hat with a brim and could not make eye contact with Nurse #1 during the activity. On 12/9/19 at 12:30 PM Nurse Aide #1 was observed to walk into the dining room and say to Nurse #1, You need to sit down. Nurse #1 was heard to reply, Why?' and then observed to sit in a chair beside Resident #27. On 12/9/19 at 12:59 PM an interview with Nurse #1 indicated she was familiar with Resident #27 and had assisted him with meals before. She stated she heard Nurse Aide #1 tell her to sit down while she was assisting Resident #27 with his meal, but she did not know why Nurse Aide #1 said this. Nurse #1 went on to say sometimes she sat down while assisting residents with meals but other times she stood up when feeding them. She stated sitting down or standing up while feeding residents was not something she ever really thought about. Nurse #1 indicated that she thought it was easier for her to reach Resident #27's food while she was standing up. On 12/9/19 at 1:09 PM an interview with Nurse Aide #1 indicated the facility provided staff with annual in-services regarding treating residents with dignity. She stated this included sitting at eye level with residents when assisting them with meals. On 12/9/19 at 1:12 PM an interview with the Director of Nursing (DON) indicated Nurse #1 received training in treating residents with dignity within the last year which included sitting at eye level with residents while assisting them with meals. She stated Nurse #1 should have been seated next to Resident #27 while feeding him and Nurse #27 knew that. The DON added staff standing over a seated resident while assisting with meals would not be appropriate. On 12/9/19 at 1:17 PM an attempt to interview Resident #27 was unsuccessful. On 12/9/19 at 3:11 PM an interview with the Administrator indicated Nurse #1 should have been aware of the need to be at eye level with residents when assisting them with meals as she had received training on treating residents with dignity which included sitting at eye level with residents when assisting them with meals within the last year. She stated she thought Nurse #1 was just having a bad day.

Based on record reviews, staff interviews, consultant pharmacist interviews, and physician interviews, the facility failed to ensure a physician's order for as needed (PRN) [MEDICAL CONDITION] (drug that affects mental state) medication was time limited in duration for 2 of 6 residents reviewed for unnecessary medication (Resident #41 and #39). Findings included: 1. Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #41 was cognitively intact and received an antianxiety medication 5 days during the look back period. A physician's order dated 10/04/19 indicated [MEDICATION NAME] (antianxiety medication) 0.5 milligrams (mg) by mouth every 12 hours as needed for anxiety. There was no stop date written for the PRN [MEDICATION NAME] order. A review of Resident #41's Medication Administration Record [REDACTED]. The Consultant Pharmacist (CP) #1 monthly drug regimen review for Resident #41 indicated the CP had recommended the physician clarify the time limit on 10/23/19 and 11/22/19. The physician response for the 10/23/19 monthly drug regimen review recommendation was a handwritten note dated 10/28/19 which stated the patient had ongoing anxiety issues and did not include a stop date. The physician response for the 11/22/19 monthly drug regimen review recommendation for a duration of therapy was a handwritten note dated 12/01/19 which stated that Resident #41 still required the [MEDICATION NAME] since she had been on it long term and did not include a stop date. An interview with CP #1 on 12/12/19 at 8:35 AM revealed she had sent recommendations for the physician to clarify the number of days for the [MEDICATION NAME] on 10/23/19 and 11/22/19. She further stated no stop date was provided for the 10/23/19 recommendation and she had sent another recommendation on 11/22/19 and was unaware if there had been a response and planned to follow up the next time she was in the facility. She further revealed it was her normal practice to discuss with the Director of Nursing (DON) or contact the physician if she did not receive a response by the third monthly drug regimen review and that would be (MONTH) for Resident #41. An interview with Physician #1 on 12/12/19 at 8:09 AM indicated he was aware of the Centers for Medicaid and Medicare (CMS) regulation that indicated PRN [MEDICAL CONDITION] medication required a duration for a PRN [MEDICAL CONDITION] medication such as the [MEDICATION NAME] prescribed for Resident #41. He stated he was usually good about review of antianxiety medications but had just not gotten around to looking at her medications and providing a stop date. An interview with the Administrator on 12/12/19 at 11:01 AM revealed the physician should provide a stop date for PRN [MEDICAL CONDITION] medications per CMS regulations. 2. Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician ' s order dated 11/10/19 indicated [MEDICATION NAME] (an anti-anxiety medication) 0.5 milligrams (mg) by mouth every 6 hours as needed for anxiety. There was no stop date written for the as needed [MEDICATION NAME] order. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #39 was cognitively impaired and received an antianxiety medication 1 day during the look back period. The Consultant Pharmacist (CP) monthly drug regimen review for Resident #39 indicated the CP recommended the physician clarify the time limit for the resident ' s [MEDICATION NAME] order on 11/22/19. There had been no response. An interview was conducted on 12/12/19 at 12:49 PM with Physician #2 who indicated he was aware the order for the [MEDICATION NAME], which was ordered to be administered on an as needed basis, should have had a stop date and he would expect the facility to contact him regarding the stop date. He continued he was not at the facility daily and only had a few residents as patients. An interview with the Administrator on 12/12/19 at 11:01 AM revealed the physician should provide a stop date when writing orders for as needed [MEDICAL CONDITION] medications.