Every finding on record at Village on the Green

Based on observation, interview, and record review, the facility failed to preserve the residents' dignity by serving half of the residents at the table over 20 minutes before the other half on one occasion, and by serving the residents' meals on serving trays at the table the next day, for all residents who ate meals in the main dining room at two different meals, for one of one dining room in the facility.Findings: On 6/29/26 at 12:06 PM, in the main dining room, Certified Nursing Assistant (CNA) C brought a lunch cart out and served meals to three residents seated at a long group table. On 6/29/26 at 12:25 PM, almost twenty minutes later, a second cart arrived at the dining room, and the CNA served the other residents seated at the same table. The initial three residents that were served first had been eating their meals and were more than halfway finished with them. The other residents seated at the table without meals, watched them eat. The last resident received her food at 12:29 PM. On 6/30/26 at 12:25 PM, CNA B received the first lunch cart in the main dining room. The second cart arrived at 12:28 PM, and she started delivering the meals by placing a tray down in front of each resident without taking the food or drinks off. On 6/30/26 at 12:35 PM, CNA B remarked sometimes she served the residents' food on the trays, especially if the table was not set with placemats. She wasn't sure why the placemats were not on the table. She acknowledged she had been educated to take the food off of the trays. On 6/30/26 at 12:50 PM, the Administrator was in the main dining room and noted the CNA served the food plates on the trays. She instructed the CNA she should take the dishes off the resident's trays. The Administrator explained dietary staff did not set the tables, and it was the responsibility of the CNA in charge of the dining room to put out the placemats to create a more homelike dining environment. On 7/01/26 at 11:50 AM, CNA C explained staff should take the food off the trays during meal service because residents should feel like they were at home, and if the food was left on the trays it would look like high school. On 7/01/26 at 12:15 PM, the Assistant Director of Nursing (ADON) commented if her mom had to sit and watch other people eat for 20 minutes because she hadn't received her food yet, she would question why; she would wonder where her mother's food was. The ADON remarked staff should know to ensure all meals were served to residents at the same time. In interviews on 7/01/26 at 12:20 PM, and at 1:30 PM, the Administrator remarked there were no residents with care plans that specified their meals should be served on a tray. The Administrator acknowledged the reason staff should not serve meals on the trays was because it was a dignity issue. She said it should feel like their home, not like they were in high school. Review of the facility's Resident Meal Service Policy, revised January 2025, revealed independence and dignity was encouraged by respecting each individual, in an environment that was as home-like as possible. The policy indicated food would only be served on trays in the dining room by resident request or per their care plan. The document detailed the facility offered a traditional dining service and would serve all residents at one table together.

Based on observation, interview, and record review, the facility failed to ensure a resident was assessed to self-administer oral medication for 1 of 1 resident reviewed for self-administration of medication, of a total sample of 24 residents, (#11).Findings: Resident #11 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, unspecified head injury, and dementia.On 6/30/26 at 9:15 AM, resident #11 was sitting in bed watching television. She had a container of a nutritional shake in her left hand and a small cup containing five pills in her right hand. She stated the nurse gave her the cup of medications and left the room. A few minutes later, the Director of Nursing (DON) entered the room and confirmed resident #11 had a cup with five pills left by the nurse. She stated the nurse should not have left the room until she verified the resident had taken all her medications.On 6/30/26 at 9:25 AM, Licensed Practical Nurse A (LPN) stated the nurse should stay with the resident until they take all their medications. She stated resident #11 asked her to fix the curtain at the window and she thought she took the pills. LPN A did not say if the resident was assessed to self-administer her medications. Review of the Order Summary Report dated 7/01/26, revealed all active physician orders. There was no order to assess the resident for self-administration of medications.Review of the most recent Care Plans dated 6/16/26 to 6/19/26, revealed resident #11 had no plan of care for self-administration of medications. Her baseline care plans dated 6/16/26 revealed a plan under medications which revealed, self-administer medications answered as No. Resident #11 had a cognition care plan, which indicated she was alert but cognitively impaired.Review of the General Dose Preparation and Medication Administration policy dated 12/01/07, last revised 11/15/24 indicated for nurses to observe the resident's consumption of the medication(s).

Based on observation, interview, and record review, the facility failed to ensure an intravenous (IV) dressing was changed as ordered for 1 of 1 residents reviewed for IV therapy, of a total sample of 27 residents, (#45). Findings: Resident #45 was admitted to the facility on [DATE] with diagnoses including infection following a procedure, superficial incisional surgical site. A care plan for IV Medication use was initiated on 3/10/25. The care plan indicated resident #45 received IV antibiotics status post exploratory surgery and drained abscess to surgical site mid lower back. Interventions included to observe IV site for possible signs/symptoms of infection or infiltrate and peripherally inserted central catheter (PICC) line care and flush as ordered. A PICC line is a long, thin tube inserted into a vein usually in your arm and passed through larger veins near your heart to give access to the larger veins for some types of medication or nutrition. A PICC line requires careful care and monitoring for complications, including infection and blood clots, (retrieved on 4/01/25 from www.mayoclinic.org). Review of resident #45's electronic medical record (EMR) revealed a physician order dated 3/14/25 which instructed licensed nurses to change injection caps weekly with PICC line dressing change every day shift every Friday for PICC line dressing. The order was cancelled 3/14/25 and another order entered to start on 3/22/25. The new order instructed licensed nurses to change injection caps weekly with PICC line dressing change every day shift, every Friday for PICC line dressing. Review of resident #45's EMR revealed a progress note dated 3/12/25 entered by Licensed Practical Nurse A which read, PICC line dressing changed. Review of the Treatment Administration Record (TAR) for March 2025 revealed documentation the IV dressing was changed on 3/14/25 by Registered Nurse B. On 3/17/25 at 10:38 AM, resident #45 was observed in bed. An IV medication bag was hanging from the IV pole. The IV site was covered with a transparent bandage with a white gauze pad underneath. The IV dressing was dated for 3/12/25. On 3/18/25 at 3:10 PM, resident #87 was observed in a wheelchair next to the bed. Transparent IV dressing with a gauze pad underneath remained in place, dated 3/12/25. On 3/18/25 at 3:20 PM, the Director of Nursing (DON) observed the transparent IV dressing applied to resident #87's right arm. She acknowledged the date on the dressing was 3/12/25. She verified there was a gauze dressing under the clear dressing which should have been changed within 24 hours. The DON stated the dressing should have been changed since 3/12/25. The DON was made aware of documentation for dressing change on 3/12/25 and of another nurse documenting dressing change on 3/14/25. She acknowledged the dressing obviously had been changed on 3/12/25. The facility's policy and procedure for Central Venous Catheter Care and Dressing Changes indicated the IV dressing should be changed at least every two days for sterile gauze dressing including gauze under a transparent semi-permeable membrane dressing.

