Every finding on record at Waters Edge Health and Rehabilitation

Based on observation, interview, and record review, the facility failed to implement their infection control program as evidenced by failure to use Personal Protective Equipment (PPE) while providing care for 1 of 1 sampled residents on Enhanced Barrier Precautions (EBP) observed for catheter care, Resident #29. The findings included: Review of the Centers for Disease Control and Prevention (CDC) guidance recommends wearing PPE for resident on EBP. The article titled Implementation of Personal Protective Equipment Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) states, Enhanced Barrier Precautions [EBP] are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. The guidance can be found at: https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html. Review of the policy titled Enhanced Barrier Precautions documented, 1. Enhanced barrier precautions are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms to residents. 2. EBP employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gowns are applied prior to performing the high contact resident care activity .3. Examples of high contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene . f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.) . Review of the record revealed Resident #29 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #29 had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. Review of the current physician orders revealed Resident #29 had an indwelling urinary catheter and an order that stated, EBP-Enhanced Barrier Precautions due to Foley Catheter every day and night shift. Review of the care plan dated 05/02/25 documented, Resident is at risk for recurrent infection due to history of UTI/ESBL [Urinary Tract Infection / Extended-Spectrum Beta-Lactamase, bacteria that has developed resistance to many common antibiotics] in his urine. He has history of frequent straight catheter prior to admission and now has an indwelling catheter in place . Interventions / Tasks: Maintain EBP while providing care to catheter. A catheter care observation was conducted on 05/29/25 at 9:20AM with Staff A, Certified Nursing Assistant (CNA). Upon entering the room, a sign titled Enhanced Barrier Precautions was observed on Resident #29's door. Staff A had a mask on and began the care by performing hand hygiene and donning gloves. Staff A was not observed putting on a gown. Staff A continued by prepping supplies, cleansing the tubing catheter, providing peri-care, and switching the regular urinary collection bag to a urinary leg bag. Hand hygiene was performed and new gloves were donned. Per Resident #29's request, Staff A adjusted the leg bag tighter to his leg. Staff A went outside of the resident's door (where the EBP gowns were located) and grabbed another box of gloves located right next to the hanging organizer of PPE. No gown was observed to be worn by Staff A. Staff A continued to provide care to Resident #29 that consisted of: changing of briefs, dressing, grooming, bed bath, (ADL- Activites of Daily Living) care, and transferring the Resident from the bed to the wheelchair and then to the sink. This was all performed during approximately 45 minutes of direct care without the use of a gown. During an interview on 05/29/25 at 10:05 AM, when asked if she knew what the EBP sign at the resident's door means, Staff A stated, It means I have to wear a gown when providing care. When asked if there was a reason she didn't wear a gown, Staff A stated she forgot and should have worn it. Observation of the sign located outside Resident #29's doorway stated, Enhanced barrier precautions: . Providers and Staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities: Dressing, Bathing / Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding, tracheostomy, and Wound care: any skin opening requiring a dressing. During an interview with Resident #29 on 05/29/25 at 11:42 AM, when asked if staff wear a gown when providing catheter care, he stated they typically wear it but sometimes they forget. An interview was conducted on 05/29/25 at 1:35 PM, the Infection Preventionist and the Director of Nursing (DON) were present, related to infection control findings. When asked who should be on EBP, the Infection Preventionist stated anyone who has an indwelling medical device, surgical wound, vascular wounds, wounds that are not fully closed, ostomies, gastrostomy tubes, or foleys (urinary catheters). When asked staff are expected to do with a residnet on EBP, the DON stated they should wear a gown and gloves during high touch care such as hands on ADL care and transfers. The Infection Preventionist and DON were informed a gown was not worn by Staff A during catheter care and the DON stated Staff A knows to wear it but was probably nervous. They both agreed with the findings.

Based on policy review, Centers for Disease Control (CDC) recommendation review, observation, interview, and record review, the facility failed to ensure appropriate infection control practices as evidenced by the failure to ensure PPE (personal protective equipment) use during COVID outbreak testing for 2 of 2 sampled residents observed, Residents #1 and #11; failed to fully implement their Enhanced Barrier Precautions (EBP) policy for 3 of 3 sampled residents who were not on EBP (Residents #2, #17, and #138), and 2 additional random residents (Residents #25 and #188); failed to implement appropriate infection prevention practices for eye drop administration and blood glucose monitoring for 3 of 7 sampled residents observed during the medication pass observation, Resident #3, #18 and #28; and failed to assist 11 of 11 residents, who ate independently or with minimal assistance, with hand hygiene prior to meals in the main dining room, that included random residents and sampled residents, Residents #15, #20, and #27. The census at the time of the survey was 30. The findings included: 1. On 02/20/24 at 8:40 AM, observation of medication administration was conducted with Staff A, Registered Nurse (RN) for Resident #28. Resident #28 was sitting in front of her closet picking out clothes to get ready for the day. Staff A approached Resident #28 with her medications in a medicine cup, Staff A asked Resident #28 if she wanted the pills to be poured into her hands as usual. Resident #28 stated yes. Staff A subsequently poured a total of 8 pills into Resident #28's hand without offering her hand hygiene and/or without asking if she had cleaned her hands. The resident had the pills in her left hand and picked the pills with her right hand and put the pills in her mouth. 2. Review of the CDC guideline last updated 04/04/22, indicated that Personnel collecting specimens or working within 6 feet of patients suspected to be infected with SARS-CoV-2 should maintain proper infection control and use recommended personal protective equipment (PPE), which could include an N95 or higher-level respirator (or face mask if a respirator is not available), eye protection, gloves, and a lab coat or gown. On 02/20/24 at 11:44 AM, COVID testing observation was conducted with the Infection Preventionist (IP), License Practical Nurse (LPN). The test was being conducted on Resident #1 and Resident # 11. This test was being conducted related to a COVID outbreak in the facility, whereas the two mentioned residents were exposed with the positive resident during dining. The facility's testing process was as follows: they conducted testing with COVID outbreak on day 1, day 3 and day 5. This testing on 02/20/24 at 11:44 AM was day 3 testing. The IP donned gloves, she had eyeglasses, no mask, and no gown or lab coat. She swabbed Resident #1's nostrils and conducted the test. She said she was going to wait 15 minutes for the result. She sanitized her hands and was waiting in front of the room. Subsequently at 11:49 AM, she voiced she was going to leave the test in the resident room and moved on to Resident #11 to test her. The IP was encouraged to do what she normally does, and to not rush the process for the surveyor. She voiced her normal process was to wait for 15 minutes, and she then encouraged to wait. At 11:50 AM, the IP went to test Resident #11. The IP did not wear PPE (to include mask and gown) while she was testing Resident #11. On 02/21/24 at 11:50 AM, an interview process was started with the IP, and an inquiry was made regarding the facility's process for doing outbreak testing for COVID. The IP explained when somebody is positive, we contact trace them. The main hall where the residents are, we would do a rapid test, day 1, day 3 and day 5. If any resident tests positive, we isolate them, and contact the Department of Health (DOH), and upload all the negative and positive in the DOH portal. When the surveyor inquired about why she did not wear PPE during the outbreak testing yesterday (2/20), she voiced she did not wear PPE because it was day 3 testing, but with day 1 she would have worn PPE. A side-by-side review of the CDC guideline was conducted with the IP, who agreed she should have worn PPE during the testing. 3. A request of the facility's Policies and Procedures for the facility's Infection Prevention and Control Program was made to the Nursing Home Administrator (NHA). The facility provided a binder which included their policy for the use of Enhanced Barrier Precautions (EBP). During the review of their infection program with the Infection Preventionist (IP), it was revealed that the facility had put into place the use of EBP. Review of the policy, titled, Enhanced Barrier Precautions, dated August 2022, indicated EBPs are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents. 2) EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. 5) EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDROs colonization. 6) EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk. Review of CDC (Centers for Disease Control and prevention) guideline for EBP, last updated 07/12/22, explained that as many as 50% of nursing home residents are infected and or colonized with MDROs that go undetected. Focusing only on residents with active infection fails to address the continued risk of transmission from residents with MDROS colonization, who by definition have no symptoms of illness. MDROS colonization may persists for long periods of time (e.g., months), which contributes to the silent spread of MDROs. Expanded residents for whom EBP applies to include any residents with an indwelling medical device or wound (regardless of MDRO colonization of infection status). Enhanced Barrier Precautions expanded the use of PPE and refer to the use of gown, and goggles during high-contact resident care activities that provide opportunities for transfer of MDROs to the staff hands and clothing. MDROs may be indirectly transferred from resident to resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. During the survey process, from 02/19/24 through 02/22/24, there were no residents on EBP. There was no signage or (Personal Protective Equipment) PPE kits in place at the residents doorways. The Infection Preventionist (IP) was asked to provide a list of current residents who had a wound or indwelling device. Review of this list revealed the following: Resident #2 was admitted to the facility on [DATE], currently had an indwelling urinary catheter, and a pressure injury to the sacrum. The resident was ordered Gentamycin ointment for 14 days as of 01/04/24, for a wound infection. Cloudy urine was observed in the resident's indwelling urinary drainage tube on 02/20/24 at 8:50 AM, and the resident was currently being treated for a Urinary Tract Infection (UTI). Resident #17 was admitted to the facility on [DATE] after hospitalization for a leg fracture. The resident had a metal external immobilizer to her left lower leg with redness observed to the surgical wound. The resident was ordered the antibiotics Cephalexin every 6 hours for 28 days as of 01/30/24 and Doxycycline twice daily for 14 days as of 02/06/24, both as prophylactic measures. Resident #25 was admitted to the facility on [DATE] and had an ostomy (surgical opening) in her abdomen. Resident #138 was admitted to the facility on [DATE] and was being fed via a PEG (percutaneous endoscopic gastrostomy/surgical placement of a feeding tube into the stomach). Resident #188 was admitted to the facility on [DATE] and had an open wound to the heel. These five residents should have been on EBP as per facility policy. During an interview on 02/21/24 at 11:50 AM, the IP confirmed as part of the infection control process, the facility utilized EBP. The IP further explained they only initiate EBP if there was a current resident on an antibiotic and was colonized with an MDRO. During an interview on 02/22/24 in the afternoon, the Director of Nursing (DON) was shown the current CDC guidelines, which was the source of their EBP policy. Upon review of the information, the DON agreed they had not fully implemented their EBP policy to include any resident with an open wound or indwelling device. 25404 4. During a medication pass observation for Resident #18 on 02/21/24 at 4:36 PM, Staff C, Registered Nurse (RN), gathered medications to include an eye drop. The RN went into the resident's room with the medication vial in the labeled box, administered the eye drops, placed the vial of eye drops back into the box, and dropped the box into her lab coat pocket, that was bulging out with other items in it. The RN then went into the resident's bathroom, washed her hands, returned to the medication cart, and placed the now contaminated box into the clean medication cart. During an interview on 02/21/24 at 5:00 PM, when asked about the eye drops in her pocket, the RN questioned, It's a problem even if they are in the box?. When told the box was now contaminated from her pocket and placed into the clean medication cart, the RN stated, Oh yea. 5. Review of the policy, titled, Blood Sampling - Capillary (Finger Sticks), revised September 2014 documented, Steps in the Procedure: . 3. Place blood glucose monitoring device on clean field. 8. Following the manufacturer's instructions, clean and disinfect reusable equipment, parts, and/or devices after each use. 11. Replaced blood glucose monitoring device in storage area after cleaning. During a medication pass observation for Resident #3 on 02/21/24 at 4:44 PM, Staff C, RN, obtained the needed supplies to obtain a blood glucose (sugar) level to include the glucometer (the machine used to obtain the blood sugar level at the bedside). The RN put the supplies in her hand, grabbed a tissue, placed the tissue on the resident's over the bed table placing the lancet, and alcohol wipes on the tissue, and placed the glucometer directly on the over the bed table, that was being used by Resident #3 as evidenced by her personal belonging on the table. Staff C obtained the blood sample and blood sugar level, and returned to the medication cart. The RN properly disposed of the supplies, but placed the glucometer back into the clear plastic storage bag, and placed the bag on top of the medication cart. Staff C proceeded to draw up and provide insulin to Resident #3, returned to the medication cart, and placed the glucometer back into the top drawer of the cart. Staff C provided an additional medication to Resident #3, assisted the resident with dinner set-up, and returned back to the medication cart, stating she was ready to move on to the next resident. During the continued observation and interview on 02/21/24 at 5:00 PM, when asked if she had any additional residents who needed a blood sugar level, the RN stated she did not. When prompted if she was done with the glucometer, Staff C, RN, stated No, I need to clean it. I don't know why I put it back in the cart. 33103 6. On 02/19/24 at 12:15 PM, observations were made in the dining room. There were 11 residents being assisted into the main dining room by staff. Of the 11 residents, 8 residents did not need assistance with their meals. There is a second dining room for residents who are totally independent with meals and had 3 residents in that dining room. Further observations were made that the staff did not offer any hand hygiene to the residents prior to their meal. On 02/20/24 at 12:05 PM, residents were observed to be brought into the dining room from the common area/activity area for lunch. Observations made by another surveyor revealed she did not see residents being offered hand sanitizer / hand hygiene prior to being served food. On 02/21/24 at 12:05 PM, residents were observed coming into the dining room with assistance of staff. They were not offered hand hygiene prior to their meal. On 02/22/24 at 12:05 PM, residents were observed coming into dining room from the common area/activity area. There were 8 residents in the main dining room with 5 residents who were independent for eating meals. The surveyor did not observe residents being offered hand hygiene or hand sanitization prior to their meal. In the secondary dining room for independent eating, there were three residents, a staff and private aide sitting at a table. During an interview on 02/22/24 at 11:38 am, with Staff D, CNA (Certified Nursing Assistant), she stated that she would wash the residents hands before and after eating, and wash them with wash cloth after getting up in morning. She was asked if she hand sanitizes or washes hands of the resident prior to a meal. She stated she will usually wash after eating but not before, During an interview on 02/22/24 at 11:47 AM, with Staff E, Agency Nurse, she stated she makes sure she washes her hands but not residents before meal. During an interview on 02/22/24 at 12:09 PM, with the Dietary Manager (DM), she was asked if staff are supposed to do hand hygiene with the residents prior to having a meal. She stated that the nursing staff is supposed to bring hand wipes prior to a meal. She stated it is her understanding that they had a cart and uses hand sanitizer or with wipes prior to eating but they took it away as one of the residents was taking the wipes. She acknowledged that the staff were not doing hand hygiene with the residents prior to a meal the last three days. She then asked a staff member where the wipes were that are kept in the corner, and they started in the other dining room. The surveyor and dietician walked over to that dining area and did not observe any hand wipes.

