Every finding on record at VI at Aventura

Based on observation, record review and interviews facility failed to use appropriate infection control practices for one Resident #187 out of seven sampled residents, as evidenced by staff using sanitizing wipes to clean blood pressure machine after taking vitals for a resident on isolation precaution. The findings included: On 4/30/2024 at 7:55 AM, Staff C, Licensed Practical Nurse (LPN) approached room of Resident#187, stopped donned gown and gloves then entered room with blood pressure machine, cleaned blood pressure machine with a wipe. On 4/30/2024 at 8:01 AM, Staff C, LPN exited Resident #187's room with blood pressure machine. On 4/30/2024 at 8:01 AM, Staff C, LPN was asked by surveyor what was used to clean blood pressure machine. Staff C, LPN stated: the resident has her own blood pressure cuff, and I cleaned the blood pressure machine with sanitizing wipes. Staff C, LPN showed surveyor a bottle of wipes with a purple top, labeled Germicidal Sani wipes. The surveyor asked Staff C, LPN to point out where it is indicated on the bottle that it is approved to disinfect surfaces for Clostridium difficile (C-diff.). C-diff was not listed on the bottle. Record review of demographic sheet for Resident #187 revealed an admitted [DATE] with diagnosis that included Enterocolitis due to Clostridium difficile (C-diff.) Record review of MDS 3/21/2024 Interim Payment assessment revealed Section C for cognitive status revealed a Brief Mental Status Score of 7 on a scale of 0-15 indicated moderate cognitive impairment. Section O for Special Treatments, Procedures, and Programs revealed Resident #187 was on Isolation or quarantine for active infectious disease (does not include standard body/fluid precautions). Record review of Care Plan start date 4/10/2024 revealed Resident #187 required isolation due to C diff. Interventions included dispose of all products in room per facility infection control protocol, place all protective equipment and garments outside of resident room and all care and services are to be brought to the resident's room. Record review of physician orders revealed an antibiotic order dated 4/20/2024 for Vancomycin 125 mg capsule by mouth twice a day 14 days for C-diff. On 4/30/2024 at 8:09 AM Staff A, Registered Nurse (RN) Unit Manager stated: blood pressure machine should be cleaned with bleach wipes after usage with a resident on isolation with a diagnosis of C-Diff. On 4/30/2024 at 10:53 AM Staff C, LPN stated: I know the procedure I used was wrong. The correct procedure when disinfecting the blood pressure machine when used with a resident under isolation precaution for C-diff is to use the bleach wipes located on the caddy outside the room. On 5/02/2024 at 8:18 AM The Director of Nursing (DON) stated: The protocol for cleaning the blood pressure machine after use with a resident under isolation precaution for C-diff is to stop at the door and don appropriate PPE (Personal protective equipment) and then bring machine into room, use the dedicated blood pressure cuff for that resident, remove cuff and clean the cuff, and use bleach wipes to clean the blood pressure machine. Staff can take the bleach wipes into room inside a plastic bag or remove bleach wipes out the container from the station in front of the door. Record review of the facility's Policy and Procedure for Equipment cleaning effective date May 2007 Revision Date October 2017 Philosophy Operations Policies are intended to describe the services of and standards for the major functional support areas of the business units and Company service lines. Purpose This policy describes the process for cleaning equipment used in the care of residents in Skilled Nursing (SN). Process Medical equipment used in the care of the resident is cleaned with community approved disinfectant before it is stored or used for another resident.

Based on observation, record review and interviews facility failed to determine whether the self-administration of medications was clinically appropriate for one resident (Resident #10) out of seven residents sampled; as evidenced by observation of medication in resident's drawer and no self-administration assessment completed. There were 36 residents residing in the facility at the time of survey. The findings included: On 4/29/2024 at 9:04 AM Resident #10 asked surveyor to retrieve lozenges from drawer. Upon opening Resident#10's top drawer, one white bottle labeled supplements and two boxes labeled lozenges were observed inside. (see photo evidence). On 4/29/2024 at 9:05 AM, the surveyor approached Staff B, Licensed practical Nurse (LPN) and asked if Resident #10 was approved to self-medicate or keep medications in room. Staff B, LPN stated [Resident #10] has not been evaluated to self-administer medication. The surveyor informed Staff B, LPN that medications were observed in the top drawer in Resident #10's room. Staff B, LPN and surveyor entered Resident #10's room; Staff B, LPN retrieved one white bottle and attempted to retrieve the boxes of lozenges however Resident #10 grabbed the Lozenges and refused to let go. Staff B, LPN explained to Resident #10 that an order from the physician for these medications was required and Resident #10 did not release the boxes of lozenges. On 4/29/2024 at 9:19 AM Staff C, LPN stated: I will notify the Unit Manger about this situation. On 4/30/2024 at 12:00 PM Staff C, LPN stated: an assessment was done for self-administration for [Resident #10] and the physician is now aware and has approved of the lozenges to be kept in [Resident #10's] top drawer and that drawer is locked, and the key kept by [Resident #10]. On 4/30/2024 at 12:06 PM. Surveyor entered Resident #10's room with Staff C, LPN, and the top drawer next to resident was locked. Record review of demographic sheet for Resident #10 revealed an admitted [DATE] with diagnosis that included Gastro-esophageal reflux disease without esophagitis. Record review of Admission Minimum Data Set (MDS) dated [DATE] Section C for cognitive status revealed a Brief Mental Status Score of score 14 out of a scale of 0-15 indicated no cognitive impairment. Section GG for functional status revealed Resident #10 required set up/clean up assistance for eating/oral hygiene. Record review of Care Plan start date 4/3/2024 and revision date 4/16/2024 revealed Resident #10 Self Care deficit with interventions that included: Encourage the resident to complete task(s) she is safely capable of and provide with assistance as needed. Record review revealed an assessment dated [DATE] for Self-Administration of medication. Record review of physician orders revealed an order dated 4/29/2024 for [brand] Dry Mouth Lozenge Administer one lozenge by mouth every one hour as needed for Dry Mouth and resident to self-administer. Record review of Progress Note 4/29/2024 revealed resident noted with home medications in room and refusing to surrender medication to the nurse despite many attempts made. Supplements and dry mouth Lozenges currently in room. [Resident #10] stated she would like to self-administer dry mouth Lozenges and does not want to continue with supplements while she is here in the facility. [Resident #10] was able to provide a return demonstration on how to properly store the dry mouth Lozenges in the drawer, how to self-administer, how to lock and unlock drawer. Physician made aware and orders obtain for dry mouth Lozenges every hour as needed for dry mouth and ok for [Resident #10] to self-administer. On 5/02/2024 at 8:05 AM The Director of Nursing stated: Upon admission we educate the resident and family that medications are not to be kept in the rooms, we complete a check of the room to determine if any medications are in the room, and we ask the resident and the family if any medication was brought into facility so we can retrieve the medication and keep it in the medication room or ADON (Assistant Director of Nursing) office and label it with the name of the resident so it can be returned to resident upon discharge. For any resident who wants to keep medications at bedside, the Unit Manager completes a self-administration assessment for that resident and then we notify the doctor to get an order for self-administration. The next step is to get a lock for the drawer to keep the medication in the room, print a paper MAR (Medication Administration Record) for the resident to notate the administration and the Unit Manger monitors the MAR to see when medication was taken. Record review of the facility's Policy and Procedure for Medications-Bedside Storage and Self-Administration effective date May 2007 revision date 2017 Philosophy Resident Care Policies are intended to describe the Company commitment to a customer -centered approach to care provided throughout the continuum of clinical services. Purpose The policy establishes guidelines for the storage and documentation of medication kept at a resident's bedside and for self-administration of medication in Skilled Nursing (SN). Process Prescription and non-prescription over the counter (OTC) medications, except narcotic analgesics and other Class II drugs, may be stored at the bedside in a secure, locked drawer when ordered by a healthcare provider with prescriptive authority, and after the assessment and approval by the interdisciplinary team of the resident's ability to self-administer medication.