Based on observation, interview, and record review, the facility failed to maintain oxygen flow rates as ordered by the physician for 1 of 1 residents reviewed for respiratory care, of a total sample of 27 residents, (#657). Findings: Review of the medical record revealed resident #657 was admitted to the facility on [DATE] from the hospital. His diagnoses included sepsis, pneumonia, acute respiratory failure with hypoxia, congestive heart failure, type 2 diabetes mellitus, and hypertension. Resident #657's Order Summary Report showed an active physician's order for oxygen at 2 liters per minute (LPM) via nasal cannula. The medical record also revealed a care plan intervention initiated on 3/17/25 that indicated the resident's oxygen settings should be administered via nasal cannula per physician orders. On 3/17/25 at 12:28 PM, resident #657 was observed in bed, being administered humidified oxygen through a nasal cannula connected to an oxygen concentrator. The concentrator's flow rate was set at 3 LPM. On 3/18/25 at 9:29 AM, resident #657 was in bed with the nasal cannula connected to an oxygen concentrator with his daughter at bedside. The concentrator's flow rate of oxygen was observed at 3 LPM and both resident #657 and his daughter stated they had not adjusted the flow rate on the oxygen concentrator. On 3/19/25 at 9:26 AM, the assigned nurse who was the Assistant Director of Nursing (ADON) verified the amount of oxygen shown on the concentrator with a flashlight from her phone, took photographic evidence and then stated it was set at 3 LPM of oxygen. She immediately went to her computer to verify the physician's order and confirmed the order was for 2 LPM of oxygen and not 3 LPM. The ADON explained she would notify the doctor. At that time the Director of Nursing (DON) passed by and stated she would verify the amount on the concentrator, just to be sure. The Facility's Policy for Oxygen Administration revised October 2010 showed that staff were to review the physician's orders for oxygen administration in preparation for administration.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and maintain a secure environment to ensure vulnerable residents did not exit the facility without supervision, for 1 of 8 residents reviewed for elopement risk, out of a total sample of 8 residents, (#1). On 1/25/25 at approximately 6:20 AM, the facility failed to prevent a cognitively impaired resident from exiting the facility unsupervised. Resident #1 exited the building without knowledge of staff through an exit door at the end of the Royal Court Hall, which led to the back parking lot. The door did not have a delayed egress bar and the alarm on the door was not loud enough for staff to hear. Licensed Practical Nurse (LPN) A stated the alarm was not heard by anyone working that morning. Resident #1 left the facility wearing only a gown, no shoes, socks or undergarments in cold January weather. She was found approximately 20 feet from the exit door, lying in the grass under a light blanket approximately 25 minutes later at 6:45 AM, when a staff member arrived for work. Facility staff were unaware of resident #1's whereabouts until the staff member brought her back inside and notified the nurse. The facility failed to ensure resident #1 was adequately supervised and failed to ensure all exit doors were secure to ensure vulnerable residents did not exit the facility without staff knowledge. The facility's failure to ensure adequate supervision and maintain a secure environment put all residents who wandered at risk and resulted in Immediate Jeopardy. The facility's Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on 3/11/25 at 1:00 PM, and provided with the Immediate Jeopardy Template. Immediate Jeopardy was determined to begin on 1/25/25 and be removed on 1/29/25 after verification of the immediate actions implemented by the facility. The scope and severity of the deficiencies were decreased to a D, no actual harm with a potential for more than minimal harm, that is not Immediate Jeopardy. Substandard Quality of Care was identified at F689. An extended survey was conducted on 3/12/25. The census at the start of the survey was 47. Findings: Resident #1 was admitted to the facility on [DATE] with diagnoses that included acute bronchitis, interstitial pulmonary (lung) disease, difficulty walking, anxiety, insomnia, dementia, muscle weakness, heart failure, depression, hydrocephalus (fluid on the brain), and hypothyroidism. The Minimum Data Set (MDS) Medicare 5-day assessment with an assessment reference date of 1/28/25 revealed resident #1 had a Brief Interview for Mental Status score of 05/15 which indicated severe cognitive impairment. Resident #1 had a care plan initiated on 1/23/25 for risk for falls and injuries related to weakness, poor endurance, prescribed medications, need for assistance with transfers, and diagnosis of dementia. The only intervention was for physical therapy to evaluate and treat as ordered or as needed. She had no other care plans related to wandering, dementia or elopement risk. The Elopement Evaluation completed upon admission, 1/22/25, scored the resident a 0 which indicated she was not a risk for elopement. The evaluation section incorrectly answered,Does the resident wander? as a No, which would have scored the resident a value of 1 and indicated she was a risk for elopement. The evaluation listed foci for staff to initiate if the resident scored 1 or higher and the risk for wandering or elopement was identified which included the goal that resident did not leave the facility unattended and interventions to engage resident in purposeful activity, identify times when wandering occurs and schedule time for regular walks/appropriate activity. The evaluation did not include if family were interviewed for information used in the assessment, and there was no accompanying documentation to show resident #1's family was asked if she had a history of wandering . In a telephone interview on 3/10/25 at 9:13 AM, resident #1's daughter stated before her mother was admitted to the facility someone called and asked her if her mother had ever left the facility where she lived unattended. She recalled she told them no, she had never left the facility, but her mother frequently wandered around the building as she had dementia. Resident #1's daughter said she was told her they could care for her mother with dementia at the facility, but no one from the facility ever asked her if her mother wandered or attempted to leave once she was admitted to the facility. She recalled that sometime during the two days prior to her mother leaving the facility someone from the facility had called her to say her mother was walking around in the halls and she told them her mother frequently wandered but had not tried to leave before. She recalled the facility called her again the next day to report her mother had gone out of the building alone. The daughter said, I was very concerned because she was outside, lying in the grass and it was during that little cold snap that we had. Review of a therapy note documented by Physical Therapy Assistant C on 1/23/25 revealed on admission resident was disoriented to person, place, time and situation which per family was her baseline cognition. The therapy assistant noted resident #1 required minimal assist in completing bed mobility activity tasks but was reeducated regarding safety issues to be observed at all times due to poor safety technique related to her cognitive status. Review of a therapy note documented by Physical Therapy Assistant C on 1/24/25 at 2:59 PM, that read, . Therapist engaged with a conversation with patient (pt.) about participating with therapy. Pt. stated she is living [leaving] this place and trying to get out of here. Pt. became combative, pulling the cover and stated she's going to make a call. Therapist exited the room shortly after. There was no documentation in the record this was reported to the nurse or any other nursing staff. In a telephone conversation on 3/09/25 at 3:35 PM, and an in-person interview on 3/11/25 at 9:45 AM, Certified Nursing Assistant (CNA) B stated it was dark and cold that Saturday morning, 1/25/25. She remembered she first noticed the blanket on the ground when she pulled up to the back parking lot in her car for work. She explained when she got out of her car for her day shift at the facility and approached the item on the ground, she saw a pair of bare feet sticking out from what looked like a pile of towels on the grass. She explained when she got closer she realized it was a resident under a light blanket on the ground between the light post and some poles. CNA B said she lifted the blanket, and the resident immediately looked at her. She said she did not recognize her but the resident was lying in a fetal position under the blanket. She asked resident #1 what her name was but she was not able to tell her or was she able to say how long she was outside in the cold or how she had gotten out there. CNA B explained she assisted the resident up to her feet but the resident could not walk very well so she sat her in a wheelchair that was parked outside the therapy door. CNA B recalled the resident's feet were cold so she grabbed a pair of socks off a nearby cart, put them on the resident and then took her to the nurse on Royal Court. She said the nurse was not aware that resident #1 was outside the building alone. CNA B said a little while later the Administrator and called her on the phone, to ask about the details of the incident. The temperature on 1/25/25 at 6:00 AM, was approximately 39 degrees Fahrenheit (F), and sunrise was at 7:16 AM, (retrieved on 3/11/25 from www.timeanddate.com). Hypothermia (low body temperature) occurs when your body's temperature drops below 95 degrees F and your brain and body can't function properly. If left untreated it can lead to cardiac arrest and death. Most cases of hypothermia occur at very cold temperatures under 40 degrees F, but environmental conditions such as wetness can cause a person's body to lose more heat than it can generate. Older adults are more at risk for hypothermia due to less body fat and less control of body temperature self regulation (retrieved on 3/24/25 from www.my.clevelandclinic.org). On 3/09/25 at 2:15 PM, Registered Nurse (RN) D stated the door resident #1 exited from did have an alarm and demonstrated how the alarm sounded when the door was opened. She explained the alarm sounded when the door opened but stopped alarming as soon as the door closed. The alarm at the Royal Court back door was audible, but not loud, and at that time the DON was the only staff to respond to the sound. RN D stated all staff were supposed to go to the alarm as soon as it was heard. On 3/09/25 at 5:15 PM, in a telephone interview LPN A stated she took care of resident #1 the night she eloped. She stated when she received report from the off-going day shift nurse, she was not told that the resident was an elopement risk. She said she was told the resident needed assistance with ambulation, otherwise she would have put a wander alarm on the resident. The LPN recalled she was in the hall outside the resident's room that morning sometime after 6:00 AM, when she heard resident #1 saying hello, hello? The nurse said she went into the resident's room to see what she needed and the resident asked her where she was, why she was there and when could she get up. The nurse said she told the resident that she was there for physical therapy, and she could get up in an hour or two. The LPN said resident #1 told her okay and said that she was going back to sleep. LPN A stated she turned on the bathroom light and left her door cracked open. LPN A explained the exit doors had alarms, but she did not hear the alarm when the door opened and resident #1 went outside. She stated the alarms were not loud, it was a faint sound and only rang while the door was open. LPN A described the alarm stopped when the door closed. She said, I do not know how resident #1 walked from her room to the door, and no one saw her. LPN A explained at that time in the morning, the CNAs and nurses were busy in the halls doing rounds. She said she was not aware that resident #1 left the building until the CNA brought her back inside. LPN A recalled when the CNA brought resident #1 back into the facility, she did a head-to-toe assessment including neurological checks and vital signs and found no injuries. She remembered the resident's gown was damp on the side where she was lying in the grass, and they changed her into dry clothes. She said she called the physician, the resident's daughter and the DON to inform them of what happened. In interviews on 3/09/25 at 4:20 PM, and 3/10/25 at 10:45 AM, the Administrator and Director of Nursing (DON), stated the elopement happened at shift change. The DON said the nurse saw resident #1 at approximately 6:20 AM in bed. The Administrator added the CNA found her at approximately 6:45 AM outside in the back and brought her back inside. They both expressed they thought resident #1 fell off the sidewalk on to the grass. The DON explained resident #1 had only been here a few days before the elopement and if she would have had a electronic wander bracelet the door alarm would have been very loud. They acknowledged the door alarm was not loud without the electronic wander bracelet present and that the door resident #1 left from could be easily opened by pushing on it as it did not have a delay to open. The Administrator and DON stated they had workers at the facility last week to put egress push bars on all of the exit doors to prevent a confused resident to be able to push the door open easily. The Administrator added that resident #1 was only in the facility for a couple of days when it happened, and she had not been assessed an elopement risk upon admission. They did not explain why resident #1 was not assessed an elopement risk if she was confused and known to frequently wander per her daughter. The Administrator acknowledged the nurse's statement read she did not believe the resident had fallen but based on her physical therapy evaluation, and the way the grass was where she was found, they confirmed it was possible she fell into the grass. On 3/10/25 at 12:00 PM, the Director of Rehabilitation stated resident #1 had her initial evaluation with therapy on 1/23/25. He summarized her therapy care as needing minimum assistance for transfer and she was able to walk 15 feet with a walker with minimum assistance per Physical Therapy (PT) evaluation. The Director of Rehabilitation indicated on 1/24/25 the PT assistant noted the resident was combative and pulled the covers over her head until the therapist left. The Director of Rehabilitation did not say whether nursing staff were notified of resident #1's behaviors on 1/24/25. He continued that on 1/25/25, after the incident, Occupational Therapy indicated resident #1 needed minimal assistance to get out of bed or for toileting and on 1/27/25 PT assessed she could walk over 100 feet with her walker, but needed to be redirected multiple times. On 3/10/25 at 2:30 PM, the DON stated there were no working cameras in the area where resident #1 eloped. On 3/12/25 at 10:30 AM, the Medical Director (MD) stated he was informed of the elopement the morning it happened. He said he was surprised resident #1 could walk that far because she had not walked that far prior to the incident. The Medical Director said the facility had an ad hoc Quality Improvement meeting the Monday morning after the incident and discussed what needed to be done to prevent future elopements. He stated we reviewed everything again on 1/31/25, which was our regular meeting. The Medical Director stated he spoke with the Administrator last night to see how things were going with education of staff and the new doors the facility was installing. He felt new doors would help prevent residents from leaving the facility unsupervised in the future. Review of the policy and procedure, Elopement, Unsupervised Absence, Hazardous Wandering and Missing Residents revised 2/18/20, revealed an elopement occurred when a resident receiving health care exited the Health Center, licensed healthcare provider or exited the community's property and was no longer under the supervision or line-of-sight of a team member, volunteer or family member. Review of the Facility Assessment Tool revealed the facility accepted and could provide care for residents with Psychiatric/Mood disorders to include impaired cognition, anxiety disorder, behavior that needs interventions, behavioral and psychological symptoms of dementia. Review of corrective measures to remove Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *Resident #1 is not a current resident in the community. *On 1/25/25 at 6:45 AM resident #1 was brought back to the room and assessed by Licensed Nurse - no injuries or changes in condition noted. Physician and family were notified on 1/25/25 by Licensed Nurse and DON. *On 1/25/25 DON/Designee completed full head count in Health Center - no other residents were unaccounted for. *On 1/25/25 DON/Designee reviewed plan of care interventions, completed Elopement Risk Assessment and implemented interventions for resident now At Risk for Elopement - Electronic wander bracelet order obtained and applied, resident added to Community Elopement Book, resident #1 placed on 1:1 supervision until she was discharged (planned) on 1/28/2025 to community. *On 1/25/25 all residents' records were reviewed for Risk of Elopement by Administrator and DON - no other residents were identified for risk of elopement. MD notified of the audit - no further orders or modifications to plan of care. *On 1/25/25 all exit doors in Health Center were checked by Plant Operations Director for functioning - no Maintenance concerns noted. *On 1/25/25 Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was completed with Administrator, Director of Nursing, and Medical Director. A Plan of Correction was initiated. *On 1/25/25 Administrator initiated investigation and in-services for nursing staff on resident interventions and elopement prevention policy. Nursing Staff education was completed on for regular staff on 1/25/25 (8 out of 34 CNAs/Nurses), 1/27/25 (3 out of 34 CNAs/Nurses) 1/29/25 (10 out of 34 CNAs/Nurses) and ongoing. Education Topics included Elopement Policy and Procedures, Elopement Assessment and Family Notification. *On 1/27/25 an elopement Drill was conducted by Administrator at the Health Center to include Director of Nursing, ADON, Social Service Director, Director of Therapy, RNs, LPNs, CNAs, MDS Coordinator, Admission Assistant, Environmental Service Lead, Therapy Director, Admission Director and Maintenance Lead. *On 1/27/24 all doors were noted with a functioning audible alarm. *On Ad Hoc 1/27/25 QAPI Meeting was held with Interdisciplinary Team including Administrator, DON, MDS Coordinator, Therapy Director, Lifestyles Director, Maintenance, Social Worker, Medical Records, to review the alleged deficiencies, policy and procedure, and plan of correction. *On 1/27/25 Director of Nursing or designee monitor compliance daily (Monday through Friday) and Administrator/DON (Saturday and Sunday) by checking new admissions records for Elopement Risk and appropriate interventions. The facility presented additional information on corrective actions which were verified by the survey team and included the following: *All new admission records are reviewed daily for Elopement Risk. Any residents noted at risk; interventions are in place. *On 1/31/25 monthly QAPI Meeting was held with Administrator, DON, Medical Director, Social Service Director, MDS, Therapy Director, Registered Dietician, Environmental Services, and Health Information Practitioner and reviewed the alleged deficiencies, policy and procedure, and plan of correction. Audit findings were reviewed at the monthly QAPI Meeting. Reviewed new doors with delayed egress with team. *In-services were provided by Administrator/Designee all team members on the facility Elopement Policy and Procedures, Elopement Screening Tool and Notification of family. In-services were provided on 2/05/25, 2/12/25, 2/26/2012, 3/04/25, 3/05/25, 3/07/2025. Education will be continued to ensure compliance. Any team member who has not received education will be provided with education prior to reporting to work. All New hires will receive education. *On 2/21/25 monthly QAPI Meeting held Administrator, DON, Medical Director, MDS, Therapy Director, Registered Dietician, ADON, Environmental Services, Lifestyles Director and Health Information Practitioner and reviewed the alleged deficiencies, policy and procedure, and plan of correction. Audit findings were reviewed at the monthly QAPI Meeting. No areas noted out of compliance. Reviewed new doors with delayed egress, plan and specifications for doors have been submitted to county for permitting. *On 3/05/2025 on 7:00 AM-3:00 PM & 3:00 PM-11:00 PM elopement Drill with CNAs and Nurses was conducted by the Administrator at the Health Center. Monthly Elopement Drills will be continued to ensure compliance. *The Administrator/Designee will continue to monitor compliance by completing a random audit of three residents twice per week monthly for the next three months, checking residents medical records for elopement risk and appropriate interventions. Audits were initiated on 1/29/25 and audits will be continued to ensure compliance. *The Executive Director provided oversight of the Administrator to ensure that the items on the plan of removal were reviewed and completed. Interviews were conducted from 3/09/25 to 3/12/25 with 29 staff members (18 CNAs representing all shifts, 9 nurses representing all shifts, 1 therapist, and 1 dietary staff). Staff interviews revealed they were knowledgeable of the elopement policy and procedures, appropriate response to alarms and supervision of all residents to include those at risk for elopement. The resident sample was expanded during the survey to include five additional residents at risk for elopement. Observations, interviews, and record reviews conducted revealed no concerns related to elopement risk evaluations, care plans and physician orders for residents #2, #3, #4, #5, and #6.