Based on observation, interview, record review, and policy review, the facility failed to ensure appropriate respiratory assessment or knowledge of possible medication side effects for 1 of 1 sampled resident, Resident #24, who received a nebulizer treatment. The findings included: Review of the policy, titled, Administering Medications through a Small Volume (Handheld) Nebulizer, revised October 2010, documented, in part, Steps in the Procedure: . 6. Obtain baseline pulse, respiratory rate and lung sounds. 18. Approximately five minutes after treatment begins (or sooner if clinical judgement indicates) obtain the resident's pulse. 19. Monitor for medication side effects, including rapid pulse, restlessness and nervousness throughout the treatment. 26. Obtain post-treatment pulse, respiratory rate and lung sounds. Documentation: The following information should be recorded in the resident's medical record. 5. Pulse, respiratory rate and lung sounds before and after the treatment. 6. Pulse during treatment. Review of the record revealed Resident #24 was admitted to the facility on [DATE]. Review of the current orders of 02/16/24 revealed a nebulizer treatment (medication administered via an aerosol to distribute medications into the lungs) of ipratropium - albuterol was to be administered four times daily, at 6:00 AM, 11:00 AM, 5:00 PM, and 11:00 PM. Further review of the record lacked any type of documented respiratory assessment with the administration of the medication. During an observation on 02/21/24 at 5:56 PM, Staff C, Registered Nurse (RN), obtained the ordered nebulizer treatment medication and went into the room of Resident #24. The RN put the medication into the nebulizer machine, applied the nebulizer mask to the resident, started the treatment, and sat down next to the resident. Staff C failed to do any type of assessment. The RN stated she was just going to sit here for the 15 minutes, and when I'm done I will clean out the machine, and that's it. The surveyor waited in the room about five minutes and then reviewed and confirmed with Staff C that she had put the medication into the nebulizer, started it, and was going to wait 15 minutes. The RN confirmed that was all she had done and was all that she was going to do. When asked if there was any type of assessment to complete, the RN stated, If I hear some wheezing I would listen to her lungs, but this is a routine treatment for her. When asked if there were any other possible side effects associated with the nebulizer medication, Staff C stated, Oh there may be nausea, GI (gastrointestinal/stomach and intestines) upset, shortness of breath, and wheezing. When asked about obtaining an oxygen level or pulse rate, the RN stated, Oh yea, I would do that after the treatment.

Based on observation, interview, and record review, the facility failed to ensure proper positioning of a catheter bag and tubing for 1 of 1 sampled resident reviewed with a history of urinary tract infection ([CONDITION(S)]), Resident #1. The findings included: On 11/14/22 at 10:17 AM, Resident #1 was observed lying in bed, the bed was at low position, and the catheter bag at the bedside was observed with scant hematuria (bloody urine). The catheter bag and tubing were observed touching the floor. When Resident #1 was asked if she had lowered the bed to low position, she stated, 'no, they did' (referring to the staff). On 11/15/22 at 09:07 AM, Resident #1 was observed lying in bed, and the catheter bag was positioned on the floor without protection. Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The significant change minimum data set (MDS) assessment, reference date 09/11/22, recorded a Brief Interview for Mental Status (BIMS) score of 14, indicating Resident #1 was cognitively intact. There were no behaviors recorded in this MDS. This MDS revealed Resident #1 required extensive assistance by staff with activity of daily living (ADLs) care. Review of Physician orders, dated 02/21/20, revealed: [MEDICATION(S)] 500 mg by mouth every 6 hours for Urinary Tract Infection ([CONDITION(S)]), which ended 02/24/20; and on 03/24/20, [MEDICATION(S)] 500 mg by mouth every four times daily for [CONDITION(S)], which ended 03/25/20. Review of care plan, revision date 09/29/22, documented Resident #1 had an infection of the urinary tract. She was at risk for recurrent infection due to use of a suprapubic catheter (SPC) being in place. She goes out to a urologist biweekly for a catheter change. Review of progress notes revealed the following: On 08/19/22 at 7:37 AM, Resident #1 'was noted with increased confusion on this shift. Resident #1 also had hematuria noted in Supra Pubic catheter bag; Medical doctor was notified; Laboratory was due on 08/22/22 were drawn today with a urinalysis, culture and sensitivity (UA, C&S) per the medical doctor to rule out [CONDITION(S)]; The laboratory was called to pick up the urine and the laboratory tech was in to pick up the urine.' On 08/19/22 at 7:38 AM, the laboratory was contacted at 7 AM to request labs results to be faxed to the facility; The laboratory results were faxed over promptly; The nurse sent the labs over to the medical doctor who stated that urinalysis showed chronic bacteriuria, and he will wait for the C&S before any further instructions. On 08/20/22 at 8:38 PM, First dose of [MEDICATION(S)] (antibiotic) was administered [to Resident #1] for bacteremia (presence of bacteria in the urine). On 10/06/22 at 1:33 PM, a noted indicated Resident #1 was started on antibiotic therapy by mouth for bacteriuria on prior shift. On 11/14/22 at 7:02 PM, a note revealed Resident #1 suprapubic catheter noted with gross hematuria output of 200cc this AM. On 11/14/22, beginning at 11:29 AM, an interview was held with the Director Of Nursing (DON) and she was made aware of concern related to catheter bag and tubing observed on the floor. Photographic Evidence had been Obtained. The photographic evidence was shown to the DON. On 11/15/22, beginning at 9:43 AM, another interview was held with the DON; she was made aware again that the catheter bag was observed on the floor today (11/15/22) at 9:06 AM. On 11/15/22 at 09:49 AM, an interview was held with the infection control (IC) nurse. Photographic Evidence had been Obtained. The photographic evidence of the catheter bag being on the floor was shown to the IC nurse, who acknowledged the finding.