Based on observation, record review and interview the facility failed to provide assistive devices to prevent accidents for one resident (Resident #185) out of seven residents sampled as evidenced by observations of Resident#185 in bed and the floor mats folded up, against the wall. There were 36 residents residing in the facility at the time of the survey. The findings included: On 4/29/2024 at 9:25 AM an observation was made of Resident#185 in bed with eyes closed, one floor mat in place on the right of the bed and the other floor mat was noted folded up against the wall. (photo evidence) On 5/01/2024 at 8:42 AM an observation was made of Resident #185. The resident was awake and in bed, the two floor mats were folded up against the wall. (photo evidence) Record review of demographic sheet of Resident #185 revealed an admitted [DATE] with diagnosis that included history of falling and other abnormalities of gait. Record review revealed an Admission Minimum Data Set (MDS) dated [DATE] was in process. Record review of Care Plan dated 4/25/2024 revealed Resident #185 at risk for fall due to debility from recent Cerebrovascular Accident, history of falls, impaired mobility, new surroundings with interventions that included keep bed in lower position, equipment and devices as ordered, Record review of physician orders revealed an order dated 4/24/2024 for floor mats at bedside twice a day 7:00 AM to 7:00PM and 7:00 PM to 7:00AM. On 5/01/2024 at 8:42 AM Staff B, Licensed Practical Nurse (LPN) was notified by surveyor that floor mats were folded and against the wall while the Resident#185 was in bed. Staff B, LPN entered Resident #185's room with surveyor and placed mats onto floor on both sides of bed. On 5/01/2024 at 8:42 AM Staff B, LPN stated: [Resident#185] has an order for floor mats twice a day. I did rounds at 7:00 AM and [Resident#185] was in bed and both floor mats were on the floor on each side of the bed. On 5/01/2024 at 9:06 AM The Assistant Director of Nursing (ADON) approached surveyor and stated: I removed the floor mats because I was readjusting the resident to prepare for breakfast and to prevent dizziness. once I left the room, I did not replace the mats because I was in and out of the room. When a resident has an order for floor mats, all staff are to follow the order. This resident has a current order for floor mats twice a day and the floor mats should have been in place this morning when I was not in the room. On 5/02/2024 at 8:14 AM The Director of Nursing (DON) stated: We use floor mats to prevent injury during a fall for residents who are at risk of falling. Also Stated there is always a physician order for floor mats. Further stated all staff are required to follow physician orders and they sign every shift for that specific order. Stated the only time the floor mats can be removed when staff are providing care or if the resident is not in bed. Record review of Policy and Procedure entitled, Fall Prevention Protocol revised October 2017 Purpose This protocol describes mechanisms for assessing residents at risk for falls and providing interventions to reduce the likelihood of falls. 13. The SN interdisciplinary team, the resident and the resident's family/responsible agent may consider using the following fall prevention devices, which include but are not limited to: concave mattress, low bed, mattress/pads on floor.

Based on observation, interview and record review, it was determined that the facility failed to ensure the hydration cart, ice cooler and ice scoop was handled in a manner to prevent contamination. The findings included: During an observation on the nursing unit on 4/30/2024 at 11:15 AM, a person was observed to walk over to the Hydration cart, that was located across from the nursing station. The person picked up the ice scoop from its holder, opened the ice cooler, put ice in a plastic glass and filled the glass with water from the water container. Then the person was observed to walk into a resident's room. The person was not observed to sanitize her hands before or after obtaining the ice and water and was not wearing gloves. On 4/30/2024 at 11:25 AM, the Assistant Director of Nursing (ADON) was observed in the hallway. The surveyor interviewed the ADON about the observation and gave a description of the person. The ADON reported, it was Resident #185's spouse. The person was then observed walking out of Resident #185's room. The ADON reported, they have spoken to her about this, and the residents wife gets upset when they speak to her. The ADON reported, the resident has water at the bedside, but the resident's spouse still gets water for him. The surveyor explained to the ADON that the person was not observed to use hand sanitizer before using the scoop and cooler. The ADON reported, she did not see her go into the cooler. (Photo of the hydration cart was obtained). The ADON reported, the cooler, scoop, and the hydration cart are changed daily and cleaned in the kitchen, then another hydration cart is put out daily. On 4/30/24 at 1:23 PM, Resident #185's spouse was observed at the ice cooler and hydration cart with a glass, obtained water and returned to Resident #185's room. The person was not observed to use hand sanitizer prior to obtaining ice and water. Record review of the facility's policy and procedure for the category of Resident Care and titled Infection Control Program and Committee revised June 2020 documents, in the section for Process - The Infection Control Team Program and Committee is responsible for investigation, reporting, control and prevention of infections, reviewing occupational exposures to blood, body fluid or other potentially infectious materials and for monitoring staff performance to ensure that infection control policies, protocols and procedures are implemented.

Based on record review and interview, facility failed to send an accurate Nursing Home Transfer and Discharge Notice to The Office of the State Long term care Ombudsman for one resident (Resident #184) out of seven residents sampled, as evidenced by a fax confirmation of The Nursing Home Transfer and Discharge Notice with a discharge date of [DATE] was sent to The Office of the State Long term care Ombudsman and a nursing note dated 12/04/2024 documented that Resident#184 was discharged to home. The findings Included: Record review of demographic sheet for Resident#184 revealed an admitted [DATE] and discharge date of [DATE] with diagnosis that included Displaced oblique fracture of shaft and right femur. Record review of discharge return not anticipated Minimum Data Set (MDS) Section A documented the resident was discharged to home and section C for cognitive status revealed a Brief Interview for Mental status score of 14 out of a scale of 0-15, indicated no cognitive impairment. Section Q for Participation in assessment and goal setting revealed active discharge planning in progress for the resident to return to the community. Review of the resident's Care Plan revealed a start date of 10/20/23 and revised date of 11/7/2023 for resident expects to return to community and discharge to community determined to be feasible. The interventions included provide written instructions for care/resources to use in case of emergency, provide education, and explain relevance of treatment regimen. Record review of physician orders revealed a discharge to home order dated 11/29/2023 for 12/1/2023. Record review of The Nursing Home Transfer and Discharge Notice signed by the resident's son on 11/28/2023 and discharge date of [DATE]. Record review of a fax confirmation sheet revealed The Nursing Home Transfer and Discharge Notice was sent to the office of The State Long Term Care Ombudsman on 12/11/2023. Review of the Social Services notes indicated on 11/07/2023, Resident #184's son was notified about the upcoming discharge date of [DATE] and on 11/17/2023 Resident #184's son stated, she will be ready to go home by that time. Further record review of the Social Services notes revealed on 11/27/2023 the Social Worker (SW) spoke to the son about an updated discharge date of [DATE], and that it can be appealed .Continued review of the social services notes revealed on 12/1/2023 the facility's Administrator confirmed Resident #184's son made a second appeal and the resident had an additional 72 hours to reside in facility. Review of nursing notes revealed on 12/04/2023 Resident #184 was discharged to home and left the facility with son. On 05/01/2024 at 11:56 AM, the Social Services Manager stated: The determination of discharging a resident is made during the care plan meetings with the resident, family, and Interdisciplinary Team (IDT) after evaluating the status of the resident and once a date is set, I notify the resident or family about the discharge date , their right to appeal if they disagree and coordinate home health services and durable medical equipment needed for discharge. This discharge was facility initiated due to the resident reaching maximum potential in therapy. [Resident #184] initial discharge date was 11/22/2023 and son the was notified on 11/7/2023 and he disagreed with the discharge date , and it was changed to 12/1/2023 and son was notified on 11/17/2023 of the change and he agreed. [Resident #184's] son was notified on 11/27/2023 of the right to file an appeal the discharge date if he disagrees and on 11/29/2023 I informed [Resident#184's] son that if his appeal was denied the discharge date would remain on 12/1/23. On 12/1/2023 the Administrator confirmed there was a second appeal pending for [Resident #184] and [Resident#184] had an additional 72 hours to remain in the facility, and that appeal was denied. Resident #184 was discharged to home on 12/4/2023 accompanied by son. The Nursing Home Notice of Transfer or Discharge was faxed to The Ombudsman on 12/11/23 and has a discharge date of [DATE] even though the resident was discharged on [DATE] because that was the initial discharge date . There is no other Transfer Letter to the Ombudsman for this resident.

Based on record review and interview the facility failed to ensure the arbitration agreements presented to residents upon admission informed residents or their representatives of the nature and implications of any proposed binding arbitration agreement, to inform their decision on whether or not to enter into such agreements. There were 36 residents residing in the facility at the time of the survey. The findings included: Record review for Arbitration agreements on facility letterhead documented the following: 1) The facility offers arbitration agreements; 2) The facility asks residents to enter into an arbitration agreement and provides new admissions with the arbitration agreement during the admission process, 3) No residents residing in the facility have signed the arbitration agreements and 4) The Outreach Manager and Admissions Assistant are responsible for the binding arbitration agreements. Review of the Arbitration Clause (Arbitration Agreement) received on 4/29/2024 revealed that the form did not document the binding arbitration agreement allowing the resident or anyone else to communicate with federal, state, or local officials such as federal and state surveyors, other federal or state health department employees and representative of the Office of the State Long Term Care Ombudsman. On 5/01/2024 at 10:24 AM, interview and record review with the Outreach Manager and Admissions Assistant of the Arbitration Clause. The Arbitration Clause revealed that the form did not document the binding arbitration agreement allowing the resident or anyone else to communicate with federal, state, or local officials such as federal and state surveyors, other federal or state health department employees and representative of the Office of the State Long Term Care Ombudsman. He stated, I have been here a year, and no one has signed the Arbitration Agreement. A subsequent interview with the Outreach Manager on 05/01/2024 at 11:11 AM, he presented a new Dispute Resolution Agreement (Arbitration Agreement), which was not given when requested upon entrance to the facility. He stated, I just got this from the Administrator, and we were using the wrong one. This one contains all of the information you requested. On 5/01/2024 at 12:47 PM, interview and record review with the Administrator confirmed that the Dispute Resolution Agreement form did not document the binding arbitration agreement allowing the resident or anyone else to communicate with federal, state, or local officials such as federal and state surveyors, other federal or state health department employees and representative of the Office of the State Long Term Care Ombudsman. Requested Arbitration policy and procedure from the Administrator and she revealed that the facility does not have one.