Based on observation, interview, and record review, the facility failed to ensure individual activities and interests significant to support well-being were provided for 1 of 1 resident reviewed for Activities from a total sample of 27 residents, (#37). Findings: A review of the medical record revealed resident #37, an [AGE] year old female was admitted to the facility on [DATE] from an acute care hospital with diagnoses that included fracture of sacrum (tailbone), leukemia, sepsis (blood stream infection), hemiplegia (one-sided paralysis), difficulty in walking, need for assistance with personal care, lack of coordination, weakness, and malnutrition. The Minimum Data Set (MDS) Admission 5-day assessment with Assessment Reference Date 12/29/23 identified a Brief Interview for Mental Status (BIMS) score of 14 out of 15 that indicated the resident was cognitively intact. Functional Abilities and Goals of everyday activities showed the resident required substantial/maximum assistance from staff to complete Activities of Daily Living (ADLs) and mobility functions in and out of bed. The assessment noted it was important to the resident to be able to listen to music she liked, keep up with the news, and do her favorite activities. The Lifestyles Evaluation for Activity Interests and Preferences and Activity Assessment Evaluation dated 12/31/23 indicated the resident preferred to spend her leisure time on individual pursuits and practices, had a strong preference for specific music, an [NAME], and she was formerly a [NAME] and ballroom [NAME]. The Comprehensive Care Plan Focus' noted the resident was dependent on staff to complete ADLs related to physical limitations including weakness, and impaired mobility, with a sacral fracture and history of cerebral vascular accident (stroke). The plan of care did not include a focus for individualized activities for psychosocial and mental well-being support. On 1/16/24 at 11:48 AM, and 1/17/24 at 9:18 AM, resident #37 was observed sitting in a wheelchair beside her bed. The television (TV) was turned off and the remote control was observed on a table directly under the TV on the wall, approximately 8 feet away from the resident's bedside table in her close proximity. Review of resident #37's January 2023 Task List Report for Certified Nursing Assistants (CNAs) use included intellectual, social, physical, and other visit or service Life Enrichment tasks. The schedule showed over eighteen days, one CNA marked the tasked items were offered. On 1/18/24 at 10:04 AM, resident #37 was observed in her room lying in bed. She explained she enjoyed watching ballroom dancing music programs on the TV, and she was familiar with available stations she could access to watch them. The remote control was on the table directly under the TV on the wall in the same location as previously observed. The resident said she would like to watch TV; however, she did not have the remote. In an interview on 1/18/24 at 10:30 AM, the Lifestyle Supervisor said she was responsible for creating and implementing residents' individualized activities program. She explained, an evaluation was completed within a few days after a resident was admitted to the facility that included finding out what types of individual or group activities the resident enjoyed, even if their preference was to stay in their room. She said residents who enjoyed music were offered access through the facility's TV music channels, and staff noted what was offered and the resident's participation status on monthly paper logs. Review of resident #37's Daily Activities Attendance record dated January 2024 included item lines for TV and music. The record did not include any entries to note staff had offered the resident music or TV. During a joint observation with the Lifestyle Supervisor on 1/18/24 at 11:30 AM, resident #37's TV remote control was observed in the same previously observed location on a table under the TV. The Lifestyle Supervisor stated the resident knew how to use it, and acknowledged the remote was not, but should have been within the resident's reach. The resident replied, yes after she asked her if she would like to listen to music on the TV. She attempted to turn the TV on, and found the remote control was broken or malfunctioned. On 1/18/24 at 11:30 AM, the Lifestyle Supervisor checked the medical record and acknowledged resident #37's Comprehensive Care Plan was missing a Focus for activities and mental and psychosocial well-being support. She stated it was important that residents were offered and had access to their preferred activities because they could become bored and depressed which affected overall health. She added, residents need activities as, joy helps with recovery, even TV. On 1/18/24 at 11:46 AM, the MDS Coordinator checked the medical record and said resident #37's Comprehensive Care Plan was signed off as completed on 1/10/24. She explained, the Lifestyle and Activities Focus was not included, should have been part of the plan of care, and must have been missed in error. The facility's standards and guidelines titled Health Center Lifestyle Department and Programs dated 5/15/18 read, The purpose of this policy is to . ensure person-centered care and purposeful programming that meets the individual needs of each resident are provided . 10. Competent Lifestyle department team members will provide person-centered care through planning, implementing, and documenting all Lifestyle programs that meet the individual needs of each resident . The facility's Quality Assurance and Improvement plan read, Scope: The scope of the QAPI program encompasses all segments of care and services provided by (facility name) that impact clinical care, quality of care, quality of life, resident choices, and care transitions with participation from all departments. Lifestyle We provide enriching and stimulating activities to every resident .