Based on observation, record review, and interview, the facility failed to act upon a decline in eating ability, ensure consistent meal intake information, and failed to assist and encourage 1 of 1 sampled resident reviewed for weight loss (Resident #16). The findings included: Review of the record revealed Resident #16 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #16 had a Brief Interview for Mental Status (BIMS) score of 4 on a 0 to 15 scale, indicating the resident was severely cognitively impaired. Further review of this assessment revealed the resident needed the limited assist of one person for eating. Review of the previous MDS dated [DATE] revealed Resident #16 needed only supervision and set up of meals, indicating a decline in ability to feed herself. Review of the current care plans for Resident #16 revealed the following: Effective 02/20/21 to present, the resident had a noted functional decline in self-care, to include feeding. Interventions included to encourage the resident to do as much as able and to promote independence by encouraging active participation. This care plan also instructed staff to use verbal cues to provide instructions. Effective 02/27/21 to present, cognitive skills for daily decision making are impaired - decisions poor; cues/supervision required. Interventions included to remind, redirect, and reorient as needed. Repeat instructions as necessary. Effective 02/21/21 to present, the resident was at nutritional risk related to multiple comorbidities to include dementia. This care plan lacked any intervention related to providing direction or encouragement. An observation on 11/07/22 at 12:11 PM revealed Resident #16 sitting in her room with a lunch tray on an over-the-bed table located to the resident's left side, and not in front of her. The resident was just sitting there, staring at her tray, which was unopened and untouched. When asked if she was going to eat, the resident stated, when they come help me. At 12:16 PM the resident was seen standing in her doorway. The Social Services Director (SSD) assisted the resident into the common area. On 11/07/22 at 12:26 PM, Resident #16 was observed going back into her room for a few minutes, the lunch tray still untouched, then back out into the hall, and headed back to the common area. As a dietary staff passed by, the staff asked the resident about her lunch, and then told the resident she had some ice cream in there (referring back to her room). Resident #16 continued out of her room and went back to common area. The dietary staff asked if she wanted coffee and the resident stated yes. On 11/07/22 at 12:32 PM, Resident #16 went into the main dining room, just off the common area, with the empty coffee cup, and sat down at a table. Her lunch tray remained in her room. At 12:35 PM, Resident #16 was given chocolate ice cream. At 12:37 PM, Staff K, a Certified Nursing Assistant (CNA), noticed the lunch tray in the resident's room, found the resident in the main dining room, and brought the tray to Resident #16, who started eating. On 11/07/22 at 12:44 PM, Resident #16 was no longer in the dining room and the lunch tray had been removed. When asked how much lunch Resident #16 consumed, the Registered Dietician stated she ate about 40% of the lunch. Documentation provided during the survey, and reviewed after the survey, revealed Staff K documented Resident #16 at 75% of the lunch meal on 11/07/22. An observation on 11/08/22 at 12:35 PM revealed the lunch tray for Resident #16 was taken to her room. Resident #16 self-propelled to the main dining room and staff brought her the lunch tray. Staff D, CNA, uncovered the lunch plate and questioned, Are you gonna eat your sandwich? Resident #16 pointed to the soup, and the CNA asked the resident if she wanted her to uncover it. Resident #16 reached over to the soup, started to uncover it, then covered it back up. Staff did not assist nor stay at the table. At 12:40 PM, the resident picked up the covered ice cream and returned it to the tray, then looked at the soup again, picking up the covered dish. Resident #16 then took her sandwich, dipped it into her coffee, and took one bite, putting the sandwich back on the plate. At 12:42 PM, Resident #16 tried to get the attention of dietary staff, who looked her way and kept going, leaving the dining room. Resident #16 put her mask back up over her mouth, which had remained hooked to her ears and just barely below her mouth the entire meal, and just sat back and looked at her tray. At 12:44 PM Staff D, Registered Nurse (RN)/the MDS Coordinator, walked over to the resident and stated, You're not eating; what is going on. Do you want something different. A dietary aide went back to the table and stated she just wanted the ice cream today. Staff D opened the magic cup ice cream, encouraged her to eat it, which the resident did independently. The RN left and the resident continued eating. At 12:50 PM, Staff D returned and asked the resident if she was good. Resident #16 stated, I'm not eating much of this. Observation revealed the soup and cookie remain covered. Resident #16 continued eating, her mask barely below her mouth the entire meal. Staff, including the MDS Coordinator, dietary staff, and the RD, did not assist or encourage her to remove the mask. On 11/14/22 at 12:11 PM, Staff E, CNA, set up the lunch tray for Resident #16, who was sitting in her recliner in her room. The CNA unwrapped the main plate and uncovered the soup. The CNA put a spoon into the soup and left the room. The surveyor remained in the hallway within view of the resident's room. Observations of Resident #16 in her room at 12:14 PM, 12:20 PM, and at 12:43 PM revealed the resident had pushed the over-the-bed table away from herself, and she was sitting back in the recliner chair with her eyes closed. At 12:55 PM, Staff H, Occupational Therapist (OT), went into the resident's room, and took Resident #16 across the hall to therapy. When asked if the resident said anything about lunch, the OT stated, No she didn't say anything about lunch. When asked if she asked Resident #16 if she was finished with lunch, the OT stated she did ask, and the resident stated she was done. The resident's lunch tray remained in her room, untouched. Photographic Evidence Obtained. On 11/14/22 at 1:00 PM, Staff E noticed the resident's room light was off. The CNA went into room, turning on the light, and stated, Are you OK looking for the resident. The CNA left the room not finding the resident, turned off the light, and went back to gathering finished lunch trays from other residents. At 1:28 PM, Staff G, CNA, took the uneaten lunch tray from the room, put it in the dining cart, and removed the cart from the unit. Review of the meal intake for 11/14/22 lacked any documented amount of consumption. On 11/15/22 at 8:16 AM, Resident #16 was observed sitting up in her recliner chair with the breakfast tray on her lap. The resident's eyes were closed, and she had not eaten anything. As per the meal schedule and the RD, breakfast trays were usually delivered at 7:10 AM. At 8:23 AM, the resident's tray had been taken from her room and identified on the dirty food cart. Resident #16 ate less than a half of a slice of toast. Photographic Evidence Obtained. Review of documented weights for Resident #16 revealed a weight of 142.8 pounds on 03/02/22, and a weight of 120.8 pounds on 04/01/22, indicating a loss of 15.41% during that 30-day period. At that time, the magic cup nutritional supplement was added and more frequent weights for one month were obtained by staff. The documented weight for Resident #16 on 11/03/22 was 123.6 pounds. On 11/15/22 at 8:53 AM, the surveyor requested staff to obtain a current weight for Resident #16. The weight obtained at this time was 117.0 pounds, indicating a weight loss of 5.34% in twelve days. The most current nutritional assessment and or nutritional note for Resident #16 was dated 10/21/22. This note documented a 1.18% weight gain in 30 days, a 2.40% gain in 90 days, and a 6.13% gain in 6 months, with a weight of 128.2 pounds as of 10/01/22. During an interview on 11/15/22 at 10:35 AM, the RD explained Resident #16 has Dementia, goes back and forth from her room to the dining room, has multiple supplements in place, and likes to sit in the common area in the evening and have snacks. When asked the process for obtaining weights related to the frequency, the RD explained a new resident was weighed at least weekly the first month, and that all residents were weighed at minimum monthly. The RD explained she uses the weights, the intake records, her observations, and any voiced concerns as a guide if weights are needed more often than monthly. When asked what interventions besides the nutritional supplements have been tried for Resident #16, the RD stated she has asked the resident her preferences. The RD further explained if the resident is not eating well, her staff will ask the resident if she wants something different. The RD stated the staff always check on her and she can have whatever she wants. When asked if they have tried sitting with the resident and encouraging her, the RD stated she believes they have tried that in the past but didn't think it worked. The RD confirmed there was no current restorative program at the facility, which would be used to encourage meal consumption for those that needed extra guidance. During an interview on 11/15/22 at 1:39 PM, Staff H, OT, explained Resident #16 was being seen for a decline in dressing, toileting, and bathing. The OT stated the resident was not currently being seen related to a decline in eating. The OT stated in the past they determined the resident could feed herself but had more of a motivation and cognition problem. When asked about encouraging the resident to eat, the OT stated sometimes the encouragement helped. When asked if she had been told Resident #16 wasn't eating recently, the OT stated she had not been told. During an interview on 11/15/22 at 1:44 PM, the Speech Therapist (ST) confirmed Resident #16 was currently on caseload for cognition issues, not for eating problems. The ST stated when she was on caseload a while back related to possible swallowing issues, the resident could tolerate a regular diet with thin liquids, but needed encouragement. When asked if she was encouraged now, would the resident understand, and the ST stated she would, but she also sometimes says no and will hold on to her no answer. Review of the meal intake record from 11/01/22 through 11/14/22 revealed a lack of documented meal consumption percentages for 13 of 42 meals. Of the documented meal intakes, the resident refused four meals, ate only 'bites' for one meal, ate 25% for 10 meals, 50% for 9 meals, 75% for 4 meals (one of which was observed as inaccurate during the survey), and 100% of one meal.