Based on interview and record review, the facility failed to coordinate care with Hospice for 1 of 1 sampled resident for hospice care (Resident #9). There were 3 residents residing in the facility receiving hospice services at the time of the survey. The findings included: Review of clinical records revealed, Resident #9 was admitted to the facility on [DATE], and readmitted on [DATE]. A comprehensive assessment dated [DATE] documented the resident had severe cognitive impairment, and required total two-person assist with activities of daily living. The assessment further documented the resident received hospice services. Resident #9 was care planned for hospice services on 03/28/22. An intervention dated 01/20/23 included: Hospice Nurse and Hospice CNA (Certified Nurse Assistant) to visit weekly/ as needed. Coordinate care and services via communication among staff. Record review revealed an order dated 03/26/22 for Resident #9 to be admitted under Hospice. An interview was conducted with the hospice nurse on 01/26/23 at 11:00 AM. The hospice nurse stated she comes once a week to evaluate Resident #9. The hospice nurse stated she communicates with the resident's nurse for any changes and updates. The hospice nurse provided documentation of such visits kept in a hospice binder at the facility's nursing station. The hospice nurse further stated Resident #9 received hospice CNA services 3 times a week. The hospice nurse stated the CNA does not leave any documentation at the facility, but does electronic charting through the hospice system. The hospice nurse stated the CNA used to make their own schedules, and just show up. Now the CNA has a set schedule, and was scheduled to visit Resident #9 on Monday, Tuesday, and Wednesday. The facility's Unit Manager (UM) overheard the above conversation and stated she did not see the hospice CNA yesterday (Wednesday). The UM presented a sign in sheet for hospice at the nursing station The sign in sheet last documented a visit from hospice on 01/07/23. When asked if there was any other place someone would have to sign in, the UM stated they would sign in at the front gate/garage prior to entering the facility. The surveyor requested documentation for hospice visits for Resident #9. An interview was conducted with Staff E, a CNA, on 01/26/23 at 11:30 AM. Staff E stated she did not know if Resident #9 was on hospice services. Staff E, CNA stated they alternate assignments, and she was a float (works where she is needed). An interview was conducted with Staff F, a CNA, on 01/26/23 at 11:35 AM. Staff F stated she works with Resident #9 frequently. The resident requires 2 persons assist. Staff F stated she usually gets assistance from restorative for care. Staff F stated she knows the resident receives hospice services, but the new CNA has not had any communication. Staff F stated they do not wait for the hospice CNA, because they don't know when they are coming. Staff F reported that hospice drops off supplies for Resident #9 on Fridays. An interview was conducted with the hospice CNA via telephone on 01/26/23 at 11:40 AM. The hospice CNA reported that she saw Resident #9 on a regular basis, and asks the CNA if they need any help. She last saw the resident on Monday and Tuesday (01/23/23 and 01/24/23). The hospice CNA stated she was not aware of a sign in sheet at the facility, as she just started working with the resident a little over a month ago. The CNA stated she spoke to the CNA on Monday, but does not remember the CNA's name. The hospice CNA stated she did not speak with anyone on Tuesday. The hospice CNA stated she did not come to the facility on Wednesday (01/25/23). She usually drops off supplies on Friday. A copy of the hospice CNA's notes was provided by the hospice nurse. The hospice CNA has notes dated 01/23/23, 01/24/23, and 01/25/23 that documented care provided by the hospice nurse for Resident #9. A review of the sign in document from the front gate/garage prior to entering the facility revealed the hospice nurse signed into the facility grounds on 01/23/23 and 01/24/23.

Based observation, interview and record review, the facility failed to assess 2 out of 13 sampled residents (Resident #74) for self-administration of medications. Resident #74 had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] # 8's room for the resident to to self administer. There were 22 residents residing in the facility at the time of the survey. The findings included: 1) During the observational tour on 09/7/21 at 9:29 AM, two eye medication were observed on Resident #74 over bed table. The eye medications were observed to be [MEDICATION(S)] Eye Drops and [MEDICATION(S)] Ointment. Resident #74 reported, she brought the medications from home, and she used the eye drops several times per day and she used the ointment at night. The resident reported she had been at the facility for 2 weeks. During observation on 9/7/21 at 12:26 PM, Resident # 74 was eating lunch in her room and the eye medications were observed on the residents over the bed table. During the review of Resident # 74's medical record it was revealed that the resident was admitted to the facility on [DATE]. The resident had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During observation of Resident #74 on 9/8/21 at 10:49 AM, the eye medications were observed on the residents over the bed table. During record review of Resident #74's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The report documented, Resident is not capable of self administration of medications. The 9/1/21 to 9/30/21 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with Staff C, Licensed Practical Nurse (LPN) Supervisor on 9/9/21 at 10:25 AM, Staff C was asked about the medications that were at Resident #74's bedside. Staff C reported, she did not see medications at the resident's bedside. Staff C was asked about the process the facility follows for residents to self administer medications. Staff C reported, they have to assess the resident, do a trial run and obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During observation on 9/9/21 at 10:40 AM, Staff C, LPN Supervisor and Staff E, LPN were observed to enter Resident #74's room to check on the medications at the resident's bedside. Staff C returned to the nurse's station with the 2 eye medications that were at Resident #74's bedside. Staff C had the [MEDICATION(S)] Eye Drops and [MEDICATION(S)] Ointment. During the review of the facility's policy titled, Medication/Treatment, effective May 2004 and revision date December 2017 revealed, Self Administration of medications/treatments is permitted only upon the written order of the healthcare provider with prescriptive authority. Additionally, an assessment (utilizing an approved tool) of the resident's ability to self-administer medications, is completed by a licensed nurse and the resident assessed as capable. 2) On 9/8/21 at 9:47 AM, during breakfast observation Resident #8 was observed sitting in a chair eating breakfast that consisted of super cereal, mighty shake yogurt and juice. A Medication cup with 7 pills was observed on Resident #8's bedside table. (Photograph evidence of medications obtained). Resident #8 was asked about the medication cup with the pills. Resident # 8 stated that she told the nurse to leave the medications on the table until she finished eating. Review Resident #8's clinical records documented an admission to the facility on [DATE]. Clinical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #8's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #8's clinical records did not show any physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident # 8 's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a BIMS (Brief Interview of Mental Status) score of 13 out of 15 which indicates intact cognition. Review of the care plans did not indicate Resident # 8 was assessed for self-administering medications. On 09/08/21 at 10:40 AM, observation revealed the medication cup containing the pills was still on the bedside table. On 09/08/21 at 10:45 AM during observation and interview the medication up that contained the pills was no longer on the bedside table. Resident # 8 stated that she had taken the medications. On 9/8/21 at 12:22 PM, Staff D, a License Practical Nurse (LPN) revealed that she has been working in the facility for two weeks and was still in training. Staff D, LPN revealed Resident # 8 requested her medications with breakfast. Staff D, LPN stated she was not sure what time the medications were left on the resident's bedside table, but it's the first medication in the morning so it was between 7:00 AM and 9:00 AM. Staff D, LPN stated that breakfast was at 8:00 AM so she waited for breakfast to be delivered. Staff D stated she gave the resident the medications and left the room with the impression that Resident # 8 had taken the medications before exiting the room. Staff D added that she spoke to Resident #8 before leaving the room, but did not see if the medications were taken. Staff D acknowledged that it was wrong to leave the medications with Resident # 8 and that the medication should have been taken back to the medication cart. During an interview on 09/09/21 at 1:33 PM, the Nursing Home Administrator (NHA) and the Director of Nursing (DON) were informed of the identified concerns related to Resident # 8 self-administering medication. They both indicated that for a resident to self-administer their medication, the physician would do an assessment and evaluate the resident.