Based on interview and record review, the facility failed to provide written Notice of Transfer or Discharge forms to the resident or their representative for 3 of 4 residents reviewed for hospitalization s out of a total sample of 27 residents, (#41, #154 and #303). Findings: 1. Resident #303 was admitted to the facility on [DATE] with diagnoses that included cancer to the urinary organs and bones, and neuromuscular dysfunction of the bladder. Review of resident #303's medical record revealed he was emergently hospitalized on [DATE]. A nurse's eInteract SBAR Summary for Providers dated 12/29/23 described the Advanced Practice Registered Nurse advised the nurse to call 911 due to bleeding from his genital organ. The medical record did not contain a written Notice of Transfer or Discharge form for the hospitalization . The resident returned from the hospital on 01/04/2024. On 1/18/24 at 3:16 PM, the Administrator confirmed they were unable to provide the form for resident #303's hospitalization on [DATE]. Review of the facility's Transfer or Discharge Notice Policy revised December 2016 read, The resident and/or representative will be notified in writing the reason for the transfer or discharge, the effective date of the transfer or discharge, the location to which the resident is being transferred or discharged , the facility bed hold policy . 45646 2. Resident #41 was admitted to the facility on [DATE] with diagnoses including interstitial pulmonary disease, anemia, hypertension, hyperlipidemia, hypothyroidism, atherosclerotic heart disease and benign prostatic hyperplasia. Review of resident #41's medical record revealed he was hospitalized on [DATE] due to abnormal laboratory results. The medical record did not contain a Notice of Transfer or Discharge form for the hospitalization . The resident returned from the hospital on 11/01/2023. 3. Resident #154 was admitted to the facility on [DATE] with diagnoses including nondisplaced fracture of right femur, unspecified dementia, chronic obstructive pulmonary disease and Alzheimer's disease Review of resident #154's medical record revealed she was hospitalized on [DATE] due to an unwitnessed fall and resident complaining of right hip pain. The medical record did not contain a Notice of Transfer or Discharge forms for the hospitalization . The resident returned from the hospital on 01/13/2024. On 1/18/24 at 2:02 PM, the Social Services Director (SSD) stated the nurse was responsible for completing the Notice of Transfer and Discharge Forms for residents who transferred to the hospital. She explained the forms then went to Medical Records. The SSD clarified she notified the Ombudsman of the hospital transfer monthly. On 1/18/24 at 3:16 PM, the Administrator stated she was aware the Notice of Transfer or Discharge forms were not being completed for all hospital transfers. She recalled the Medical Records Director discussed the issue in their Quality Assurance (QA) meeting on 1/14/23. The Administrator stated they had an audit and planned to address the issue but had not been able to do so. On 1/18/24 at 3:33 PM, the Medical Records Director verified she audited the transfer and discharge process to ensure the required paperwork was completed. She confirmed she identified the Notice of Transfer and Discharge forms were not being completed consistently. She stated she brought the issue to the QA Committee. The Medical Records Director reviewed the audit sheet provided by the Administrator and stated she was familiar with the form. She clarified she had been using the form since she was hired in October 2022 to audit charts. The Medical Records Director explained she reported the incomplete Notice of Transfer and Discharge forms every month in QA Meeting. She stated this was an on-going issue and had not been resolved.

Based on observation, interview, and record review, the facility failed to ensure 2 of 4 residents with physical limitations reviewed for Environment were provided call light device access within reach from a total sample of 27 residents, (#34, #37). Findings: 1. A review the medical record revealed resident #34, a [AGE] year old female was admitted to the facility on [DATE] from an Assisted Living Facility and had diagnoses that included encephalopathy (brain dysfunction), psychotic disorder, anxiety disorder, dysphagia (difficulty swallowing), dementia, cerebral (brain) vascular disease, and heart disease. The Minimum Data Set (MDS) quarterly assessment with Assessment Reference Date (ARD) 10/26/23 identified a Brief Interview for Mental Status (BIMS) score of 4 out of 15 that indicated the resident was severely cognitively impaired. Functional Abilities and Goals of everyday activities noted the resident was dependent or required substantial/maximum assistance from staff to complete Activities of Daily Living (ADLs), mobility functions in and out of bed, always incontinent of bladder and bowel functions, required a mechanically altered diet, and the resident received high risk anti-anxiety and anti-coagulant (blood thinner) medications during the look back period. The Comprehensive Care Plan Focus' noted the resident was at risk for falls and dependent on staff to complete ADLs related to physical limitations including weakness, impaired mobility, failure to thrive, cognitive deficits, and incontinence. Additional focuses included dining dependence, risk for falls, injury, and adverse effects of anxiety and anti-coagulant (blood thinner) medications. On 1/16/24 at 11:20 AM resident #34 was observed alone in her room sitting in a wheelchair mid-way between the right side of her bed. The call light device was behind the wheelchair. The cord was wrapped twice around the bed rail with the button portion hung towards the floor. At 2:12 PM, the resident was observed uttering nonsensical statements while sitting in a wheelchair in the same location as earlier observed. The call light cord was wrapped around the bed rail and hung towards the floor behind the resident, out of her reach. On 1/17/24 at 9:24 AM, Certified Nursing Assistant (CNA) B was observed exiting resident #34's room with a meal tray. At 9:27 AM, the resident was observed alone in her room, awake while she lay in bed. The call light device cord was wrapped around the right bed rail and the button hung approximately 1 inch from the floor. During a joint observation with CNA B and Registered Nurse (RN) D on 1/18/24 at 9:54 AM, resident #34 was observed alone and awake while she lay in bed. The call light device hung off the right side of her bed and the button touched the floor. CNA B said the resident could and had used the button, and described her cognition as, totally confused; have to constantly remind her for everything. The CNA picked up the device and acknowledged the resident was not able to reach it while she demonstrated how an adjustable clip attached to the cord was used to secure it to clothing or linen so the resident could reach and use it. RN D acknowledged the device was out of the resident's reach and it should've been secured where she could access it. The RN stated, she can push the button. 2. A review the medical record revealed resident #37, an [AGE] year old female, was admitted to the facility on [DATE] from an acute care hospital with diagnoses that included fracture of the sacrum (tailbone), leukemia, sepsis (blood stream infection), hemiplegia (one-sided paralysis), difficulty in walking, need for assistance with personal care, lack of coordination, weakness, and malnutrition. The MDS Admission 5-day assessment with ARD 12/29/23 identified a BIMS score of 14 out of 15 that indicated the resident was cognitively intact. Functional Abilities and Goals of everyday activities noted the resident required substantial/maximum assistance from staff to complete ADLs and mobility functions in and out of bed. The assessment noted the resident was always incontinent of bowel and bladder functions, had shortness of breath or trouble breathing when lying flat, a fall history within the last month, and two to six months that resulted in a fracture prior to her facility admission. The Comprehensive Care Plan focus showed the resident was dependent on staff to complete ADLs, transfer in and out of bed and to the toilet related to physical limitations, incontinence, weakness, impaired mobility, risk for fall and injury, cardiovascular (heart) complications, sacral fracture, and history of cerebral vascular accident (stroke). On 1/16/24 at 11:48 AM, and 1/17/24 at 9:18 AM, resident #37 was observed alone in her room sitting in a wheelchair beside her bed. The call light device was lying across the bed approximately three feet behind the chair. The resident stated she needed to use the restroom. She reached backwards and demonstrated she was not able to reach the call light behind her. The resident was visibly frustrated and explained she needed staff's assistance to get to the bathroom, and she had to wait for someone to come in the room if she couldn't reach the light. At 2:18 PM, the resident was again observed sitting in a wheelchair beside her bed. The call light was behind the resident lying across the bed out of the resident's reach. On 1/17/24 at 9:18 AM, resident #37's call light was observed with the cord wrapped around her right bed rail and the button was located at the head of the bed. The resident was sitting in a wheelchair beside the bed, approximately four feet out of reach from the device. In an interview on 1/18/24 at 10:48 AM, the Director of Nursing (DON) explained she expected CNAs and nurses to lay call light devices across the bed or have them clipped to clothing so residents could reach them. She said she was concerned when staff notified her of the earlier problem. Review of the facility's Quality Assurance Performance Improvement (QAPI) Plan dated 1/12/24 read, . We provide comprehensive clinical care to residents with acute and chronic disease, rehabilitative needs, as well as end-of-life care. All care is resident-centered and focused around choice and individualized treatment plans. We provide comprehensive building safety, repairs, and inspections to ensure all aspects of safety are enforced, assuring the safety and well-being for each resident .