Based on observation, interview, and record review, the facility failed to ensure care and services for residents with limited range of motion (ROM) was provided for 2 of 2 sampled residents reviewed, Residents #14 and #18. The findings included: 1. Record review revealed Resident #14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly minimum data set (MDS) assessment, reference date 08/18/22, revealed there was no Brief Interview for Mental Status (BIMS) score, indicating Resident #14 was rarely/never understood. There were no behaviors recorded in this MDS. The MDS recorded Resident #14 required total assistance by staff for activity of daily living (ADLs) care. Review of care plan, effective date of 10/18/22, documented Resident #14 had stiffness to bilateral hands. The intervention included: Resident #14 was to have palm guards in place daily, may remove for skin checks and hygiene. On 11/07/22 at 1:50 PM, Resident #14 was observed lying in bed, her hands were tightly closed and there was no splint or palm guard in place. On 11/08/22 at 10:35 AM, Resident #14 was observed lying in bed with no splint or palm guard in place. On 11/08/22 at 11:44 AM, Resident #14 was observed sitting in her wheelchair in her room, both hands were tightly closed, and there was no splint or palm guard in place. On 11/08/22 at 12:30 PM, Resident #14 was observed sitting in her wheelchair in her room, both hands were tightly closed and there was no splint or palm guard in place. On 11/14/22 at 10:33 AM, Resident #14 was observed sitting in her wheelchair in room by herself, she had just received morning care, her hands tightly closed and there was no splint or palm guard noted in place. On 11/14/22 at 11:21 AM, an observation was made of Resident #14 accompanied with the Director Of Nursing (DON), who acknowledged that Resident #14's hands were tightly closed and there was no splint or palm guard in place. She voiced there should be palm guard or rolls in her hands. She added she was going to find out what happened to the palm guards. On 11/14/22 at 1:01 PM, Resident #14 was observed being assisted with feeding by Staff D, Certified Nursing Assistant (CNA). During this time, Resident #14 was observed with palm guards applied to both hands. During an interview with Staff D, she stated she failed to apply the palm guards to the resident's hands this morning. 2. Record review revealed Resident #18 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual MDS assessment, reference date 09/15/22, revealed no documented BIMS score, inidcating Resident #18 is rarely/never understood. There were no behaviors recorded in this MDS. This MDS further revealed Resident #18 required total assistance by staff with ADLs care. Review of care plans, revision date 09/29/22, documented Resident #18 had tightness to left hand, BL knee and right ankle. Resident #18 was immobile and needed assistance with range of motion (ROM). Intervention included: ensure resident was wearing resting hand splint to the left hand daily as tolerated. On 11/07/22 at 9:29 AM, Resident #18 was observed sitting in wheelchair. She had a private aide who revealed 'she was a paid companion;' and she is here every day with Resident #18. Resident #18 was observed with both hands tightly closed. The left hand was tighter than the right hand. When inquired about hand splint or palm guard, the aide showed demonstration of the hands being able to open. She stated I usually apply the palm guard to her hands, but I've been trying to keep her nails nice. At the time, there was no hand splints or palm guard in place. On 11/07/22 At 1:57 PM, Resident #18 was observed lying in bed, both hands were tightly closed, no splint in place. On 11/08/22 at 10:08 AM, Resident #18 was observed in room, sitting in her wheelchair accompanied by the private aide. Resident #18 kept both hands tightly closed, and agian she was not wearing hand splint. The private aide showed that Resident #18 could open her hands with assistance, otherwise, she kept her hands tightly closed. On 11/08/22 at 12:27 PM, Resident #18 was observed sitting in the room by herself, both hands kept tightly closed and there were no splints in place to the hands.

Based on policy review, observation and interview, the facility failed to ensure proper storage of medications in 1 of 2 medication carts observed on the Gardenia Hall and 1 of 1 treatment carts observed on the Gardenia Hall. The findings included: 1. The Policy, Storage of Medications, revised November 2020, indicated the facility stores all drugs and biologicals in a safe, secure, and orderly manner. Under policy interpretation and implementation, #6 revealed compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. On 11/07/22 at 9:13 AM, while standing at the Gardenia unit, the medication cart was observed left opened, and unlock, while unattended. Several staff walked by the medication cart without acknowledging it. At that time, the attending nurse, Staff B, Registered Nurse (RN) was in room [ROOM NUMBER]. The medication cart was facing forward located between rooms [ROOM NUMBERS], and it was not positioned in a place where the nurse could have been able to monitor it. At 9:18 AM, a housekeeping staff walked by without acknowledging the opened medication cart. At 9:19 AM, a Certified Nursing Assistance (CNA) walked by the opened medication cart without acknowledging it. At 9:21 AM, Staff B returned to the hallway and attended to the medication cart. At 9:22 AM, an interview was conducted with Staff B and he confirmed the cart was left opened and unlock and shouldn't have been. On 11/14/22 at 10:56 AM, while at the Gardenia unit, the treatment cart was noted unlock and unattended. On 11/14/22 at 11:24 AM, an interview was held with the Director Of Nursing (DON). Photographic Evidence had been Obtained of the medication cart which was left unlock and opened. The photographic evidence was shown to the DON who acknowledged the finding, stating, she would be doing in-services with the staff. 2. An observation of wound care was made on 11/14/22 beginning at 10:55 AM with Staff F, Licensed Practical Nurse (LPN). Staff F took supplies into the room of Resident #5, and provided the wound care, leaving the locked cart near the room in the Magnolia Hall. Staff F finished care at about 11:05 AM, cleaned up the area, disposed of the trash, hand sanitized and returned to her cart to document the care. Staff F then went to the treatment cart, which was now located at the entrance of the Gardenia Hall (the other unit), and noticed it was unlocked and unattended. Staff F stated she had locked the cart and left it outside of Resident #5's room, and that someone must have moved it. An observation by another surveyor on 11/14/22 at 10:56 AM revealed the treatment cart at the entrance of the Gardenia Hall, unlocked and unattended. During an interview on 11/14/22 at 11:14 AM, Staff J (LPN) and the only other direct care nurse in the facility, confirmed she had moved the treatment cart from the Magnolia Hall and brought it to the current location at the entrance of the Gardenia Hall, to stock the cart. When asked if there was a reason, she had left it open, Staff J stated, not really . but I was having problems with my contact lenses. Resident #16, who is cognitively impaired and was observed multiple times during the survey, self-propelling from her room on the Gardenia unit to the common area, passed the area where the unlock cart was located.

Based on observation, record review and interviews, the facility failed to ensure ongoing activities were provided for 1 of 3 sampled residents, Resident#24, reviewed for activities. The findings included: Review of Resident #24 records revealed an admission to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #24 was currently on Hospice care. Review of her comprehensive MDS (Minimum Data Set), dated 11/25/22, revealed a Brief Interview for Mental Status (BIMs) Score of 99, indicating her cognition was severely impaired. Further review of her section F: Activity Preferences documented: Very Important: Listening to music is very important to her; Books, newspapers, and magazines to read; be around animals such as pets, to do favorite activities; and go outside and get fresh air is somewhat important to her. Review of her care plans revealed she did not have an activities' care plan. Observations of Resident #24 were made throughout the survey process on 11/07/22, 11/08/22, 11/14/22 and 11/15/22. Resident #24 was always observed in her bed or in her high back wheelchair in her room. The resident was never observed in activities, nor was she observed with activity staff coming to see her, during the survey. Throughout the 4-day survey, activities were observed going on in the activities room, but Resident #24 was not observed in attendance at these activities. Review of the Resident #24's activity progress notes documented the following four notes: On 07/30/22, Staff M documented the resident is alert to self with one-word answers. Enjoys listening to 40's big band music on her tv. likes to look at picture magazines especially animals. On 11/03/22, the Social Service Director documented the resident is verbal but unable to follow conversational exchanges; Resident displays some mood issues as evidenced by appearing tired, sleeping more, and problems with conversation; on hospice; and will attend group activities and listen/watch tv in her room. On 11/14/22, during the survey process, it was brought to the Activities Director's attention that the surveyor was reviewing activities for this resident. The Activities Director was home on this day and imputed the following note: 'On 11/14/22, Resident #24 continues to be a Long-Term Care resident, alert to self with confusion, forget fullness and hallucinations. Family is very supportive and visit regularly. Daughter takes her outside for fresh air when she visits. Staff visits daily for friendly visits. She attends group activities to be around others. She likes music programs and socials. Staff takes her to and from groups. She is under hospice care. She has been sleeping more. Staff will continue to visit with her and bring her to groups of interest.' On 11/14/22 at 2:58 PM: 'a 1:1 visitation provided by activities' assistant to Resident#24 this afternoon. She was in her broda chair by her bedside. I spoke with here and read today's [NAME] she mumbled some words and opened her eyes. I asked if she would like to hear some music. She mumbled what sounded like a yes before leaving I put the television on 'sounds of the season'.' Review of the Daily Activities Log that was inputted into the Kiosk by activities' staff documented the following: 08/02/22, family under individual activity 09/04/22, family under individual activity Family outside 10/30/22, Family 11/13/22, Family 11/14/22, 1:1. During an interview on 11/07/22 at 11:53 AM, with the resident's family member, she stated she was not sure if [the resident] goes to activities but she would benefit from it, and she cannot participate but she can sit and listen. During an interview on 11/14/22 at 9:45 AM with Staff L, Activities Assistant, she stated Resident #24 does not come to activities, she likes to be inside her room, we will go in and see her and the Certified Nursing Assistants (CNAs) will bring her out in her chair. She was asked where they document the resident had activities. Staff L stated we will document on the screen on the wall. She was then asked if she could show documentation of activities for or with this resident, and she acknowledged she had never documented on the resident coming to activities. During an interview on 11/14/22 at 1:40 PM with the Activities Director, she stated Resident #24 is up in morning; she comes to things for socialization; she doesn't participate; and likes music, exercise program. She stated the Activities Assistants put in a note and which resident went to activities for the day. During an interview on 11/15/22 at 1:51 PM with Staff M, Activities Assistant, Staff M stated Resident #24 will come out sometimes in morning or when we do activities in the atrium; if she is up, I will include her in group; I will bring her into activities; and we document on the kiosk in the hallway.