Based on record review and interview, the facility failed to provide the SNF-ABN (Skilled Nursing Facility - Advance Beneficiary Notice) and the Notice of Medicare Non-Coverage (NOMNC) forms as required to one (Resident #17) of five residents reviewed for Beneficiary Protection Notification. The findings included: Record review of the census report revealed Resident #17 was admitted to the facility on [DATE] and her payer source was listed as private. Resident #17 was transferred to the hospital on 06/27/21 and readmitted under Medicare Part A on 07/2/21. Her payer source changed back to private on 08/21/21. Resident #17 remained in the facility. Interview with the Rehab Director (Staff F) on 09/09/21 at 3:47 PM revealed Resident #17 received skilled therapy under Medicare Part A. She received skilled physical therapy (PT) and occupational therapy (OT) following a hospital stay. She had a functional decline and was evaluated on 07/3/21 for both PT and OT and received treatment through 08/20/21. She was discharged from skilled services after meeting her goals on 08/20/21. Record review of the SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review (CMS Form ) completed by the facility revealed Resident #17's Medicare Part A services started on 07/2/21 and her last day covered was 08/20/21. The Medicare Part A Service Termination/Discharge determined: The facility / provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. Question 1. Was the SNF-ABN (CMS Form ) provided to the resident indicated the form was not provided. Question 2. Was a NOMNC (CMS Form ) provided to the resident indicated the form was not provided. Interview with the Nursing Home Administrator (NHA) on 09/10/21 at 9:18 AM revealed Social Services handles the SNF-ABN and NOMNC (Notice of Medicare Non-Coverage) notices. The NHA reported, my Social Worker's last day was 07/30/21. Since then, I assumed the responsibility for providing the notices. The NHA explained stated that Resident #17's payer source changed from Medicare Part A to private pay but she had Medicare Part A coverage days remaining. We discussed her status at our utilization review meeting and determined she no longer needed skilled therapy services. The notice of non-coverage and the advance beneficiary notices were not provided to this resident as required when her skilled services were discontinued and her payer source changed. During a follow up interview with the NHA on 09/10/21 at 10:10 AM, the NHA revealed , as far as the SNF-ABN and NOMNC notices we have recently on boarded a new Social Worker and she will assume the responsibility of providing the required notices.

Based on record review and interview, the facility failed to provide evidence that written copies of the resident's transfer form related to two hospitalization s were provided to the resident and or representative and failed to ensure the notice of transfer was sent to the Office of the Long-Term-Care Ombudsman's for one (Resident #18) of one resident reviewed for hospitalization s. The census at the time of the survey was twenty two residents. The findings included: Record review of Resident #18's clinical record revealed he was admitted to the facility on [DATE]. Resident #18 was transferred to the hospital on 06/25/21, returned 07/02/21 and subsequently transferred back to the hospital on 07/02/21. Record review of Resident #18's hybrid clinical record revealed there was no Nursing Home Notice of Transfer - Discharge Form on file in the Electronic Health Record (EHR) or the paper record for the transfer on 06/25/21 or 07/02/21. Interview with the Nursing Home Administrator (NHA) on 09/09/21 at 10:00 AM revealed, it is not the facility's responsible to provide a resident with a notice of transfer discharge when they are transferred to the hospital because this is not considered a facility initiated discharge. The discharge for Resident # 18 was initiated by his physician, not the facility so the facility is not required to provide the form. The bed hold notices are provided at the time of transfer to the hospital. When asked again about the Nursing Home Notice of Transfer Discharge Form the NHA stated that when the physician transfers a resident to the hospital it is not considered to be a facility initiated discharge because it is the physician that is initiating the transfer. The administrator was asked if the physician was acting on behalf of the facility, and the NHA stated, no and that the physician was acting independently as the resident's physician. On 09/10/21 at 10:19 AM the NHA revealed the Nursing Home Transfer Discharge Forms are not sent to the Ombudsman's office. We send a log to the Ombudsman every month with the list of transfers and discharges. We do not send them the actual notices, just the log with the residents names, dates and locations of transfer or discharge. Review of the Transfer/Discharge Logs for June 2021 and July 2021 revealed the Ombudsman was not notified of Resident 18's transfer. Resident #18's name was not listed on the log. The NHA stated , I guess we considered him a bed hold and not a discharge so he was not listed on the log. We did not notify the Ombudsman of the transfers.

Based on record review and interview the facility failed to file a grievance for one resident (resident # 10) related to care and services out of fifteen residents sampled. This has the potential to affect twenty-six residents residing in the facility during the time of the survey. The findings included: Record review of the facility's policy revised on (MONTH) 2012 revealed: Grievance Resolution Process: This policy describes the grievance resolution process for residents in the licensed care venues. Process: 2. Grievances include formal written complaints submitted to the Administrator and / to other care venue staff as well as verbal complaints. 2.1 If a resident and / or their responsible agent is unable to complete a written complaint, assistance may be provided by the Administrator or any other employee. 4. The grievance resolution process includes several steps. 4.1 The grievance is received by the Administrator or designee. 4.2 The Administrator or designee works with the resident to identify the issue fully. 4.3 The Administrator or designee works with other members of the licensed care venue team to resolve the issue. 4.4 The resident is kept apprised of resolution efforts. 4.5 All steps of the grievance resolution process are documented on designated forms. 5.1 One Grievance log is initiated per resident occurrence. Record review of facility's grievance log from (MONTH) 2019 to (MONTH) 2019 revealed no grievances filled for resident #10. Interview on 09/17/2019 at 10:27 AM resident #10 revealed: I like other staff members more than others, the staff member is unpleasant to work with and she irritates me. She doesn't smile and is not pleasant to look at. She walks around with a sour look. I notified the administrator and nothing was done in respect to the complaint, that I know about. I don't know how deep I went regarding respect of the staff to the administrator. Interview on 09/19/2019 at 8:33 AM the Administrator revealed that resident # 10 had informed them on 04/24/2019 about concerns regarding Staff B, Registered nurse (RN). The son of resident #10 reported that resident # 10 stated that he did not like Staff B or Staff B, RN did not like him and resident #10 did not want to file a grievance. Interview on 09/19/2019 at 09:05 AM with the Social Services Director revealed that they were not aware that resident # 10 had a concern with Staff B, RN and was currently working with resident #10.