Based on observation, interview and record review, the facility failed to provide services and treatments to prevent further decrease in range of motion for 2 of 3 residents reviewed for positioning and mobility of a total sample of 23 residents, (#1 and #14). Findings: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) quarterly assessment with assessment reference date (ARD) of 7/15/22 revealed resident #1 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated she had moderate cognitive impairment. She required extensive to total assistance with Activities of Daily Living (ADLs). The document revealed the resident did not exhibit any behavioral symptoms including rejection of care. The assessment indicated resident #1 had limited range of motion (ROM) to one side of her body for both upper and lower extremities. A care plan for limited physical mobility related to [CONDITION(S)] with right sided [CONDITION(S)] was initiated 4/30/21 and revised 4/28/22. Interventions included monitor/document/report as needed any signs/symptoms of immobility: contractures forming or worsening, and skin breakdown; Physical Therapy/Occupation therapy referrals as ordered; and passive range of motion to right upper extremity. Review of resident #1's Medication Review Report for July 2022 revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The report did not contain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] On 7/25/22 at 11:35 AM, 7/25/22 at 3:26 PM, 7/26/22 at 9:11 AM and 7/27/22 at 9:56 AM, resident #1 was observed in bed. Her right hand and arm were contracted and held tightly to her chest. Resident #1 did not have a splint on her right arm or hand and did not have a hand roll in her right hand. On 7/27/22 at 10:21 AM, Certified Nursing Assistant (CNA) A stated the resident was dependent on staff for most ADLs. She reported the resident was contracted on her right side and did not have a splint or assistive device. She could not recall the resident ever having a splint. CNA A explained she washed resident #1's right hand as part of ADL care and used a washcloth to clean inside her hand and between her fingers. She reported the resident expressed discomfort when she performed ADL care on her right hand. CNA A demonstrated how she washed the resident's contracted hand and the resident grimaced but allowed CNA to open her hand. At this time CNA A searched the resident's room but was unable to find a splint. On 7/27/22 at 10:44 AM, the Therapy Director stated resident #1 was not currently on therapy caseload. He recalled she had been evaluated in May 2022 and was seen up by OT from May 11 - June 23, 2022. The Therapy Director reviewed the therapy notes and reported OT worked with the resident on right upper extremity range of motion and splint tolerance for 6-8 hours. He explained resident #1 was transferred to restorative nursing program at discharge from therapy with a restorative form completed and emailed to the restorative nurse. At 11:04 AM, the Therapy Director entered resident #1's room and assessed the resident's right hand and ROM to the right arm. The resident grimaced as he attempted to straighten her right arm. He stated the resident needed a right elbow splint and a right hand splint. He conveyed the splint would reduce pain and allow staff to clean her hands and provide nail care. He recalled an elbow splint was recommended but stated she should had a hand splint as well. The Therapy Director explained when limbs were not being used, the muscles tighten and shorten causing a contracture. He clarified that a splint would help to prevent a contracture and did not say why resident #1 did not have one. On 7/27/22 at 11:17 AM, OT B recalled resident #1 was on caseload previously with ROM to bilateral upper extremities. He stated the goal was for resident to wear a right elbow splint and a right hand splint for 6-8 hours per day to prevent contractures. He could not recall if the splint was left for the resident. He validated in the absence of a hand splint, the expected nursing intervention was to use a towel roll. On 7/27/22 at 11:43 AM, the Therapy Director reviewed the Restorative Nursing Documentation Tool and acknowledged the form did not contain any splinting information. On 7/27/22 at 11:46 AM, Restorative Aide CNA C stated she was familiar with resident #1 and reported the resident was on restorative therapy 3 times a week for upper and lower ROM. She verbalized she was aware of her right hand contracture but did not have a splint program for her. Restorative Aide CNA C reviewed the restorative program for resident #1 and verified the program contained information for Passive and Active ROM but no information for splinting. On 7/27/22 at 12:00 PM, the Administrator brought a clear plastic bag that contained a blue hard plastic splint which extended from forearm to hand and stated it was in resident #1's upper drawer of the bedside table. The Administrator explained she asked the resident if she wanted to wear the splint and the resident declined. The Administrator was informed the drawers were searched by CNA A and there was no splint in any of the drawers or in the closet. On 7/27/22 at 12:06 PM, CNA A validated she searched all drawers in the dresser, bedside table and closet and did not see a splint. She informed the Administrator that surveyors were present when she searched the room and the splint was not in the drawer at that time. The Administrator said, I wonder who has been in that room since then. The Administrator was informed that the splint she held was not the type of splint that was recommended by therapy. Restorative Aide CNA C was present in the hallway and confirmed she had never seen that splint and did not recall the resident wearing a splint on either her elbow or her hand. CNA A confirmed that she had never seen the splint either. The Administrator could not explain where the splint came from or why the splint was not of the recommended type. On 7/27/22 at 2:11 PM, the Therapy Director stated OT B erroneously checked completion goal for resident's hand splint but not the elbow splint. The Therapy Director confirmed he was still unsure of what happened to the hand splint. The Therapy Director recalled his earlier assessment resident #1 and reiterated she would benefit from both a hand splint and elbow splint. On 7/27/22 at 2:29 PM, the Director of Nursing (DON) stated she served as the restorative nurse. She explained when therapy determined a resident had met goals and needed a maintenance plan, the therapist created a restorative plan and emailed it to the nursing team to implement. The DON acknowledged she did not have a plan for resident #1's discharge from therapy on 6/23/22. She verbalized her expectation if a resident had a contracture with no obvious treatment or device in place, the staff member should report it to a floor nurse, to PT or to the DON. She conveyed she would expect staff to place a rolled washcloth if a resident did not have a hand splint or refused splint. The DON stated she reviewed the current restorative plan for resident #1 and noted, Obviously there is a break in the process since we missed the form from 6/23/22. She acknowledged the possibility of a decline for resident with a contracture that was not maintained. 2. Resident #14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS quarterly assessment with ARD of 6/15/22 revealed resident #14 had a BIMS score of 14 which indicated she was cognitively intact. She required extensive to total assistance with ADLs. The document revealed the resident did not exhibit any behavioral symptoms including rejection of care. The assessment indicated resident #14 had limited ROM to one side of her body for both upper and lower extremities. A care plan for history of Cerebral Palsy initiated 12/23/19 and revised 7/05/21 included interventions to maintain good body alignment to prevent contractures, use braces and splints as ordered and encourage resident/caregivers to use and correctly apply all splints and braces. On 7/25/22 at 10:51 AM, resident #14 was in bed and two multi-podus boots were noted on the floor next to a recliner. The resident stated she did not wear the boots because they were stretched out and did not fit properly. She said she requested new ones from therapy but only received one. On 7/26/22 at 8:58 AM, the resident was in bed and the boots were no longer beside the recliner in her room. She stated she was not wearing them and did not know where they were. On 7/27/22 at 10:52 AM, the Therapy Director explained resident #14 had been on case load but was not currently not being seen by therapy. He recalled she had been treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . He noted he was not aware the boots were too big. On 7/27/22 at 10:56 AM, resident #14 was observed in a wheel chair next to her bed. The multi-podus boots were on the floor next to her recliner. The resident stated it had been about two years since she wore them. The Therapy Director checked both boots on the floor and noted they were both large size. He located another multi-podus boot in the resident's closet which was regular size. He stated the resident should be wearing them when she was out of bed. He explained restorative nursing program would have initially been assigned to put the boots on the resident. On 7/27/22 at 11:28 AM, OT B stated he was familiar with resident #14 and recalled he recommended resident to wear her the podus boots while up in the wheel chair and when in bed. On 7/27/22 at 11:52 AM, Restorative Aide CNA C verified resident #14 had multi-podus boots and mentioned they were too big. She reviewed the restorative program for resident #14 and noted the resident was on a restorative program for the multi-podus boots to be applied during the day. On 7/27/22 at 12:02 PM, CNA D stated she was familiar with resident #14. She reported the resident had multi-podus boots that were applied by restorative CNA. She recalled the boots did not fit well. On 7/28/22 at 3:45 PM, the Therapy Director provided the Physical Therapy Plan of Care for resident #14 with an end date of 5/02/22. Review of the plan revealed resident only had one proper fitting splint at the time and the therapist was donning a brace one foot at a time while waiting for the new splint. On 4/26/22, the therapist documented therapy was on hold due to waiting on ankle brace/splint. The Therapy Director clarified the plan was to use the boot that fit and alternate ankles until the new boot arrived. He acknowledged the boots mentioned in plan were never delivered. Review of the job description for Rehabilitation Program Manager dated 2/02/22, revealed the program manager would develop programs appropriate to the needs of the residents in the facility, to assist them in achieving their highest feasible level of functioning. Review of the job description for Director of Nursing Services dated 4/05/16, revealed the DON's essential job functions included organize resident care programs which include the interdisciplinary team, resident care planning team, the restorative care program and other programs as necessary to provide optimal care. The facility's policy and procedure for Assistive Devices and Equipment provided policy interpretation and implementation guidelines that included assessing the resident for lower extremity strength, range of motion, balance and cognitive abilities when determining the safest use of devices and equipment; and, the equipment is measured to fit the resident's size and weight.

Based on observation, record review and interview, the facility failed to ensure potentially hazardous foods were at a hot holding temperature of 135 degrees Fahrenheit, or above, to prevent foodborne illness. Finding Review of the facility's lunch menu on 7/27/22, revealed the residents had a choice of Baked Ziti or Turkey Enchilada Casserole. The side items included Green Peas, Red Potatoes and Coconut Cake. On 7/27/22 at 11:55 AM, the lunch tray line was observed. There were two cooks and several dietary aides at or near the tray line. Cook A stated the Baked Ziti and Turkey Enchilada Casserole were in the hot box, a full size temperature controlled, hot holding cabinet. The side items were on the steam table. The hot holding temperatures were checked with the facility's digital, bayonet style thermometer. The Turkey Enchilada Casserole had a hot holding temperature of 119 degrees Fahrenheit. Further temperatures taken of the Turkey Enchilada Casserole ranged from 119 to 129 degrees Fahrenheit. Cook B stated the holding temperature was supposed to be 160 degrees Fahrenheit. A few minutes later, the Chef was at the tray line and was informed of the hot holding temperatures of the food. The Chef instructed the cooks to reheat the Turkey Enchilada Casserole. When asked who took the hot holding temperatures prior to the start of tray line, Cook A and Cook B did not respond. Cook B indicated he did not take the temperatures as, I was too busy. The Chef stated the lunch tray line holding temperatures had not been done. The United States Food and Drug Administration's Food Code 2017, notes in chapter that potentially hazardous foods, need to be at a hot holding temperature of 135 degrees or above.