Based on record review and interview, the facility failed to ensure care plans were developed for activities and anticoagulant for 3 of 11 sampled residents, Resident #8, Resident #24 and Resident#12, reviewed for care plans. The findings included: 1. Review of Resident #8's records revealed Resident #8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS (Minimum Data Set) documented the resident did not have a Brief Interview for Mental Status (BIMS) Score, indicating the resident's cognition was severely impaired. Review of Resident #8's progress notes documented: activities is spending 1:1 time with the resident. Review of the care plans revealed he did not have a care plan for activities. 2. Review of Resident #24's records revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the comprehensive MDS, dated [DATE], documented the resident had a BIMS of 99, indicating the resident's cognition was severely impaired. Further review of the MDS documented the resident had been on an anticoagulant medication for 7 days prior. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #24's care plans revealed there is no care plan for anticoagulant use or for activities. 3. Record review revealed Resident #12 was admitted to the facility on [DATE]. The admission MDS assessment, reference date 10/18/22, revealed a BIMS score of 15, indicating Resident #12 was cognitively intact. This MDS recorded the activity preferences as follows: 'Somewhat important to have books, newspaper, and magazines to read. Somewhat important to listen to music he likes. Somewhat important to be around animals such as pets. Very important to keep up with the news. Somewhat important to do things with group of people. Very important to do favorite activities. Very important to go outside to get fresh air when whether is good, and somewhat important participate in religious services or practices.' It was documented that Resident #12's care plans were reviewed on 10/27/22, with the participation of required IDT (Interdisciplinary Team) members. Further review of Resident #12's records lacked any documented evidence of care plans specific for activity. On 11/14/22 at 12:07 PM, a side-by-side review of Resident #12's records and interview were held with the MDS coordinator, who acknowledged there were no care plans initiated for activities.

Based on record review and interview, the facility failed to include required point of care staff in the development of care plans for 12 of 15 residents reviewed for care planning, Residents #7, #14, #1, #25, #19, #5, #25, #12, #9, #2, #17 and #10; and failed to review 1 of 15 resident's care plan at least quarterly, Resident #14. The findings included: The facility's policy, titled Care Planning - Interdisciplinary Team, revised September 2013, documented, in Section 2, the care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team which includes, but is not limited to the following personnel: a. The resident's Attending Physician; b. the Registered Nurse who has responsibility for the resident; c. The Dietary Manager/Dietician; d. The Social Services Worker responsible for the resident; e. The Activity Director/Coordinator; f. Therapists (speech, occupational, recreational, et.) as applicable; g. Consultants (as appropriate); h. The Director of Nursing (as applicable); i. The Charge Nurse responsible for resident care; j. Nursing Assistants responsible for the resident's care; and k. Others as appropriate or necessary to meet the needs of the resident 1. Record review of the Interdisciplinary Team (IDT) Care Plan Conference Summary for Resident #1, dated 08/31/21, documented via signature of staff who attended the conference that only the Registered Dietitian and Social Services Coordinator was in attendance. There was no point of care staff, including a nurse responsible for direct resident's care and a direct care certified nursing asssitant (CNA), documented as having attended or who provided input to the development of the resident's care plan. 2. Record review of the IDT Care Plan conference Summary for Resident #5, dated 06/29/21, documented via signatures of the staff who attended the conference that only the Registered Dietitian, a Registered Nurse and Social Services Coordinator was in attendance. There were no other point of care staff, including a nurse responsible for direct resident's care and a direct care CNA, documented as having attended or who provided input to the development of the resident's care plan. 3. Record review of the IDT Care Plan Conference Summary for Resident #14, dated 04/22/21, documented via signature of the staff who attended the conference that only the Director of Nursing (DON), the Activities Director and the Social Services Coordinator was in attendance. There were no other point of care staff, including a nurse responsible for direct resident's care and a direct care CNA, documented as having attended or who provided input to the development of the resident's care plan. Further review of Resident #14's health record revealed that there were no other care plans developed / implemented since the resident's Base Line Care Plan upon admitted [DATE]. During an interview via telephone with the MDS (Minimum Data Set) Coordinator, on 09/10/21 at 8:51 AM, the MDS Coordinator stated that she works remotely and that the Social Worker is responsible for scheduling the meetings with the IDT. During an interview, on 09/10/21 at 8:59 AM with the Social Services Coordinator, she stated that she was responsible for completing the care plans in the facility. She said she would look for the documentation for the care plans in Resident 14 chart. She later reported that she could not find one, and that the Quarterly assessment that should have been completed in July 2021, was not completed. 4. Review of the record for Resident #19 revealed the Interdisciplinary Care Plan Conference (IDT) on 09/07/21 failed to include required personnel. Missing from the IDT conference were a nurse responsible for direct resident's care and a direct care CNA. 5. Review of the record for Resident #12 revealed the Interdisciplinary Care Plan Conference (IDT) on 01/12/21 failed to include required personnel. Absent from the conference were a nurse responsible for the resident's care and a direct care CNA. On 04/16/21, the IDT conference failed to include a direct care CNA. 6. Review of the record for Resident #21 revealed the Interdisciplinary Care Plan Conference (IDT) on 08/17/21 failed to include required personnel. A direct care CNA was not present at the conference. 7. Review of the record for Resident #25 revealed the Interdisciplinary Care Plan Conference (IDT) on 12/29/20 failed to include required personnel. Missing from the conference was a direct care CNA. On 03/22/21, the Interdisciplinary Care Plan Conference (IDT) failed to include a direct resident care nurse. 8. Record review revealed Resident #2 was admitted on [DATE]. An Interdisciplinary (IDT) Care Plan Conference Summary, dated 04/13/21, documented, via signature of participants, attendance by Social Services, Therapy, Dietary, the DON, Activities and the Resident. A Care Plan Meeting Sign-in Sheet completed for meetings that were conducted on 06/09/21 and 06/16/21 documented, via signature, attendance by Activities, Social Services and Rehabilitation. There was no documentation that nursing staff with responsibility to care for the resident attended the care plan conferences. 9. Record review revealed Resident #10 was admitted on [DATE]. An Interdisciplinary (IDT) Care Plan Conference Summary, dated 04/13/21, documented, via signature of participants, attendance by Social Services, Dietary, the DON and Activities. There was no documentation on the summary of nursing staff with responsibility to care for the resident attended the care plan conference. 10. Record review revealed Resident #17 was admitted on [DATE]. The Interdisciplinary (IDT) Care Plan Conference Summary, dated 02/25/21, documented, via signature, attendance by Social Services with no other documentation of attendance of any other staff members, including point of care staff with responsibility of care for the resident, in attendance. An Interdisciplinary (IDT) Care Plan conference Summary, dated 08/19/21, documented, via signature, attendance by Social Services and Dietary. A Care Plan Meeting Sign-in Sheet for meetings conducted on 07/21/21 and 07/28/21, documented, via signature, attendance by Social Services, the Executive Director for the Campus and Rehabilitation. There was no documentation of nursing staff with responsibility to care for the resident in attendance for the care plan conferences. 11. Record review for Resident #7 revealed the care conference was held for the admission care plan review on 07/08/21. There was no evidence of certified nursing assistants' (CNA), dietary, and direct care Nurse participation in this review. On 09/10/21 at 8:51 AM, a phone interview was held with the regional MDS coordinator, who confirmed she was the only MDS coordinator for the facility. She revealed she worked remotely, and the social worker was the person who scheduled the meetings with the Interdisciplinary team (IDT). This MDS coordinator stated, she does the MDSs offsite, and comes to the facility maybe every two months. She advised the surveyor to talk to the social worker regarding MDS care plan meetings. On 09/10/21 at 8:59 AM, an interview was held with the Social Worker, who revealed that the mentioned staff did not participate in the care plan review for Resident #7. She agreed there was no evidence to proof their participation in the review, that included direct care staff for the resident. 12. Record review for Resident #9 revealed the care conference was held for the annual care plan review on 07/07/21. There was no evidence of the certified nursing assistants' (CNAs), dietary, and direct care Nurse participation in this review. On 09/10/21 beginning at 8:51 AM, a phone interview was held with the regional MDS coordinator, who confirmed she was the only MDS coordinator for the facility. She revealed she worked remotely, and the social worker was the person who scheduled the meetings with the Interdisciplinary team. This MDS coordinator stated, she does the MDSs offsite, and comes to the facility maybe every two months. She advised the surveyor to talk to the social worker regarding MDS care plan meetings. On 09/10/21 beginning at 8:59 AM, an interview was held with the Social Worker, who revealed that the mentioned staffs did not participate in the care plan review for Resident #9. She agreed there was no evidence to proof their participation in the review, that included direct care staff for the resident.