Based on record review and interview the facility failed to accurately code the Minimum Data Set (MDS) for one resident (resident # 20) with a hearing impairment and was wearing a hearing device out of fifteen sampled residents. There were twenty-six residents in the facility during the time of the survey. The findings included: Record review of the face sheet revealed that resident # 20 was admitted on [DATE]. Record review of the Minimum Data Set ((MDS) dated [DATE] for resident # 20 revealed section B for hearing was coded as minimal difficulty and hearing aid section was coded as no. Record review of the care plan for resident # 20 dated 07/28/19 and revised on 09/19/2019 revealed problem: Resident has difficulty hearing when not in a quiet setting and wore hearing aids. Goal: Resident will be able to hear and understand communication daily through next review date. Approach: Adjust tonal quality and speak distinctly. Allow resident ample time to process and respond to questions as needed. Assure hearing aid was clean, functioning and properly in place into left and right ear. Face resident when speaking. Nurse to apply hearing aid in AM (morning) and then remove at HS (night) and store hearing aid at bedside on her night stand. Record review of the Physician Order Sheet for (MONTH) 2019 for resident # 20 revealed nurse to apply hearing aids in the morning and then remove at bedtime. Store hearing aid at the bedside on her night stand twice a day. Phone interview on 09/17/2019 at 3:30 PM a family member of resident # 20 revealed: I don't know if she got her hearing aid batteries. Interview on 09/18/2019 at 10:07 AM with wound care Registered Nurse regarding resident # 20 revealed that she was alert and forgetful at times. Resident # 20 was hard of hearing, did wear hearing aids, but still had trouble hearing. Observation and interview on 09/18/2019 at 1:30 PM with staff C, private duty Home Health Aid (HHA), revealed that staff C started last year in (MONTH) (YEAR). Staff C, HHA noted that she assisted resident # 20 with the Activities of Daily Living, but facility staff mainly helped. Staff C, HHA noted that resident # 20 was aware of her surroundings and had hearing aids in both ears. Staff C, HHA stated that: I place the hearing aids in her ears every morning, but even with them she did not hear well. The hearing aids are rechargeable. I noticed that they were not charging properly. Staff C, HHA noted that she had told the nurse that resident # 20 ear aids were not charging, and the nurse told her to contact the Power of Attorney (POA) for resident # 20. Staff C, HHA mentioned that she contacted the POA of resident # 20 two weeks ago and gave him a card for the doctor to order a new hearing aid battery for resident # 20. Observation and interview on 09/18/2019 at approximately 1:40 PM with resident # 20 in her room in the presence of Staff C, HHA revealed that resident # 20 was in bed and was wearing hearing aids in both ears. Resident # 20 was not able to hear well. Interview on 09/18/2019 at 2:15 PM Staff D, Certified Nursing Assistant (CNA) revealed that resident # 20 was alert, she was able to communicate with her. Staff D, CNA noted that she had to say sentences loud or repeat them a few times since resident # 20 had trouble hearing. She did not know if resident # 20 had hearing aids when she saw her one month ago, since she had to repeat her words louder to resident # 20. Interview on 09/18/2019 at 2:27 PM with staff E, Licensed Practical Nurse (LPN) regarding resident # 20 revealed that she was alert and forgetful and needed total assistance. Resident # 20 was hard of hearing and wore hearing aids. Resident # 20 had a private aid and the staff would check that resident # 20 hearing aids was always on. Staff E, LPN explained, regarding the hearing aids that were not working properly for resident # 20 : The private duty is supposed to take the hearing aids to check them, she knows this, she is aware if the hearing aids are not working and knows where to go. Staff E, LPN explained that the POA was aware. Staff E, LPN noted that regarding the hearing aids for resident # 20 this had been going on for approximately one week and mentioned that it might be a connection problem. Interview on 09/19/2019 at 12:11 PM with the MDS coordinator regarding resident # 20 revealed that the MDS dated [DATE] for hearing was coded as minimal difficulty and no hearing aids. The MDS coordinator reviewed the care plan for resident # 20 dated 07/28/2019 noted that resident # 20 had hearing aids. The MDS coordinator noted that she saw Resident #20 recently, but was not aware if resident # 20 was wearing hearing aids or not. The MDS coordinator noted that if the staff were aware of concerns with batteries for Resident #20's hearing aids they would report this to the nurse because they had batteries for certain hearing aids. The MDS coordinator noted that she had not heard anything about concerns with the hearing aid batteries for resident # 20. Interview on 09/19/2019 at 12:21 PM with the Social Services Director (SSD) regarding resident # 20 revealed that resident # 20 was alert and oriented in her interactions with her. Resident # 20 hearing had been fine, and she knew she wore hearing aids. The SSD noted that there was a care plan meeting for resident # 20 on 08/08/2019 and the POA of resident # 20 was on the conference call. The POA noted to make sure that the batteries were changed while he was on the phone with the private duty aid and to make sure resident # 20 was hearing alright. The SSD mentioned that she did not know if the hearing aid batteries for resident # 20 needed to be changed and explained to her knowledge staff placed hearing aids and changed the batteries as necessary. The SSD noted that she had a phone communication with POA for resident # 20 on 08/29/2019 there was no discussion about the hearing aids. the SSD noted that the unit secretary could schedule a medical appointment for the hearing aid, if this was brought to her attention. Sometimes when the family scheduled an appointment they would let the desk know. The SSD noted that she was not aware of this problem with the hearing aid and was hearing about this for the first time. The SSD acknowledged that she did not follow up after the care plan meeting for resident # 20 to see if the hearing aid batteries were changed. Interview on 09/19/2019 at 1:02 PM with staff A, Registered Nursing (RN) supervisor noted that resident # 20 had hearing loss and was wearing bilateral hearing aids. Normally if they had batteries they would put them on in the morning and charge it at night. Staff A, RN reviewed the medical doctor order for the placing of the hearing aids, removing them every night and storing them at Resident #20's bedside. Staff A stated that the unit secretary who was not available now could schedule an appointment .Staff A (RN) stated that families hire an aid to take the hearing aids to the hearing specialist and have them checked approximately every 6 months. Staff A, RN noted that she was not aware of concerns regarding the hearing aids for resident # 20 until yesterday when Staff E, LPN told her that the hearing aids for resident # 20 were not working properly, or the battery was not charging properly and resident # 20 was not able to hear adequately. Record review of the facility policy, revised on (MONTH) 2011, titled Hearing, Speech and Vision Impairment Services revealed: This policy establishes guidelines for communicating with hearing impaired or vision impaired residents in the facility. When the hearing impaired resident is admitted the resident is asked to indicate his or her preference relative to method of communication. This information is documented in the care plan. When the hearing impaired or communication impaired resident is admitted , the information is placed on the face sheet in the alert section and all departments who serve the resident are notified.

Based on observation, interview and record review the facility failed to coordinate care and services related to hearing services for a resident (resident #20) with a hearing impairment requiring a hearing device for one resident (resident number 20) out of fifteen sampled residents. There were twenty-six residents in the facility during the time of the survey. The findings included: Record review of the face sheet revealed that resident # 20 was admitted on [DATE]. Record review of the Minimum Data Set ((MDS) dated [DATE] for resident # 20 revealed section B for hearing was coded as minimal difficulty and hearing aid section was coded as no. Record review of the care plan for resident # 20 dated 07/28/19 and revised on 09/19/2019 revealed problem: Resident has difficulty hearing when not in a quiet setting and wore hearing aids. Goal: Resident will be able to hear and understand communication daily through next review date. Approach: Adjust tonal quality and speak distinctly. Allow resident ample time to process and respond to questions as needed. Assure hearing aid was clean, functioning and properly in place into left and right ear. Face resident when speaking. Nurse to apply hearing aid in AM (morning) and then remove at HS (night) and store hearing aid at bedside on her night stand. Record review of the Physician Order Sheet for (MONTH) 2019 for resident # 20 revealed nurse to apply hearing aids in the morning and then remove at bedtime. Store hearing aid at the bedside on her night stand twice a day. Phone interview on 09/17/2019 at 3:30 PM a family member of resident # 20 revealed: I don't know if she got her hearing aid batteries. Interview on 09/18/2019 at 10:07 AM with wound care Registered Nurse regarding resident # 20 revealed that she was alert and forgetful at times. Resident # 20 was hard of hearing, did wear hearing aids, but still had trouble hearing. Observation and interview on 09/18/2019 at 1:30 PM with staff C, private duty Home Health Aid (HHA), revealed that staff C started last year in (MONTH) (YEAR). Staff C, HHA noted that she assisted resident # 20 with the Activities of Daily Living, but facility staff mainly helped. Staff C, HHA noted that resident # 20 was aware of her surroundings and had hearing aids in both ears. Staff C, HHA stated that: I place the hearing aids in her ears every morning, but even with them she did not hear well. The hearing aids are rechargeable. I noticed that they were not charging properly. Staff C, HHA noted that she had told the nurse that resident # 20 ear aids were not charging, and the nurse told her to contact the Power of Attorney (POA) for resident # 20. Staff C, HHA mentioned that she contacted the POA of resident # 20 two weeks ago and gave him a card for the doctor to order a new hearing aid battery for resident # 20. Observation and interview on 09/18/2019 at approximately 1:40 PM with resident # 20 in her room in the presence of Staff C, HHA revealed that resident # 20 was in bed and was wearing hearing aids in both ears. Resident # 20 was not able to hear well. Interview on 09/18/2019 at 2:15 PM Staff D, Certified Nursing Assistant (CNA) revealed that resident # 20 was alert, she was able to communicate with her. Staff D, CNA noted that she had to say sentences loud or repeat them a few times since resident # 20 had trouble hearing. She did not know if resident # 20 had hearing aids when she saw her one month ago, since she had to repeat her words louder to resident # 20. Interview on 09/18/2019 at 2:27 PM with staff E, Licensed Practical Nurse (LPN) regarding resident # 20 revealed that she was alert and forgetful and needed total assistance. Resident # 20 was hard of hearing and wore hearing aids. Resident # 20 had a private aid and the staff would check that resident # 20 hearing aids was always on. Staff E, LPN explained, regarding the hearing aids that were not working properly for resident # 20 : The private duty is supposed to take the hearing aids to check them, she knows this, she is aware if the hearing aids are not working and knows where to go. Staff E, LPN explained that the POA was aware. Staff E, LPN noted that regarding the hearing aids for resident # 20 this had been going on for approximately one week and mentioned that it might be a connection problem. Interview on 09/19/2019 at 12:11 PM with the MDS coordinator regarding resident # 20 revealed that the MDS dated [DATE] for hearing was coded as minimal difficulty and no hearing aids. The MDS coordinator reviewed the care plan for resident # 20 dated 07/28/2019 noted that resident # 20 had hearing aids. The MDS coordinator noted that she saw Resident #20 recently, but was not aware if resident # 20 was wearing hearing aids or not. The MDS coordinator noted that if the staff were aware of concerns with batteries for Resident #20's hearing aids they would report this to the nurse because they had batteries for certain hearing aids. The MDS coordinator noted that she had not heard anything about concerns with the hearing aid batteries for resident # 20. Interview on 09/19/2019 at 12:21 PM with the Social Services Director (SSD) regarding resident # 20 revealed that resident # 20 was alert and oriented in her interactions with her. Resident # 20 hearing had been fine, and she knew she wore hearing aids. The SSD noted that there was a care plan meeting for resident # 20 on 08/08/2019 and the POA of resident # 20 was on the conference call. The POA noted to make sure that the batteries were changed while he was on the phone with the private duty aid and to make sure resident # 20 was hearing alright. The SSD mentioned that she did not know if the hearing aid batteries for resident # 20 needed to be changed and explained to her knowledge staff placed hearing aids and changed the batteries as necessary. The SSD noted that she had a phone communication with POA for resident # 20 on 08/29/2019 there was no discussion about the hearing aids. the SSD noted that the unit secretary could schedule a medical appointment for the hearing aid, if this was brought to her attention. Sometimes when the family scheduled an appointment they would let the desk know. The SSD noted that she was not aware of this problem with the hearing aid and was hearing about this for the first time. The SSD acknowledged that she did not follow up after the care plan meeting for resident # 20 to see if the hearing aid batteries were changed. Interview on 09/19/2019 at 1:02 PM with staff A, Registered Nursing (RN) supervisor noted that resident # 20 had hearing loss and was wearing bilateral hearing aids. Normally if they had batteries they would put them on in the morning and charge it at night. Staff A, RN reviewed the medical doctor order for the placing of the hearing aids, removing them every night and storing them at Resident #20's bedside. Staff A stated that the unit secretary who was not available now could schedule an appointment .Staff A (RN) stated that families hire an aid to take the hearing aids to the hearing specialist and have them checked approximately every 6 months. Staff A, RN noted that she was not aware of concerns regarding the hearing aids for resident # 20 until yesterday when Staff E, LPN told her that the hearing aids for resident # 20 were not working properly, or the battery was not charging properly and resident # 20 was not able to hear adequately. Record review of the facility policy, revised on (MONTH) 2011, titled Hearing, Speech and Vision Impairment Services revealed: This policy establishes guidelines for communicating with hearing impaired or vision impaired residents in the facility. When the hearing impaired resident is admitted the resident is asked to indicate his or her preference relative to method of communication. This information is documented in the care plan. When the hearing impaired or communication impaired resident is admitted , the information is placed on the face sheet in the alert section and all departments who serve the resident are notified.