Based on observation, interview and record review, the facility failed to follow-up on pharmacy recommendations for 1 of 5 residents reviewed for unnecessary medications of a total sample of 23 residents, (#1). Findings: Resident #1 was admitted to the facility on [DATE] with diagnoses including [CONDITION(S)], cerebral infarction, and [CONDITION(S)] [CONDITION(S)]. A care plan for resident has [CONDITION(S)] was initiated 4/30/21 with interventions for staff to administer [CONDITION(S)] replacement medication as ordered and obtain and monitor lab/diagnostic work as ordered. Review of the pharmacy Consultation Report for April 2022 revealed a recommendation for the facility to monitor resident #1's [CONDITION(S)] Stimulating Hormone (TSH) concentration on the next convenient lab day and at least annually due to resident receiving [CONDITION(S)] replacement medication, [MEDICATION(S)]. The report was unsigned and did not indicate whether the physician agreed or disagreed with the recommendation. Review of the Medication Review Report for July 2022 revealed resident #1 had a physician order dated 11/17/21 for [MEDICATION(S)] Sodium Tablet 100 micrograms to be given every morning for low [CONDITION(S)] hormone. The report did not contain an order for labs to monitor TSH level. On 7/28/22 at 5:21 PM, the Administrator reviewed the pharmacist's recommendations and the resident #1's Electronic Medical Record and acknowledged there was not any physician order to monitor TSH levels. On 7/28/22 at 5:22 PM, the Director of Nursing (DON) stated the consultant pharmacist reviewed medications monthly. The pharmacist then emailed recommendations to the facility which were printed and put in physician binders at the nursing stations. She explained once the recommendations were reviewed and signed by the physician, they were returned to her for reconciliation. The DON stated she was ultimately responsible for following through with pharmacy recommendations and acknowledged resident #1's recommendation to complete lab work for TSH levels was missed. The facility's policy and procedure for Medication Regimen Review (MRR) dated 12/01/07 included guidelines for the facility to encourage Physician/prescriber or other Responsible Parties receiving the MRR and the Director of Nursing to act upon the recommendations contained in the MRR. For those issues that require Physician/Prescriber intervention, Facility should encourage Physician/Prescriber to either (a) accept and act upon the recommendations contained within the MRR, or (b) reject all or some of the recommendation contained in the MRR and provide an explanation as to why the recommendation was rejected.

Based on record review and interview, the facility failed to maintain the survey book with all surveys conducted in the past three years. Findings: Review of the survey book located in the facility's main lobby revealed it did not include all recent surveys. A complaint survey conducted on 10/7/21 resulted in deficiencies and the survey book did not include the statement of deficiencies or the facility's plan of correction for viewing by residents, visitors, and staff. On 7/26/22 at 3:20 PM, the Administrator acknowledged the complaint investigation results of 10/7/21 were not included in the survey book. There were no additional survey books readily available for review and the Administrator acknowledged it was her responsibility to update the survey book.

Based on observation, interview and record review, the facility failed to obtain physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Finding: Resident #3 was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's admission Minimum Data Set (MDS) assessment with reference date 9/16/21 revealed the resident received O2 therapy. On 10/6/21 at 10:25 AM, resident #3 was noted with oxygen therapy via nasal cannula (NC) at 2 Liters Per Minute (LPM). A review of the residents' medical records revealed there were no current orders in place for oxygen liter flow. The AHCA Form 5000-3008 from the hospital dated 9/13/21 indicated O2 at 2.5 LPM. On 10/6/21 at 12:30 PM, the Director of Nursing (DON) acknowledged resident #3 had O2 via NC at 2 LPM without a physician order. On 10/7/21 at 12:20 PM, the resident's assigned nurse, Licensed Practical Nurse (LPN) A said, she was responsible for entering the resident's orders at admission and missed the orders for oxygen liter flow rate. She acknowledged that other nurses assigned to the resident since admission 9/13/21 could have added the orders but did not. Review of the Oxygen Therapy policies and procedures dated 8/31/14 noted, Procedure: Verify physician order [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observation, record review and interview, the facility failed to ensure the physician justified the continued use and duration of [MEDICAL CONDITION] medication ([MEDICATION NAME]) on an as needed (PRN) basis beyond 14 days for 3 of 7 residents in a total sample of 32 residents, (#25, #14, #199). Findings: 1. Resident #25 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record revealed that resident #25 had an active order dated 12/08/20 for [MEDICATION NAME] 1 milligram (mg) three times daily as needed (PRN) for agitation with no stop date. The Centers for Medicare and Medicaid Services (CMS) require the PRN orders for non-antipsychotic [MEDICAL CONDITION] drugs be limited to 14 days unless prescriber documents the diagnosed specific condition being treated, the rationale for the extended period, and the duration of the PRN order. Review of the Medication Administration Record [REDACTED]. The 14 day duration for the PRN medication should have been 12/08/20-12/22/20. The resident received 43 doses of [MEDICATION NAME] after the 14 days. Further review of the medical record revealed the physician did not provide a rationale for the extended time period for [MEDICATION NAME] use and did not indicate a specific duration or stop date. On 01/21/21 at 2:50 PM, the Director of Nursing (DON) stated PRN [MEDICAL CONDITION] medications should be discontinued after 14 days unless the physician assessed the resident and documented the reason the medication needed to be continued. She acknowledged resident #25's PRN [MEDICATION NAME] order should have had a duration and rationale for continued use. On 01/21/21 at 4:14 PM, Registered Nurse (RN) A said that if a medication was given PRN for anxiety, it should only be given for 14 days unless the doctor gave a new order as PRN orders needed to have a stop date. RN A did not provide an answer as to why resident #25's PRN [MEDICATION NAME] did not have rationale for continuing the medication past the 14 days. 2. Resident #14 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. A review of the most recent Quarterly Minimum Data Set Assessment ((MDS) dated [DATE] revealed no signs or symptoms of disorganized thinking, delusions, hallucinations, physical or verbal behavioral symptoms directed towards others, or other behavioral symptoms. The resident received both anti-psychotic and anti-anxiety medications. Resident #14 was observed on 1/21/2021 at 1:45 PM, in bed in her room. The resident was watching television and appeared calm. A review of the physician orders [REDACTED]. The plan of care revised on 1/5/21, showed resident #14 used anti-anxiety medications related to anxiety disorder. The interventions included administration of anti-anxiety medication ([MEDICATION NAME]) as ordered by physician. A review of the Medication Administration Record [REDACTED]. A review of the Consultant Pharmacy Recommendation dated 9/20/2020 noted a recommendation to, discontinue PRN [MEDICATION NAME] tapering as necessary. If the medication cannot be discontinued at this time current regulations require that the prescriber document the indication for use, the intended duration of therapy, and the rationale for the extended time period. The physician reviewed the pharmacy recommendation on 9/28/2020 and declined the recommendation. Patient remains anxious and agitated. The benefits outweigh the risks. The physician did not provide an order to extend the [MEDICATION NAME] past the 14-day limit. A pharmacy recommendation dated 10/13/2020 showed the same recommendation as the 9/20/20 recommendation. The physician again declined the recommendation on 10/19/2020. The patient remains agitated and needs the medication for behavior . The physician did not provide a duration for [MEDICATION NAME] PRN. On 01/21/21 at 1:48 PM, Registered Nurse (RN) A who was caring for resident #14 stated that PRN anti-anxiety orders should only be for 14 days only . On 01/21/21 at 2:50 PM, the Director Of Nursing (DON) stated that [MEDICATION NAME] PRN medication orders should be reviewed by the pharmacy and should be discontinued after 14 days. She stated that the doctor's order needs to say why it is to be continued if they don't agree with pharmacy recommendation to discontinue the medication. She further stated the physician must note what the benefit versus risk of the medication is and the order must specify how long the medication should be given. The DON acknowledged resident #14's PRN [MEDICATION NAME] order should have had a rationale for continued use or been discontinued after 14 days. 3. Resident #199 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Review of the resident's physician orders [REDACTED]. There was no end date indicated. Review of the January 2021 Medication Administration Record [REDACTED]. On 1/21/21 at 2:50 PM, the Director of Nursing (DON) stated that in order for PRN [MEDICATION NAME] to be given past 14 days, the physician must assess the need for the medication. She noted if the PRN order was to be extended past the 14 days, the physician must state the benefit versus risk of medication and the duration of the order.