Based on record review and interview, it was determined, the facility failed to ensure advance directives were clearly identified in the medical record. This failure affected 1 of 11 sampled residents (Resident #9). The findings included: Clinical record review conducted on 01/22/20 revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) annual assessment with reference date of 11/21/19, documents the resident is independent for skills of daily decision and does not have a condition or chronic disease that may result in a life expectancy of less than six months. Record review revealed a physician order, dated 11/13/18, that the Resident is a full code. Care Plans, dated 11/13/18, document Resident #9 is a full code. The goal noted the resident will have request honored during facility stay with goal date of 02/23/20. The care plan interventions document the nursing staff will provide chest compressions/respirations when the residents heart stops and call ambulance to transfer to hospital. If code status changes, the clinical record will be updated to reflect change. Further review of the record provides evidence of a signed DNR (Do Not Resuscitate) form by the resident and physician, dated 05/01/19. Interview with the Director of Nursing (DON), conducted on 01/23/20 at 9:42 AM, confirmed the advance directives need to be updated to reflect the DNR status. Facility policy, titled Advance Directives, dated 11/23/18, documents, The facility Shall provide each competent resident, at the time of resident's admission to the health center, written information concerning: a resident's rights under state law to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate, at the individual's option, advance directives. The facility should document in the resident's medical record whether or not the resident has executed an advance directives The facility shall ensure compliance with requirements of state law respecting advance directives when the individual is a resident of the health center. The facility will comply with the written or oral declaration of a resident, or the treatment decision of his or her surrogate, made in accordance with the rights granted to the resident and his or her surrogate under Florida law.

Based on record review and interview, it was determined, the facility failed to revise the comprehensive plan of care related to advance directives for 1 of 11 sampled residents (Resident #9). The findings included: Clinical record review conducted on 01/22/20 revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed a physician order, dated 11/13/18, that the Resident is a full code. Care Plans, dated 11/13/18, document Resident #9 is a full code. The goal noted the resident will have request honored during facility stay with goal date of 02/23/20. The care plan interventions document the nursing staff will provide chest compressions/respirations when the residents heart stops and call ambulance to transfer to hospital. If code status changes, the clinical record will be updated to reflect change. Further review of the record provides evidence of a signed DNR (Do Not Resuscitate) form by the resident and physician, dated 05/01/19. Interview with the Director of Nursing (DON), conducted on 01/23/20 at 9:42 AM, confirmed the advance directives need to be updated to reflect the DNR status.

Based on observation, record review and interview, the facility failed to ensure staff provided respiratory care consistent with professional standards of practice, the comprehensive resident-centered care plan, and physician's orders [REDACTED].#13). The findings included: Resident #13 was admitted to the facility with [DIAGNOSES REDACTED]. Physician order, dated 11/22/19, documents to provide continuous oxygen, via nasal cannula, at 4 liters per minute. Oxygen (O2) saturation levels were to be checked each shift. On 01/21/20 at 9:10 AM, Resident #13 was observed with nasal cannula in place. The resident's O2 concentration tank was set at 1.5 liters per minute. The oxygen tubing connected to the O2 tank was dated 01/12/20. The resident was alert and oriented and not observed to be experiencing any shortness of breath, nor did she voice any concerns regarding her breathing (photographic evidence obtained). On 01/22/20 at 11:03 AM, the resident was observed with nasal cannula in place. Resident #13's O2 gauge on her concentrator tank read 1.5 liters per minute. The tubing connected to the O2 tank still had a date of 01/12/20. Resident #13 was alert and oriented and not observed to be experiencing any shortness of breath, nor did she voice any concerns regarding her breathing. The resident stated she was waiting on the nurse to do an oxygen saturation check (photographic evidence obtained). On 01/23/20 at 9:22 AM, Resident #13 was observed with nasal cannula in place. The resident's O2 gauge on her concentrator tank read between 3.5 - 4 liters per minute. The date on the O2 tubing was still documented as 01/12/20 (photographic evidence obtained). On 01/23/20 at 9:23 AM, during an interview with Staff A, she stated, (Resident #13's) Oxygen order is for 4 liters per minute. I check the levels on each shift that I work. The O2 tubing is to be changed every Sunday, but the resident is particular about the tubing and likes it to be changed more often. When the nurse was shown that the tubing was still dated for 01/12/20, she stated she would go and change the tubing immediately. In response to questions about the Resident's oxygen concentrator not being set to 4 liters per minute as ordered, the nurse stated that there had been times she has noticed the settings being off. She was unsure as to who was adjusting the settings. Review of 5-day MDS assessment shows the resident is receiving oxygen therapy. The resident's Care Plan for Ineffective Airway Clearance (Pneumonia), initiated 11/25/19, documents: Resident will maintain normal respirations daily without decreased O2 saturation or respiratory distress through the next 90 days: Interventions include: change all oxygen equipment weekly; check O2 stats every shift and as needed; O2 as ordered 4 liters per minute via nasal cannula. A review of Resident #13's O2 saturation log shows saturation levels being completed per shift. On the following dates/times, the O2 dosage is recorded at between 2-3 liters per minute: 01/23/20 at 5:54 AM and 00:00: saturation was recorded at 94%. 01/22/20 at 9:45 PM and 00:00 (2 undocumented times): saturation was recorded at 94%. 01/21/20 at 2:20 PM and 00:00: saturation was recorded at 95%. 01/19/20 at 9:30 PM and 12:08 AM: saturation was recorded at 96% and at 93%. All other documented O2 saturation checks shows O2 dosage recorded between 3-4 liters per minute, except for 01/20/20 at 6:33 PM, at which time the dosage was recorded at between 4-5 liters per minute.

Based on record review, policy review and interview, it was determined, the facility failed to follow up on a pharmacy recommendation addressing the dose of a [MEDICAL CONDITION] medication for 1 of 5 sampled residents (Resident #5). The findings included: Facility policy, titled Consultant Pharmacist Report dated (MONTH) 2013, documents, the consultant pharmacist performs a comprehensive review of each resident's medication regimen (MRR) at least monthly. The MRR includes evaluating the resident's response to medication therapy to determine appropriate dose, therapeutic effect and possible presence of adverse effects. findings and recommendations are reported to the director of nursing, the attending physician, and if appropriate, the medical director and or the administrator. Recommendations are acted upon and documented by the facility staff and or the prescriber. Clinical record review conducted on 01/23/20 revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The record indicates the psychiatrist saw the resident on 11/05/19 and adjusted the medications. Pharmacy recommendation, dated 11/14/20, documents the Resident is ordered [MEDICATION NAME] 0.5 mg twice a day. According to OBRA guidelines, doses of [MEDICATION NAME] above 0.75 mg daily are not recommended in long term care residents. if the above dose is to continue please document the benefits and why this dose is appropriate for this resident. The recommendation was addressed by the primary care physician with a notation, Defer to Psychiatrist on 11/16/19. Further review of the record failed to provide evidence the psychiatrist had addressed the recommendation, agreeing or disagreeing with a clinical rationale. Interview with the Director of Nursing (DON) conducted on 01/23/19 at 10:13 AM revealed after review of the clinical record, the psychiatrist typically comes every quarter and there is no evidence the recommendation had been addressed since 11/16/19.

Based on record review and interview, it was determined the facility failed to ensure services of a registered nurse was provided seven days a week for at least eight hours a day. This failure is evident by failure to obtain services of a registered nurse during 2 of 55 days reviewed. The findings included: Review of the facility schedules and staffing sheets, dated 12/01/18 through 01/24/19 revealed on 12/30/18, the facility did not have a registered nurse on duty for the 24 hour period. In addition, on 12/02/18, the facility had one registered nurse on duty for five hours during the 24 hour period, failing to meet the eight hour requirement. Interview with the unit secretary and the director of nursing (DON) conducted on 01/24/18 at 2:13 PM revealed that on 12/30/18, the registered scheduled to work, called off and the director of nurses was the substitute noted on the staffing records. The director of nursing clarified and said she was out on vacation on that day, and will investigate further. The secretary confirmed on that 12/02/18, the registered nurse hours did not meet the eight hour requirement. Subsequent interview with DON 01/24/19 at 2:57 PM confirmed the facility did not have the services of a registered nurse on 12/30/18.

Based on clinical record review and interview, it was determined the facility failed to ensure Minimum Data Set (MDS) assessments were coded accurately. This failure affected 4 of 13 sampled residents (Residents #20, #4, #30 and #35). The findings included: 1. Clinical record review conducted on 01/24/19 revealed Resident #20 had a MDS (Minimum Data Set), Quarterly assessment with reference date of 12/24/18. The assessment failed to document active [DIAGNOSES REDACTED]. Review of the Medication Administration Record (MAR), dated 12/2018, indicates the resident received [MEDICATION NAME] 25 micrograms and [MEDICATION NAME] 2.5 mg during the seven-day look back period to treat [MEDICAL CONDITION] and Hypothyrodism. In addition, the records indicate the resident received the flu vaccine at the facility on 10/03/18. Interview with the MDS Coordinator conducted on 01/24/19 at 2:32 PM revealed the active [DIAGNOSES REDACTED]. The MDS Coordinator confirmed the active [DIAGNOSES REDACTED]. 2. Clinical record review conducted on 01/24/19 revealed Resident #4 had a quarterly MDS assessment with reference date 01/17/19. The assessment documents the resident had no behaviors during the seven-day look back period. Review of the MAR, dated 01/2019, revealed the resident experienced behaviors of yelling and striking out staff on 01/12/19, 01/13/19, 01/14/19 and 01/15/19. These behaviors were documented on the behavior monitoring section of the MAR for the use of an antipsychotic. Interview with the MDS Coordinator on 01/24/19 at 2:40 PM confirmed the behaviors should have been documented on the assessment and explained the social worker coded this section. 3. Clinical record review conducted on 01/24/19 documents Resident #30 had an annual MDS assessment with reference date 01/04/19. The assessment documents the resident received the flu vaccine in 10/06/17. Review of the MAR and Nurses notes indicates the resident did not receive the flu vaccine after agreeing to the immunization on 09/01/18 due to medical reasons. The resident had symptoms of upper respiratory infection and the vaccine was held and subsequently given on 01/11/19. Interview with the MDS Coordinator on 01/24/19 at 2:35 PM confirmed the resident initially did not receive the flu vaccine due to medical contraindications and the assessment is coded incorrectly. It should document the vaccine was not given due to medical contraindications, not that the vaccine given in (YEAR). 4. Clinical record review conducted on 01/24/19 documents Resident #35 had an admission MDS assessment with reference date 12/01/18. The assessment documents the resident had behaviors and had no rejection of care during the seven-day look back period. Review of the Nurses notes, dated 11/30/18 and 11/26/18, indicates the resident refused showers, vital signs and Foley catheter care. Interview with the Social Worker on 01/25/19 at 10:38 AM after review of the record, confirmed the behaviors should have been documented on the assessment. The social worker explained the behaviors were not noted, as the resident has a right to refuse care.