Based on observation, interview and record review the facility failed to ensure proper storage of a refrigerated emergency kit containing emergency medication, as evidenced by kit containing [MEDICATION NAME] 2 milligrams (mg) / milliliters (ml) injection that expired on 08/31/2019 for one medication storage room out of the facility's one medication storage room observed during the time of the survey. The findings included: Review of the facility policy dated (MONTH) 2019 revealed: Storage of medications. Medications and biologicals are stored safely, securely, and properly, following manufacturers recommendation or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures: H. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal and reordered from pharmacy, if a current order exists. I. Medication storage conditions are monitored on a monthly basis by the consultant pharmacist or pharmacy designee and corrective action taken if problems are identified. Expiration Dating (beyond-use dating): G. All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner. I. Nursing staff should consult with the dispensing pharmacist for any questions related to medication expiration dates. Medication storage observation on 09/17/2019 at 3:28 PM with Staff A, Registered Nurse (RN) revealed that the medication refrigerator had one locked affixed clear box containing an emergency kit with [MEDICATION NAME] 2 milligrams (mg) / milliliters (ml) injection with an expired date of 08/31/2019. Photographic evidence was obtained. Interview on 09/17/2019 at 3:43 PM with Staff A, RN revealed that checking the refrigerator for expired medication was the responsibility of all the nursing staff. Phone interview on 09/17/2019 at 4:03 PM with Staff G (Pharmacy Consultant ) revealed that: Monthly inspections are performed in the medication storage area. the Pharmacist stated, I have not checked the medication storage area for this month. If the emergency medication kit was expired, the staff must place a call to the pharmacy to have the emergency kit replaced. Interview on 09/18/2019 at 2:35 PM the Director of Nursing (DON) revealed : They performed weekly checks of the refrigerator on Sunday night , any medication that is open has to have a label and a time. The nurses go through each cart, emergency kit and for residents that were discharged . The pharmacist comes monthly and verifies the logs, goes through all the narcotics and disposes of them. I was made aware yesterday of the [MEDICATION NAME] 2 mg / ml that was expired. The refrigerator is checked constantly, it is checked every weekend and pharmacy is aware .

Based on observations and interviews, the facility failed to ensure that resident care equipment was stored under sanitary conditions. Resident wheelchairs were stored in the bathroom. This deficient practice has the potential to affect all the residents residing in the facility at the time of the survey. The findings included: Observations on 6/6/17 at 9:37 AM in room 155 revealed, the resident's wheelchair was stored in the bathroom. The wheelchair was in the area between the shower and the toilet, facing the wall. Two of the resident's scarves were on the top backside of the wheelchair. (Photo taken) Observations on 6/7/17 at 9:30 AM in room 155 revealed, the resident's wheelchair remained in the bathroom. Observations on 6/7/17 at 10:30 AM in room 155 revealed, the resident's wheelchair remained in the bathroom. Interview on 6/7/17 at 10:37 AM with staff C, a Certified Nurse Assistant, (CNA) revealed, she was the CNA assigned to room 155. The CNA reported, the resident in room 155 used the toilet and that staff stores wheelchairs in the bathroom. She explained, wheelchairs are sometimes stored in the bathroom in an effort to provide residents with a clutter free environment. Interview on 6/8/17 at 11:06 AM with Staff B, a Charge Nurse, revealed the expectation was for the residents wheelchairs to be stored out of the resident's way. The Charge nurse confirmed, placing wheelchairs in the bathroom and in front of the toilet was a common practice. Interview with the Director of Nurses (DON) on 6/7/2017 at approximately 1:00 PM revealed, the facility did not have a policy on the storage of resident care equipment. Interview with the Administrator on 6/8/17 at 1:59 PM revealed, she had learned about the environmental concerns earlier that day. The Administrator agreed that wheelchairs should not be stored in bathrooms and reported she would immediately start working on a plan of correction.

Based on interview and record review, the facility failed to develop a care plan related to [MEDICAL CONDITION] for one (resident #83) out five residents sampled for medication regimen review out of nine residents whose care plans were reviewed. There were a total of 24 residents present in the facility at the time of this survey. The findings included: Record review of the medical facesheet for resident #83 revealed, the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of the physician's orders [REDACTED].#83 was prescribed by the physician 3 milligrams (mg) of [MEDICATION NAME], a hormone, to be given as a sleep aid once in the evening. Record review of the Psychiatric Evaluation and Treatment Consultation dated 05/23/2017 revealed, resident #83 was seen and examined by the psychiatrist. The resident's [DIAGNOSES REDACTED]. Record review of the Medication Administration Records (MARs) for the months of May 2017 and June 2017 revealed, resident #83 received 3 mg of [MEDICATION NAME] once an evening daily as a sleep aid. Record review of the medical record for resident #83 revealed, no care plan developed with goals or interventions for the resident's inability to sleep. Interview with the Licensed Practical Nurse (Staff A) on 06/07/2017 at 3:32 pm revealed, she worked with resident #83 during the 3 pm to 11 pm shift. She reported, the resident would sleep good during the night; sometimes he would get up around 6:30 am and ask for assistance to use the bathroom. She reported, at night the resident was given [MEDICATION NAME] as a sleep aid, and she monitored the medication to see if it was effective and the resident was sleeping peacefully. Interview with the Director of Nursing (DON) on 06/08/2017 at 11:17 am revealed, with regards to a care plan related to the [MEDICATION NAME] medication and resident #83's inability to sleep, this was something that could be implemented. Interview with the Minimum Data Set (MDS) Coordinator on 06/08/2017 at 11:41 pm revealed, she confirmed that there should be a care plan in place for resident #83's inability to sleep, and that she was going to develop one for the resident.

Based on interview and record review, the facility failed to complete the Pre-Admission Screen and Resident Review (PASRR) process for one (resident #22) out of twenty-two residents reviewed for Level I PASRR's. The facility did not ensure that a Level I PASRR was completed for the resident upon admission. The findings included: Record review of the medical facesheet revealed, resident #22 was admitted to the facility on [DATE]. Record review of the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 06/01/2016 revealed, resident #22 was transferred from the facility's independent living community. In the section for attached reports, there was no indication that the resident's Pre-Admission Screen and Resident Review (PASRR) form was completed. Record review of the medical record for resident #22 revealed, no completed Level I PASRR form. Interview with the Administrator on 06/06/2017 at 8:15 am revealed, they could not locate a Level I PASRR form for resident #22, and they would have to initiate a new one. The Administrator reported, Social Services was responsible for ensuring that the Level I PASRRs were in place upon admission. However, if the resident did not have one, then ultimately the Administrator would get involved.