Based on observation, interview and record review, the facility failed to ensure that proper thawing procedures were followed, failed to maintain acceptable refrigerator temperatures during food production, failed to prevent potential food contamination from chemical and dust particles, and failed to discard opened enteral formula after expiration. Findings: 1. On 5/30/19 at 1:31 PM, observation in the main kitchen revealed a small pan with two small blocks of frozen fish fillets being thawed under running water. The temperature of the cold water was checked with a calibrated thermometer at 80° Fahrenheit (F). The temperature was confirmed by the sous chef. Interview at this time with cook J confirmed that he was thawing the block of frozen fish to prepare a portion of it. He stated that he was not aware of the proper cold water temperature needed to thaw food items. TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be followed when thawed. Completely submerge under running water at a water temperature of 70° F or below, and with sufficient water velocity to agitate and float off loose particles in an overflow, (USDA Food Code (YEAR) Chapter 3). 2. On 5/28/19 at 9:30 AM, observation of the 4 door line refrigerator revealed the refrigerator temperature was 52° F. The refrigerator was again checked at approximately 1:30 PM. It remained at 52° F. Review of the temperature monitoring log revealed that the early morning temperature was 43° F. Interview with the executive chef at this time revealed that he was not informed that the temperature at the start of the day exceeded safe refrigeration storage temperature of below 41 °F. On 05/28/19 at 4:45 PM, interview with the executive chef noted that the air conditioning in the kitchen was not working and the kitchen temperature was up to 100°F. On 5/29/19 at 11 AM, the executive chef stated that the service company had assessed the refrigerant was at the proper levels. He stated that the refrigerator was probably not holding the proper temperature as the kitchen was very warm with only partial air conditioning working. 3. On 5/28/19 at 9:30 AM, observations in the kitchen revealed the top of the holding cabinet had toothpick, labels and a few other paper product on the top. There were dust particles stuck on the top of the unit and fluttering with the air movement potentially coming in contact with foods being prepared on the work surface. On 5/29/19 at 4:46 PM, a large floor fan was operating at high speed in the kitchen. It was plugged into an outlet in the mop and chemical closet with the door fully open. The potential for chemicals to be transferred to the production area was present. The cooks in the cold production area next to the fan were preparing fresh salads. The fan was blowing over the food items. The hot production area had cooked chicken on the table for the salad. The fan was also blowing on these food items. Interview with the executive chef at this time confirmed that the air was being blown directly onto the food and had the potential for food contamination. Food Contamination means the unintended presence of potentially harmful substances, including, but not limited to microorganisms, chemicals, or physical objects in food. (USDA Food Code (YEAR) Chapter 3). 4. On 5/28/19 at 11:27 AM, an observation of the medication room refrigerator with registered nurse (RN) U revealed an open can of 2 Cal HN (enteral feed) with a latex glove secured on top of the can. The label on the can read, resident #81 and was dated 5/24/19 at 8:00 PM. The RN U stated that the can should have been discarded after 24 hours. It should not be in the refrigerator. I think when he came from the hospital his order was for 1&½ cans but it's been changed, now he receives 1 can. She stated that the cleaning of the refrigerator was everyone's responsibility. On 5/28/19 at 1:12 PM, the director of nursing (DON) stated that the night shift was responsible for cleaning out the refrigerator. She said that staff should follow manufacturer's guidelines or expiration dates when discarding residents' food items. On 5/28/19 at 4:07 PM, the director of food and beverage and the interim dietician confirmed that dietary staff did not have access to enter the medication room. They stated that the cleaning of the refrigerator was done by nursing staff. On 05/29/19 at 9:35 AM, the charge nurse, RN T stated that food should not be in the refrigerator for more than 24 hours. She confirmed that dietary staff did not have access to the medication room. She said that the 11 PM-7 AM shift nurse was responsible for checking the refrigerator daily as they had to do the temperature checks. Review of the labeled manufactures instructions on the outside of 2 Cal HN can revealed .ONCE OPENED, COVER, REFRIGERATE AND USE WITHIN 48 HOURS . Review facility policy Foods Brought by Family/Visitors 2001 Med Pass Inc. Revised (MONTH) (YEAR) showed the nursing staff will discard perishable foods on or before use by date .The nursing staff will discard perishable foods on or before use by date, The nursing and or food service staff will discard any foods prepared for the resident ., past due package expiration dates The nursing and/or food service staff will discard any foods prepared for the resident that show obvious signs of potential foodborne danger (for example, mold growth, foul odor, past due package expiration dates).

Based on observation, interview and record review, the facility failed to ensure proper use of personal protective equipment (PPE) for contact isolation for 1 of 1 resident on transmission-based precautions (#181), and failed to ensure appropriate hand washing during wound care to prevent cross-contamination for 1 of 1 resident observed during wound care (#185), of a total sample of 21 residents. Findings: 1. Resident #181 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. MRSA is a type of bacteria that is resistant to several antibiotics. Salmonella is a bacteria that can be found in a variety of foods and causes diarrhea, fever, and abdominal cramps. [MEDICAL CONDITION] and salmonella infections can be spread directly from person to person or by touching shared equipment and supplies. (www.cdc.gov) Review of the medical record revealed resident #181 had a physician's orders [REDACTED]. He received an antibiotic twice daily and had his left elbow dressing changed once daily. Isolation precautions create barriers between people and germs. Contact isolation precautions help keep staff and visitors from spreading the germs after touching an infected person or an object the person has touched. A gown and gloves should be worn by anyone who may touch the person or objects in the room. (www.medlineplus.gov) Resident #181 had a care plan for activities of daily living that indicated he required extensive assistance from staff for bathing, bed mobility, transfers, ambulation and toilet use. A care plan for risk of transmitting an infection had a goal of Infection will not spread. The interventions included contact precautions, appropriate signage outside resident's room and Follow facility protocol for isolation precautions. Resident #181 also had a care plan [MEDICAL CONDITION] in the left elbow that directed staff to instruct visitors to wear gown and gloves when in the room. Resident #181's private room included an anteroom with a sink, soap, paper towels and a trash can. A caddy on the room door contained PPE including yellow isolation gowns and gloves. A red stop sign was prominently displayed on the wall to the left of the door, and printed directions detailed the type of isolation precautions and PPE required for entrance into resident #181's room. On 5/28/19 at 11:41 AM, occupational therapist (OT) C was observed working with resident #181 in his room. Resident #181 was seated on the side of his bed, and a visitor was seated on the arm of a chair at bedside. Resident #181 confirmed he [MEDICAL CONDITION] in a wound and salmonella in his stool sample so everyone who was in his room needed to wear a gown. The visitor was not wearing a yellow gown. The OT C wore a yellow isolation gown that covered only the front of his body. The neckline of OT C's isolation gown hung at his mid-chest area and the sleeves only partially covered his arms. The OT C's shoulders, sides, back and upper arms were uncovered by the isolation gown. When asked if he was wearing the gown correctly, OT C lifted his arms to demonstrate it was too small and explained it covered all it could fit. Later that afternoon at 12:20 PM, OT C was observed in the therapy gym completing a session with another resident. In an interview conducted after the session, OT C acknowledged the isolation gowns did not fit him and could not cover his arms, back or sides. He explained in almost 1 year on staff, it was the only size isolation gown he ever used. The OT C stated he was aware resident #181 [MEDICAL CONDITION] and validated improper use of the isolation gown could cause resident#181's infection to spread to other residents and staff. OT C said, I did touch him during the session, and acknowledged the unprotected areas of his body and clothes could have come in contact with resident #181's body, clothes, linen, bed and other items in the room. On 5/29/19 at 9:45 AM, dietary staff B was observed in resident #181's room beside his bed. She did not wear an isolation gown or gloves as directed by the signage at the door. Dietary staff B stood close to resident #181's bed and over bed table. She held a clipboard while they discussed menu choices. She then handed the clipboard to resident #181. He placed the clipboard on his abdomen, reviewed the paperwork, circled some items and handed it back to dietary staff B. After further discussion, she handed the clipboard back to resident #181. He placed it on his abdomen, on top of his gown, completed his menu selections and returned it to dietary staff B. On 5/29/19 at 9:49 AM, dietary staff B exited the room. She walked through the anteroom, past the sink towards the hallway, and turned back to wash her hands only after she was asked if she was just in an isolation room by the surveyor. Dietary staff B acknowledged she did not wear a gown and gloves in the room although resident #181 was on contact isolation precautions. She confirmed after resident #181 held her clipboard to complete his menu choices, she touched it with her bare hands. Dietary staff B validated her clothing, hands and clipboard were possibly contaminated and explained she could spread whatever the resident had throughout the facility. Dietary staff B stated she was on her way to the kitchen. On 5/29/19 at 4:50 PM, the Director of Nursing (DON) confirmed it was not acceptable for OT C to interact with a resident on contact isolation precautions if his clothing was not properly protected by an isolation gown. The DON said, The gowns are one size fits most, and he did not let us know this was a concern for him. She stated she could have ordered extra large gowns at any time if she had been informed. She explained there was a danger of cross-contamination to other residents, staff and their families. On 5/29/19 at 4:51 PM, the Culinary Director explained all dietary staff received the same education and training on infection control as facility staff. She stated her expectation was dietary staff would follow facility policy regarding isolation precautions. The Culinary Director acknowledged that dietary staff B could have put other residents and staff at risk by returning to the kitchen with contaminated clothes and clipboard. Review of the therapy department's policy and procedure Standard Precautions dated 9/23/16, revealed therapists were expected to wear gloves when there was a potential for contact with residents' body fluids, and Follow specific guidance and processes where more stringent. The facility's Infection Control Manual 2019 revealed Contact Precautions are intended to prevent transmission of infectious agents . spread by direct or indirect contact with the resident or the resident's environment. The document indicated gloves and gown should be donned upon entry into the room, and worn when touching potentially contaminated articles or surfaces near the resident such as over bed tables and bed rails. The procedures for contact precautions included discarding gloves and gown before leaving the room, followed by hand hygiene. 2. Resident #185 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) admission assessment with assessment reference date of 5/22/19 revealed resident #185 had a skin tear and an open lesion. The MDS assessment indicated treatments included ointments and/or medications and non-surgical dressings. Review of the medical record revealed resident #185 had a physician's orders [REDACTED]. On 5/28/19, the physician ordered an antibiotic, Keflex 500 milligrams, three times daily for 5 days for right shin redness. Resident #185 had a care plan for a right shin infection with a goal that she would be free from complications. A care plan for impaired skin integrity of the right shin revealed an intervention to administer treatments as ordered. A Skin & Wound Evaluation done on 5/28/19 revealed resident #185 had an open lesion that was deteriorating. The evaluation indicated the wound bed had 25% slough or dead tissue, and 75% granulation, or healthy and viable tissue. The wound measured 3.5 x 4.0 centimeters, had a small amount of clear drainage and surrounding redness. On 5/30/19 at 10:14 AM, Registered Nurse (RN) A washed her hands and placed treatment supplies for resident #185's wound care on the over bed table. Resident #185 was seated in a wheelchair and RN A knelt on the floor to begin the dressing change to the right shin wound. RN A removed the soiled dressing, pulled her glove over it and dropped the dressing and both gloves into a bag on the floor. The tissue surrounding the wound was red and slightly inflamed. RN A then reached up to the over bed table for a pair of clean gloves. The RN A then donned the clean gloves and cleansed the wound with normal saline soaked gauze. She applied Santyl to the wound bed and covered it with a dry dressing. The RN A then removed her gloves, discarded them in the trash bag and washed her hands. The procedure for resident #185's wound care was reviewed with RN A. She confirmed she discarded her gloves after removal of the soiled dressing, but did not wash or sanitize her hands before she donned clean gloves to cleanse the wound and complete the dressing change. RN A acknowledged she should have performed hand hygiene between glove changes, before moving from dirty to clean parts of the procedure. On 5/30/19 at 10:30 AM, the DON stated RN A should have either washed her hands or used sanitizer between glove changes to prevent contamination of the wound. She validated resident #185's dressing change was not done according to facility policy. Review of the policy and procedure for Dressings, Dry/Clean revised in (MONTH) 2013, revealed the procedural steps to remove the soiled dressing and then discard it with the soiled gloves. The next step in the document read, Wash and dry your hands thoroughly. Then the procedure directed nurses to open packages of dressing supplies and again wash and dry hands before donning clean gloves to cleanse the wound and apply the dressing as ordered.