Based on observation, record review and interviews, the facility failed to ensure that a care plan was developed to monitor therapeutic blood levels of [MEDICATION NAME], medication changes, and medication administration not by licensend staff, for one (1) of five (5) sampled residents (Resident #34). The findings included: 1. Review of the clinical record of Resident #34 revealed that the resident had physician orders dated 12/29/19 to receive [MEDICATION NAME] 7.5 mg four days a week and [MEDICATION NAME] 5 mg three days a week. The comprehensive care plan for the resident, dated 12/18/19, revealed that the resident was at risk for bleeding due to daily anticoagulant therapy. The care plan goal is documented to maintain lab values within prescribed therapeutic range. Interventions on this care plan included administering medications as ordered, monitoring lab results and reporting abnormal lab results to the Physician. On 01/22/19 at 9:30 AM, the surveyor entered the room of Resident #34 and observed the resident seated in a chair with the spouse at her side. The surveyor observed a plastic medication cup on the top of the bedside chest containing 2 pills and an orange capsule. The medication cup was positioned on a pad of paper entitled, INR and dates listed with the number 7.5 mg and INR 2.9 written on the paper. The surveyor asked the spouse what the documentation was for. He stated that he tests the resident weekly, and calls in the results to a remote lab company. The spouse said the Nurse from the company then calls him back and tells him if he needs to change the dose of [MEDICATION NAME]. The surveyor asked if the nursing staff were aware of the test results and if the facility was aware of any dose changes. The spouse stated the staff remind him to give the resident her evening dose of [MEDICATION NAME], and he then documents what he gives her at that time. He maintains a record of all PT/ INR testing that he performs, the results, and the dose of [MEDICATION NAME] he administers in a log book, which is kept at the bedside. He was unsure if the nursing staff documented the PT/ INR levels in the clinical record. On 01/23/19 at 7:30 AM, the surveyor conducted the medication pass with the nurse. When asked about the resident's anticoagulant monitoring, she stated the husband tracks this and it is not documented in the clinical record. She stated that the resident receives the medication in the evening, so was unaware of the dose the resident received. On 01/24/19 at 10:30 AM, the surveyor accompanied by the Director of Nursing (DON) entered the room of Resident #34. The DON opened the top drawer of the bedside cabinet and observed the following bottles of medications: [REDACTED]. The DON confirmed that the facility failed to ensure that the medications were secured. She stated she would obtain a lock box for the spouse to secure the medications. The surveyor then requested to speak to the evening nurses who ensure the administration of [MEDICATION NAME] in the evening. The DON stated that even though the spouse has been assessed to administer the [MEDICATION NAME], the nurses should observe him actually doing so, to determine if he is administering the appropriate dose each day. A call was placed to one nurse who did not return the call. A second call was placed to Nurse B, who stated that she does not actually observe the spouse give the medications, but she asks him if he has already done so. Nurse B said, sometimes he has to go back to his apartment to get the med's. She confirmed that she does not verify if the resident receives a 5mg or a 7.5 mg dose, but does document the dose as administered on the Medication Administration Record [REDACTED]. The DON confirmed that there was no documentation in the clinical record of the weekly PT/ INR testing conducted by the spouse and that staff were assuming that he was administering the correct dose every day. The DON confirmed that the remote testing firm did not provide the facility with the test results reported by the spouse to them. A side-by-side review of the comprehensive care plan for Resident #34 revealed that the goal was to ensure that the resident's lab values would remain within the prescribed therapeutic range. Facility staff were to administer medications as ordered, to monitor lab results, and report abnormal results to the health care provider. The DON confirmed that since the facility was not verifying what dose was given on any particular day and did not monitor the lab results, they failed to follow the care plan to ensure the resident's lab values remained within the prescribed therapeutic range. A comparison of the MAR for (MONTH) 2019 to the Spouse's log revealed that the Nurses documented that Resident #34 received 5mg of [MEDICATION NAME] on 01/01/19 and 01/09/19. However, the spouse's log revealed that he administered [MEDICATION NAME] 10 mg on 01/01/19 and 01/09/19. The spouse documented that the resident's ordered [MEDICATION NAME], which was 5mg on Mondays, Wednesdays, and Fridays, was reduced to just Monday and Friday on 01/16/19. There were no physician orders in the clinical record or on the Medication Administration Record [REDACTED]. Nursing staff were unaware of this change in the orders. On 01/24/19 at 3:00 PM, the surveyor again interviewed the spouse, who again confirmed that he does not report the PT/ INR results or any changes in doses to the nurses, but that he maintains a log and it is kept at the bedside. The surveyor entered the charting room and spoke to all of the nurses in the room. When asked if they had any PT/ INR results for Resident # 34 in her record, they confirmed that they did not monitor the test results obtained by the spouse. Review of the care plans did not reflect the spouse administering the resident's [MEDICATION NAME], and testing and monitoring the resident's labs.

Based on observation, record review and interviews, the facility failed to coordinate the administration of [MEDICATION NAME] and lab work to monitor the PT/ INR values of 1 of 5 sampled residents (Resident #34). The findings included: 1. Review of the clinical record of Resident #34 revealed that the resident had physician orders [REDACTED]. On 01/22/19 at 9:30 AM, the surveyor entered the room of Resident #34 and observed the resident seated in a chair with the spouse at her side. The surveyor observed a plastic medication cup on the top of the bedside chest containing 2 pills and an orange capsule. The medication cup was positioned on a pad of paper entitled, INR and dates listed with the number 7.5 mg and INR 2.9 written on the paper. Interview with the spouse at this time revealed that he (spouse) had been cleared by the Nurse Practitioner and the facility allowed him to administer all doses of [MEDICATION NAME] to the resident. In addition, he (spouse) said he conducted weekly monitoring of lab work from a remote lab company to ensure that her PT/INR remained at a therapeutic level. He said he did not report the results to facility staff, but showed the surveyor the log book which he kept at the bedside noting the doses of [MEDICATION NAME] he administered each day, INR results, and any changes he was instructed to make by the remote testing company. On 01/23/19 at 7:30 AM, the surveyor conducted the medication observation pass with the nurse. When asked about the resident's anticoagulant monitoring, she stated the husband tracks this, and it is not documented in the clinical record. She stated that the resident is administered the medication in the evening, so was unaware of the dose the resident received. A comparison of the Medication Administration Record (MAR) maintained by the Nursing staff and the bedside log maintained by the spouse revealed the following irregularities: 01/01/19, no administration of [MEDICATION NAME] on MAR; spouse's log had [MEDICATION NAME] 10 mg, with no rationale for increased dose by spouse. 01/02/19, 5mg on MAR; spouse's log had 7. 5mg. 01/03/19, 7. 5mg on MAR; spouse's had log 5mg. 01/09/19, 5mg on MAR; spouse's log had 10 mg. 01/16/19, 5mg on MAR; spouse's log had 7.5mg, and New dose of 5mg on Mondays and Fridays only, with no changes documented on the MAR. On 01/23/19 at 4:30 PM at the request of the surveyor, the DON obtained a copy of the PT/ INR results. It was noted that on 01/09/19, the Nurse for the Cardiologist documented, Patient may have missed one dose, take an extra 7.5mg dose and recheck in one week. The DON confirmed that until the surveyor requested the lab results, the facility was unaware of the order for the additional dose of [MEDICATION NAME], and that the spouse had administered 10 mg of [MEDICATION NAME] on 01/09/19. The DON, at this time, confirmed that the facility staff failed to ensure that the spouse was giving the appropriate dose and that the documentation on the MAR was accurate. She also confirmed that there was no monitoring of the lab testing conducted by the staff, and since the remote testing company did testing, the facility is unaware of the resident's weekly PT/ INR levels. The facility was unaware that the Remote Company had reduced the [MEDICATION NAME] 5mg dose from 3 days a week to 2 days a week due to this lack of communication and/or coordination. On 01/24/19 at 10:30 AM, the surveyor accompanied by the Director of Nursing (DON) entered the room of Resident #34. The DON opened the top drawer of the bedside cabinet and observed the following bottles of medication: one over the counter bottle of [MEDICATION NAME] 100 mg, one over the counter bottle of Senna/[MEDICATION NAME], one labeled bottle of [MEDICATION NAME] 5 mg , one clear plastic container with 5 orange capsules and 5 orange tablets. The Director confirmed that the facility failed to ensure that the medications were secured. She stated she would obtain a lock box for the spouse to secure the medications. The surveyor then requested to speak to the evening nurses who were responsible to ensure the administration of [MEDICATION NAME] in the evening. The DON stated that even though the spouse has been assessed to administer the [MEDICATION NAME], the nurses should observe him actually doing so, to determine if he is administering the appropriate dose each day. A call was placed to one nurse who did not return the call. A second call was placed to Nurse B at this time, who stated that she does not actually observe the spouse give the medications, but she asks him if he has already done so. Nurse B said, sometimes he has to go back to his apartment to get the med's. She confirmed that she does not verify if the resident receives a 5mg or a 7.5mg dose, but does document the dose as administered on the Medication Administration Record (MAR). When asked about the lab monitoring, Nurse B stated that the spouse does this and she does not monitor the results. The DON confirmed that there was no documentation in the clinical record of the weekly PT/ INR testing conducted by the spouse and that staff were assuming that he was administering the correct dose every day. The DON confirmed that the remote testing firm did not provide the facility with the test results reported by the spouse to them. Interviews with the nursing staff on the day and evening shifts confirmed that they did not verify the actual dose of each [MEDICATION NAME] administered each day, although they documented administering the dose on the electronic Medication Administration Record (MAR). The nurses stated that they did not verify the actual test results obtained by the spouse or document the results in the clinical record. The nursing staff also confirmed that there was no documentation from the remote testing company of the spouse reported test results or of any charges in orders that they gave to the spouse. Staff confirmed that they did not compare the spouse's log to the MAR to determine the PT/INR results and did not ensure that the correct dose was documented and/or changed. It was noted that the resident's lab values remained in the therapeutic range. However, there was no evidence of coordination between the spouse, remote testing firm, the cardiologist, and the facility. There was no evidence that the admitting / attending physician was aware that the Cardiologist group was ordering and adjusting the [MEDICATION NAME] dose. On 01/24/19 at 3:00 PM, the surveyor again interviewed the resident's spouse, who again confirmed that he does not report the PT/ INR results or any changes in doses to the nurses, but that he maintains a log and it is kept at the bedside. The surveyor entered the charting room and spoke to all of the nurses in the room. When asked if they had any PT/ INR results for Resident #34 in her record, they confirmed that they did not monitor the test results obtained by the spouse.