Based on interview and record review, the facility failed to provide documentation to indicate adequate monitoring for the use of a medication ordered as a sleep aid for one (resident #83) out five sampled residents for medication regimen. The findings included: Record review of the medical facesheet for resident #83 revealed that the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of the physician's orders [REDACTED].#83 was prescribed by the physician 3 milligrams (mg) of [MEDICATION NAME], a hormone, to be given as a sleep aid once in the evening. Record review of the Medication Administration Records (MARs) for the months of May 2017 and June 2017 revealed, resident #83 received 3 mg of [MEDICATION NAME] once an evening daily as a sleep aid. There was no documentation on the MARs to indicate that the resident was monitored for the inability to sleep, or the effectiveness of the medication. Interview with the Psychiatrist on 06/07/2017 at 1:41 pm revealed, resident #83 was seen by him and even though the [MEDICATION NAME] was a benign medication, it still should be monitored as if it were a sedative. The psychiatrist reported, the nursing staff were good at monitoring residents for over-sedation. Record review of the Nurses' Notes for the months of May 2017 and June 2017 revealed, no notation in the notes to indicate resident #83 was monitored for [MEDICAL CONDITION], or the effectiveness of the [MEDICATION NAME] medication. Interview with the Licensed Practical Nurse (Staff A) on 06/07/2017 at 3:32 pm revealed, she worked with resident #83 during the 3 pm to 11 pm shift. She reported, the resident would sleep good during the night; sometimes he would get up around 6:30 am and ask for assistance to use the bathroom. She reported, night the resident was given [MEDICATION NAME] as a sleep aid, and she monitored the medication to see if it was effective and the resident was sleeping peacefully. Staff A reported, documentation of monitoring for the [MEDICATION NAME] medication was not done because it was not the process in the facility. They only monitored for antipsychotics, anxiolytics, and hypnotics. Staff A confirmed, since the medication was being used as a hypnotic it should be monitored as such. Interview with the Pharmacist Consultant on 06/08/2017 at 10:34 am revealed, with the [MEDICATION NAME] medication, nursing staff should document by exception. He reported, when he spoke to nursing staff about the medications given to residents, he was specific and more outcome-oriented; if the residents were eating well, sleeping well, etcetera. He said, he would talk to the Director of Nursing (DON) about implementing something where nursing staff documented if the medication was effective, and if resident #83 was sleeping well. Interview with the Director of Nursing (DON) on 06/08/2017 at 11:17 am revealed, if the [MEDICATION NAME] medication was not effective, they would document it, contact the physician and then possibly order a real hypnotic for the resident. The DON reported, documenting on the monitoring and effectiveness of the [MEDICATION NAME] medication was something the facility could implement.

Based on observation, interview and record review, the facility failed to implement an effective infection control program for a resident on contact precautions by not maintaining a personal protective equipment (PPE) cart outside the room and not having a sign on the door to check before entering the room for one (resident # 125) out of one residents reviewed for contact precautions during the time of the survey. The findings included: Record review of the face sheet for resident # 125 revealed, the resident was admitted on [DATE]. The [DIAGNOSES REDACTED]. Record review of the Physician Order Sheet (POS) for resident # 125 dated 5/24/2017 revealed [MEDICATION NAME] 250 mg(milligrams) / 5 ml(milliliters). Administer 2.5 ml which was 125 mg by mouth every 6 hours for 12 days. Given for[DIAGNOSES REDACTED]. Stop date was 06/05/2017. Record review of the Physician Order Sheet (POS) for resident # 125 dated 05/24/2017 revealed, maintain contact precautions every shift (Shift1, Shift2, Shift3) for [DIAGNOSES REDACTED]. Record review of the POS dated 06/5/2017 at 12:39 pm for resident # 125 revealed, discontinue contact precautions. Record review of the POS dated 06/5/2017 at 12:40 pm for resident # 125 revealed, discontinue [MEDICATION NAME] 250 mg / 5 ml, 125 mg was 2.5 ml orally. Record review of the nurse's notes dated 06/5/2017 at 11:45 am for resident # 125 revealed, Medical Director telephoned. Contact isolation and [MEDICATION NAME] discontinued per physician order for [REDACTED]. Note created by Director of Nursing (DON). Interview on 6/5/2017 at approximately 8:20 am during the tour with Staff B, Registered Nurse/Charge Nurse revealed, there was one resident currently on contact precautions and this was resident # 125 in room [ROOM NUMBER]. Observation on 6/5/2017 at 8:27 am of room [ROOM NUMBER] revealed, there was no stop sign or check with the nurse before entering on the door. The door was closed. There was no Personal Protective Equipment (PPE) cart in front of room [ROOM NUMBER]. A photo was taken for photographic evidence. Observation on 6/5/2017 at 12:11 pm revealed, the Certified Nursing Assistant (CNA) Staff Z walked into room [ROOM NUMBER] for resident # 125. Staff Z did not have personal protective equipment (gloves or gown) on before entering the room of a resident on contact precautions for[DIAGNOSES REDACTED]. Staff Z was carrying a regular covered food tray into the room. A personal protective equipment cart (PPE) cart was located to the right side inside the room of resident # 125. No personal protective equipment cart was outside of resident # 125 room and there was no check with nurse sign on the door of room [ROOM NUMBER]. Staff Z proceeded to walk towards resident # 125 and then the door was closed. Interview on 6/5/2017 at approximately 12:17 pm with the certified nursing assistant, Staff Z revealed, she explained that she entered the room of resident #125 and she donned on gloves after she had entered room [ROOM NUMBER]. Staff Z noted, she then set the regular tray on the bedside table for resident # 125 and donned on a gown in the room. Staff Z confirmed, she was aware that resident # 125 was on contact precautions. Staff Z explained, Usually for morning care I would gear up completely. Interview on 6/5/2017 at 1:58 pm with the wound care, a Registered Nurse revealed, the medical doctor of resident # 125 had told the resident she was cleared from[DIAGNOSES REDACTED] last week, but was waiting for the official clear from the medical director. The wound care nurse reported, in report today resident # 125 did not have any diarrhea symptoms. All we were doing was wearing gloves and washing hands and then donning gloves when in the room. She was cleared by the surgeon. Every single nurse and every single CNA knows that this resident is on contact precautions. The wound care nurse confirmed, there was no stop sign on the door,I did not see a stop sign on the door for room [ROOM NUMBER]. Interview on 6/7/2017 at 1:01 pm with the medical director revealed, if a resident was on contact precautions for[DIAGNOSES REDACTED] for example, then he would expect the cart with personal protective equipment to be outside of the door, someone going into the room would have easy access to this. The medical director stated, he had to defer the question regarding a sign on the door for a resident on contact precautions to the Director of Nursing. The medical director noted, Prior to entering a room, I would expect staff to don the personal protective equipment. The medical director confirmed, this would be an infection control concern if this was not done before. Interview on 06/7/2017 at 4:07 pm with the Director of Nursing (DON), Infection Control Registered Nurse revealed, if a resident was on contact precautions for[DIAGNOSES REDACTED] the facility would place the personal protective cart at the door way, so that staff can put on gloves and a gown if needed. The DON confirmed, staff would don the PPE before they entered the room. The DON explained, for a resident on contact precautions the staff would have received this information in report and then place a PPE cart in the room. A printed, sign on the outside of the door for a resident on contact precautions would be placed that read - please check with the nurse before entering. The DON said, resident # 125 never had diarrhea the entire admission, her [DIAGNOSES REDACTED].# 125 for[DIAGNOSES REDACTED], resident # 125 was on [MEDICATION NAME]. The DON said, resident # 125 went out to her surgeon last week. The DON explained, She had a verbal from the surgeon that she didn't need to be contact isolation, the contact order was not discontinued at that time, this came from the family, the surgeon was going to notify the medical director as per family. The DON stated, the medical director called her early this morning to discontinue the [MEDICATION NAME] and contact precautions. The DON explained, I told central supply staff to take down all the isolation for the resident in room [ROOM NUMBER]. The Director of Nursing agreed, staff needed to put on a gown or gloves before they enter the room for a resident on contact precautions, they should be accessible before you get into the room. The DON, infection control nurse confirmed that the Personal Protective Equipment was inside the room, near the door. The DON explained, It is accessible, grab it and put it on before you enter for a resident on contact precautions. Record review of the facility policy revised on June 2011 titled, Contact Isolation Precautions revealed, This describes the implementation of contact precautions. 1. The Director of Nursing (DON) or designee may initiate implementation of contact precautions when a resident exhibits the signs and symptoms of a transmittable infection. An order is obtained from a healthcare provider with prescriptive authority within 24 hours to continue the precautions. 3. Visitors must first see the nurse before entering the resident's room; sign will be placed outside the door to indicate the same. 4. Gloves are worn when entering the room and while providing care. 6. A gown is worn when entering the room if it is anticipated that clothing will have substantial contact with the resident, environmental surfaces or items in the resident's room.