Based on record review and interview, the facility failed to ensure accurate assessment coding of the Minimum Data Set (MDS) fall status for 1 of 1 residents reviewed for accident assessment, out of a total sample of 17 residents (#282). Findings: Resident #282 was admitted to the facility on [DATE] from the hospital with [DIAGNOSES REDACTED]. Review of the history and physical dated 3/29/18 revealed a fall in the bathroom brought him to the emergency room . Resident #282's medical record revealed his first fall in the facility was on 4/02/18 when he was observed on the floor in his room, and the second fall occurred in the activity room on 4/05/18. Upon review of the MDS admission assessment, dated 4/08/18, coding showed 0 for No Falls since admission or prior assessment, and documentation for the number of falls since admission were not coded or documented within the MDS assessment. In an interview and record review of the facility incident log with on 4/12/18 at 10:54 AM, the director of nursing (DON) validated the resident had two falls since admission in the facility, one on 4/02/18 and the second on 4/05/18. On 4/12/18 at 11:44 AM, the MDS Assistant confirmed she was aware of the instructions in the MDS manual 3.0 that information for residents is gathered from reports, nurse's notes, physician orders, interviews with nursing staff and families. She said falls since admission in the facility should have been recorded onto the MDS. The MDS director validated the resident's falls should have been include in the MDS admission assessment. Review of the MDS instruction manual section J1800 and J1900 Any Falls Since Admission or Prior Assessment, whichever is more recent revealed the manual steps for assessment and described how all available information should be reviewed for a complete representation of resident falls. The manual explained, under planning for the resident's care, the importance of ensuring accuracy within the assessment of falls.

Based on observation, interview, and record review, the facility failed to assess, document, and obtain physicians orders for treatment and monitoring a skin tear out for 1 resident admitted to the facility of 2 residents reviewed for skin non-pressure issues (#132). Findings: Review of resident #132's medical record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations conducted on 02/21/17 at 9:31 AM and on 02/21/17 at 4:15 PM revealed an approximately 3 inch linear black scab with reddened surrounding skin on resident #132's right forearm. Review of the hospital 3008 form dated 02/14/17 documented a skin tear on the resident's right arm. Review of the Nursing Admission Assessment form dated 02/14/17 revealed no documentation of the skin tear on the right forearm arm. Review of the 02/14/17 nurses admission note revealed no documentation of the skin tear on the right forearm and no communication with the physician regarding any orders for treatment or monitoring. On 02/22/17 at 12:11 PM, Registered Nurse (RN) B confirmed that resident #132 has a skin tear on his right forearm. In an interview conducted on 02/22/17 at 12:24 PM the Director of Nursing (DON) stated if a resident has a skin tear upon admission, the nurse is to do a skin sweep/inspection, document in the nursing notes, verify with the physician, and put a treatment in place. The DON confirmed that if a resident is admitted with a skin tear it should be documented on the Nursing Admission Assessment form and on the Weekly General Observation form. In an interview conducted on 02/22/17 at 12:50 PM Licensed Practical Nurse (LPN) C stated she was the nurse that admitted resident #132 and was aware of the dried scab on his right forearm. I reviewed the hospital 3008 form and there was documentation of a skin tear on his right arm. I assessed his body, but did not document anything on the nursing admission form, did not complete the skin and wound form or do a nursing quick note. I should have noted the skin issue. In an interview conducted on 02/22/17 at 1:04 PM, the DON stated that if there was an issue with residents' skin it should have been documented and communicated with the physician for any orders for treatment.

Based on observation, interview, and record review the facility failed to ensure the laundry department provided a clean and sanitary environment to process facility linens and failed to ensure the housekeeping supplies were stored properly to prevent cross contamination and potential for spread of infection. Findings: 1. An observation conducted in the laundry department on 02/22/17 at 3:06 PM revealed a black pocket book, [MEDICATION NAME] soft sided lunch bag, and large multi colored Hello Kitty bag on a shelf labeled to store housekeeping towels. Two personal bags, a plastic drinking cup, and plastic water bottle with a small amount of clear fluid in the bottom were sitting on the clean linen folding table where residents' clean linens and personal clothing are folded. In an interview conducted in the laundry department on 02/22/17 at 3:09 PM the Director of Nursing/Infection Control Nurse (DON/ICN) stated The staffs personal items should not be in the laundry area. In an interview conducted on 02/22/17 at 3:11 PM Laundry Attendant (LA) E stated, we are not to have personal items in the laundry area, and no eating or drinking in the laundry area. An observation conducted in the laundry department on 02/22/17 at 3:11 PM revealed a 3 tier metal shelf with a bag labeled M&M and another staff member's personal bag. In an interview conducted on 02/22/17 at 3:14 PM the Environmental Service Director stated the plastic cup, water bottles and the 2 staff personal bags should not be on the clean folding table. 2. An observation conducted on 02/22/17 at 3:22 PM with the Environmental Services Director in the soiled linen room where soiled linens are separated, revealed a large gray plastic barrel with 7 spray bottles hanging on the rim of the barrel. Three bottles contained a green fluid, 1 with pink fluid, 1 labeled neutral floor cleaner, 1 labeled vinegar, a broom, a dust pan, a mop head stick, and a yellow mesh bag containing a towel and mop head. The Environmental Services Director stated These items should not be in the room because this is soiled linen room. They are usually stored in the clean side of the laundry room. In an interview conducted on 02/22/17 at 3:48 PM LA F stated that the smiley face bag and plastic water bottle belonged to her. LA F stated We should not have personals in the laundry department because of possible germs and contamination of the residents clean linens. I could get get gems that make us sick and we could bring it home to our family. In an interview conducted on 02/22/17 at 3:55 PM LA E stated that the gray barrel with the spray bottles is used to clean the employee break room where the staff eat every day. The barrel stays outside of the employee break room, but the spray bottles and supplies go into the break room to clean it. Dirty items in the clean break room is not right. Review of the facility Departmental (Environmental Services) - Laundry and Linen), dated April 2013 read, Purpose, The purpose of this procedure is to provide a process for the safe and aseptic handling, washing and storage of linen. Standard Precautions . 3. Consider all soiled linen to be potentially infectious and handle with standard precautions.

Based on interview and record review the facility failed to develop a comprehensive plan of care for [MEDICAL CONDITION] medications for 1 of 5 residents reviewed for unnecessary medications (#40). Findings: Review of resident #40's medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS documented resident #40 received 1 day of antianxiety medication and 7 days of antidepressant medication. Review of the medical records revealed physician orders [REDACTED]. Review of the care plan revealed no individualized plan of care with measurable goals and approaches, and time frames for the use of her antianxiety and antidepressant medications. In an interview conducted on 02/22/17 at 2:24 PM MDS Coordinator A stated Resident #40 should have a care plan for her antianxiety and antidepressant medications and she does not have one. In an interview conducted on 02/22/17 at 4:33 PM the Director of Nursing (DON) stated All residents on antipsychotic medications should have a care plan. At 5:04 PM the DON confirmed that resident #40 is on antipsychotic medications and should have had a care plan for her medications. In an interview conducted on 02/23/17 at 1:42 PM the DON stated that in January they identified an issue with the data entered on residents' MDS assessments. She said it was brought to quality assurance and audits were completed. In an interview conducted on 02/23/17 at 1:42 PM the MDS Coordinator was asked Why was resident #40 care plan for her medications missed? The MDS Coordinator stated I failed to check resident #40 Care Area Assessment (CAA) (on the comprehensive assessment to her care plan to make sure that everything on the CAA was on the care plan. I should have checked it more carefully, it got missed. The audits did not identify the missing CAA information. Review of the facility Antipsychotic Medication Use Policy dated April 2007 read, . Policy Interpretation and Implementation .6. Staff will observe, document, and report to the Attending Physician information regarding the effectiveness of any interventions, including antipsychotic medications. Review of the Care Plan - Interdisciplinary Team dated December 2008 read, Policy Statement, Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. Policy Interpretation and Implementation, 1. A comprehensive care plan for each resident is developed within (7) days of completion of the resident assessment (MDS)