Based on observation, record review and interviews, the facility failed to ensure that the nursing staff properly monitored medication for self administration and failed to coordinate monitoring of PT/ INR within the facility for 1 of 5 sampled residents reviewed for Unnecessary Medications (Resident #34). The findings included: 1. Review of the clinical record of Resident #34 revealed that the resident had physician orders [REDACTED]. On 01/22/19 at 9:30 AM, the surveyor entered the room of Resident #34 and observed the resident seated in a chair with the spouse at her side. The surveyor observed a plastic medication cup on the top of the bedside chest containing 2 pills and an orange capsule. The medication cup was positioned on a pad of paper entitled, INR and dates listed with the number 7.5 mg and INR 2.9 written on the paper. The spouse of Resdient #34 informed the surveyor that he had been cleared by the Nurse Practitioner and the facility allowed him to administer all doses of [MEDICATION NAME] to the resident. In addition, he conducted the weekly monitoring of lab work to ensure that her PT/INR remained at a therapeutic level. He said he did not report the lab results to facility staff, and showed the surveyor a log book, which he kept at the bedside, noting the dose he administered each day, the INR results, and any changes he was instructed to make by the remote testing company. Interview with nursing staff on the day and evening shifts confirmed that they did not verify the actual dose each of [MEDICATION NAME] administered each day, although they documented administering the medication on the electronic Medication Administration Record (MAR). The nurses stated that they did not verify the actual test results obtained by the spouse or document the results in the clinical record. The nursing staff also confirmed that there was no documentation from the remote testing company of the spouse reported test results or of any charges in orders that they gave to the spouse. A comparison of the Medication Administration Record (MAR) maintained by the Nursing staff and the bedside log maintained by the spouse revealed the following irregularities: 01/01/19, no administration of [MEDICATION NAME] on MAR; spouse's log had [MEDICATION NAME] 10mg, with no rationale for increased dose by spouse. 01/02/19, 5mg on MAR; spouse's log had 7.5mg. 01/03/19, 7.5mg on MAR, spouse's had log 5mg. 01/09/19, 5mg on MAR; spouse's log had 10mg. 01/16/19, 5mg on MAR; spouse's log had 7.5mg, and a new dose of 5mg on Mondays and Fridays only, with no changes documented on the MAR. On 01/23/19 at 4:30 PM at the request of the surveyor, the DON obtained a copy of the PT/ INR results. It was noted that on 01/09/19, the Nurse for the Cardiologist documented, Patient may have missed one dose, take an extra 7.5mg dose and recheck in one week. The DON confirmed that until the surveyor requested the lab results, the facility was unaware of the order for the additional dose of [MEDICATION NAME], and that the spouse had administered 10 mg of [MEDICATION NAME] on 01/09/19. The DON, at this time, confirmed that the facility staff failed to ensure that the spouse was giving the appropriate dose and that the documentation on the MAR was accurate. She also confirmed that there was no monitoring of the lab testing conducted by the staff, and since the remote testing company did testing, the facility is unaware of the resident's weekly PT/ INR levels. The facility was unaware that the Remote Company had reduced the [MEDICATION NAME] 5mg dose from 3 days a week to 2 days a week due to this lack of communication and/or coordination. Interviews with staff nurses on the day and evening shifts confirmed that they did not compare the spouse's log to the MAR to determine the PT/INR results and did not ensure that the correct doses were documented, and/or changed medication doses. It was noted that the resident's lab values remained in the therapeutic range. However, there was no evidence of coordination between the spouse, remote testing firm, the cardiologist, and the facility. There was no evidence that the admitting / attending physician was aware that the Cardiologist group was ordering and adjusting the [MEDICATION NAME] dose. An additional observation was conducted on 01/24/19 at 10:30 AM, accompanied by the Director of Nursing (DON) after entering the room of Resident #34. The DON opened the top drawer of the bedside cabinet and observed the following bottles of medication: one over the counter bottle of [MEDICATION NAME] 100 mg, one over the counter bottle of Senna/[MEDICATION NAME], one labeled bottle of [MEDICATION NAME] 5 mg, one clear plastic container with 5 orange capsules and 5 orange tablets. The Director confirmed that the facility failed to ensure that the medications were secured. She stated she would obtain a lock box for the spouse to secure the medications. The Self Administration of Medication policy revealed that Self administered medications must be stored in a safe and secure place which is not accessible by other residents. Nursing will document the doses that were self-administered. Review of the policy and procedure for self administration of medications dated 12/19/19 and signed by the spouse of Resident #34 and the Advance Registered Nurse Practitioner, revealed that the resident's spouse was assessed as being safe to administer medications for his spouse The DON confirmed that nursing staff failed to ensure that medications were secured at all times and that the spouse was actually administering the correct doses of [MEDICATION NAME] as ordered by the attending physician. The facility staff failed to monitor the PT/ INR testing and the changes to doses administered by the spouse, as compared to the documentation on the MAR. The nursing staff documented that all doses were self administered by the spouse for Resident #34. However, when interviewed, nursing staff stated that the spouse was only allowed to administer the [MEDICATION NAME]. Nursing staff failed to verify what dose was actually being administered by the spouse as evidenced by conflicting documentation on the spouse's log and the MAR. The DON confirmed that the facility failed to ensure that the resident was monitored appropriately and provided medications in accordance with physician orders, due to their failure to coordinate the testing and administration of [MEDICATION NAME] by the spouse. Refer to F656 and F684.

Based on obervation, record reveiws and interviews, the facility failed to ensure that all medications were secured for 1 of 33 sampled residents, (Resident #34), and a vaccine vial opened for use and not dated. The findings included: 1. An observation of Resident #34 was initiated on 01/22//19 at 9:30 AM. The surveyor entered the room and noted the resident was seated in a chair and her spouse standing at the bedside. A pastic medication cup was positioned on the bedside table and contained 2 round pills and an oblong orange capsule. The sureyor asked the spouse of the resident if the nurse had left the medictions in the room. The spouse stated that he administers the resident's [MEDICATION NAME] and poured it into the cup in preparation for the evening dose. He confirmed that the staff were unaware that he had done so. The surveyor requested that the spouse store the medicaitons in a secure location for the safety of the resident and other residents in the facility. The surveyor then asked the day shift nurse if they kept [MEDICATION NAME] in the medication cart for Resident #34. She showed the sureyor a blister card which had 4 doses of [MEDICATION NAME] 5mg remaining. The nurse stated that the spouse administers the Coundadin and faciltiy staff administered all other ordered medications. On 01/23/19, the surveyor oberved that the resident was not in the room and the top drawer to the bedside table was slightly open. The surveyor could see a bottle of over the counter [MEDICATION NAME] 100mg, a bottle of Senna/[MEDICATION NAME] over the counter, a labeled bottle of Counadin 5mg and two clear plastic containers. One container appeared to have almonds and the other container had 4 large orange capsules and 4 oval orange pills. There were no labels on the containers. On 01/24/19 at 10:30 AM, the surveyor accompanied by the Director of Nursing (DON) entered the room of Resident #34. The DON opened the top drawer of the bedside cabinet and observed the following bottles of medication; one over the counter bottle of [MEDICATION NAME] 100 mg, 1 over the counter bottle of Senna/[MEDICATION NAME], 1 labeled bottle of [MEDICATION NAME] 5 mg , 1 clear plastic container with 5 orange capsules and 5 orange tablets. The Director confirmed that the facility failed to ensure that the medications were secured. She stated she would obtain a lock box for the spouse to secure the medications. 2. Observation of the medication room conducted on 01/23/19 at 9:58 AM while accompanied by Staff A, a Licensed Practical Nurse, revealed a vial of Influenza vaccine opened and not dated. Interview with Staff A during the observation confirmed the vial should have been dated when opened.