Based on record review, observation and interview 1.) the facility failed to implement appropriate hand hygiene for 1 (resident # 126) out of 6 residents observed during medication administration and 2.) the facility failed to store employee food heating equipment appropriately for 1 laundry area (a microwave and toaster oven for employees located in the clean laundry area) out 1 laundry area observed during the time of this survey. This has the potential for cross contamination. The findings included: 1.) Record review of the face sheet for resident # 126 revealed that he was admitted on [DATE]. The [DIAGNOSES REDACTED]. Medication administration observation on 3/2/16 at 9:46 am with the wound care nurse revealed that she had pulled the oral medications for resident # 126 and placed them in a small cup. The wound care nurse entered the room for resident # 126 in 125 C. Resident # 126 was sitting in a chair. The wound care nurse gave the oral medications to resident # 126. The wound care nurse did not wash her hands when she entered the room of resident # 126. Resident # 126 had several question regarding his oral medications. Physical therapy then entered the room. The wound care nurse left the room of resident # 126 and did not wash her hands. There were infection control concerns noted that the wound care nurse did not wash her hands upon entrance and exit of resident # 126's room after the oral medication administration. Interview on 3/2/16 at approximately 10:00 am with the wound care nurse revealed that she stated that she washed her hands after the last resident which had received a breathing treatment and before she pulled the next medications for resident # 126. She noted that she was normally the wound care nurse. She said that the nurse for the floor called out today and she took over. The wound care nurse mentioned that physical therapy came in, was waiting for the resident # 126 and she was answering some questions for this resident, so she handed him the cup of medications. The wound care nurse stated that she had no physical contract with resident # 126 and their was no spilling. The wound care nurse stated that it was important to wash hands. The wound care nurse confirmed that she did not wash her hands when she entered the room of resident # 126 and also did not wash her hands after she left the room. Interview on 3/3/16 at 5:28 pm with the director of nursing (DON) revealed that a nurse giving medications needed to wash her hands when she entered the room, if the hands were soiled they needed to be washed right away and when the nurse left the room she should be washing her hands. Record Review of the facility policy dated 05/2007 revealed hand hygiene: This policy outlines the hand washing requirements for resident care employees. It is understood that hand washing is the single most important means of preventing the spread of infection. The hand washing of the facility policy did not specify in depth the hand hygiene that should be conducted by staff caring for residents. 2.) Observation on 3/3/16 at 3:25 pm with the director of housekeeping revealed that the clean laundry area had 3 dryers, a folding station and a pressing station. There was a employee microwave and toaster oven in the clean laundry area in the same room as the dryers. There was a shelf with clean linen nearby. Interview on 3/3/16 at 3:25 pm with the director of housekeeping revealed that she acknowledged that there was a microwave and toaster oven for employees in the clean laundry area. She stated that employees don't eat here, they heat their food and bring it to the break room. The director of housekeeping noted that the break room also had a microwave. Interview on 3/3/16 at 4:55 pm with the director of nursing (DON) revealed that she did not think that the toaster oven and microwave should be in the clean laundry room. The DON confirmed that the Clean side, should be separate from the food.

Based on observation, interview, and record review the facility failed to provide pain management interventions according to the resident's written plan of care for 1 (Resident #112) out of 1 resident sampled for pain management by not monitoring for pain management for multiple shifts on four (4) separate dates and not giving the proper pain medicine dosage, as ordered by the physician on one (1) day. The facility's actions of failing to provide Resident #112's pain medication according to the comprehensive care plan resulting in actual harm, as the resident experienced significant episodic pain. The findings include: Observation on 12/15/14 at 11:41 am revealed that Resident #112 was sitting in a recliner chair in her room, reading a magazine. She was grimacing in pain, restless and rubbing her left side. Interview with Resident #112 at this time revealed that she had hip replacement surgery and was experiencing pain on her left side. She further revealed that she received regular Tylenol but it did not help with the pain and she was told that the doctor did not order anything stronger. Review of Resident #112's care plan (written 12/13/14) revealed, "Problem: alteration in comfort as evidence by resident complaint of incisional pain status [REDACTED]." Interview with the Registered Nurse (RN) Charge Nurse on 12/17/14 at 12:43 pm revealed that the resident was to receive [MEDICATION NAME] (a mild pain reliever) 325mg tablet (tab) 2 tabs PO (by mouth) every 4 hours PRN (as needed) for mild pain, if the pain is rated 1-3 on a numerical pain scale of 0-10 (where the rating of 0 equals no pain and 10 is the worst pain) . The resident was to receive [MEDICATION NAME]-[MEDICATION NAME] (a stronger pain reliever) 300-30mg tab, 1 tab PO every 4 hours PRN, for moderate (4-6) to severe pain (7-10) on a pain scale of 0-10. Furthermore, she confirmed that the nurse should have given the resident the [MEDICATION NAME]-[MEDICATION NAME] on 12/12/14 at 8:39 pm when the pain was a 7 on a pain scale of 0-10. Interview with the Assistant Director of Nursing (ADON) on 12/18/14 at 9:25 am revealed that the resident was to receive [MEDICATION NAME] 325mg tab 2 tabs PO every 4 hours PRN for mild pain, if the pain is 1-3 on a pain scale of 0-10. The resident was to receive [MEDICATION NAME]-[MEDICATION NAME] 300-30mg tab 1 tab PO every 4 hours PRN for moderate (4-6) to severe pain (7-10) on a pain scale of 0-10. The ADON confirmed that the nurse gave the resident [MEDICATION NAME] 325mg tab on 12/12/14 at 8:39 pm when the pain was 7 on a pain scale of 0-10. The ADON further confirmed, the nurse should have administered [MEDICATION NAME]-[MEDICATION NAME] 300-30mg tab on 12/12/14 at 8:39 pm when the pain was 7 on a pain scale of 0-10". In addition, she stated that the pain assessment and documentation every shift was not done on the following days: 12/14/14 Shift 1, 2 & 3; 12/15/14 Shift 2 & 3; 12/16/14 Shift 1 & 3; and 12/17/14 Shift 1, 2 & 3. Refer to F309

Based on observation, interview, and record review the facility failed to provide interventions for pain management for one resident who had a medical condition (recent post hip surgery) in which pain was anticipated. This affected one resident (Resident #112) out of one sampled resident identified with pain concerns. Resident #112 was not monitored for pain management for multiple shifts on four (4) separate dates and not given the proper pain medicine dosage, as ordered by the physician on one (1) day. The facility failure to provide resident #112's pain medication resulted in actual harm, as the resident experienced significant episodic pain. The findings include: Record review revealed Resident #112 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 12/15/14 at 11:41 am revealed that Resident #112 was sitting in a recliner chair in her room, reading a magazine. She was grimacing in pain, restless and rubbing her left side. Interview with Resident #112, at this time, revealed that she had hip replacement surgery and was experiencing pain on her left side. She further revealed that she received regular Tylenol, but it did not help with the pain and she was told that the doctor did not order anything stronger. Record review for Resident #112 revealed the physician's orders [REDACTED]. 0-10; Pain assessment and documentation every shift; Shift 1 (7-3), Shift 2 (3-11), Shift 3 (11-7)." The 0 -10 pain scale indicates 0 = no pain and 10 = the most severe pain. Review of the Medication Administration Record [REDACTED]. It also showed that pain assessment and documentation every shift was not done on the following days: 12/14/14 Shift 1, 2 & 3; 12/15/14 Shift 2 & 3; 12/16/14 Shift 1 & 3; 12/17/14 Shift 1, 2 & 3. Review of the Comprehensive Care Plan for Resident #112 related to pain management revealed the following: "Resident is at risk for alteration in comfort as evidence by resident complaint of incisional pain status [REDACTED]." Interview with the Registered Nurse (RN) Charge Nurse on 12/17/14 at 12:43 pm revealed that the resident was to receive [MEDICATION NAME] (a mild pain reliever) 325mg tablet (tab) 2 tabs PO (by mouth) every 4 hours PRN (as needed) for mild pain, if the pain is rated 1-3 on a numerical pain scale of 0-10 (where the rating of 0 equals no pain and 10 is the worst pain) . The resident was to receive [MEDICATION NAME]-[MEDICATION NAME] (a stronger pain reliever) 300-30mg tab, 1 tab PO every 4 hours PRN, for moderate (4-6) to severe pain (7-10) on a pain scale of 0-10. Furthermore, she confirmed that the nurse should have given the resident the [MEDICATION NAME]-[MEDICATION NAME] on 12/12/14 at 8:39 pm when the pain was a 7 on a pain scale of 0-10. Interview with the Assistant Director of Nursing (ADON) on 12/18/14 at 9:25 am revealed that the resident was to receive [MEDICATION NAME] 325mg tab 2 tabs PO every 4 hours PRN for mild pain, if the pain is 1-3 on a pain scale of 0-10. The resident was to receive [MEDICATION NAME]-[MEDICATION NAME] 300-30mg tab 1 tab PO every 4 hours PRN for moderate (4-6) to severe pain (7-10) on a pain scale of 0-10. The ADON confirmed that the nurse gave the resident [MEDICATION NAME] 325mg tab on 12/12/14 at 8:39 pm when the pain was 7 on a pain scale of 0-10. The ADON further confirmed, the nurse should have administered [MEDICATION NAME]-[MEDICATION NAME] 300-30mg tab on 12/12/14 at 8:39 pm when the pain was 7 on a pain scale of 0-10". In addition, she stated that the pain assessment and documentation every shift was not done on the following days: 12/14/14 Shift 1, 2 & 3; 12/15/14 Shift 2 & 3; 12/16/14 Shift 1 & 3; and 12/17/14 Shift 1, 2 & 3. Review of the medication administration protocol policy and procedure (written November 2011) revealed to "verify the physician's orders [REDACTED]. Refer to F282