Every finding on record at Westminster Point Pleasant

Based on observations, staff interviews and facility record review, the facility failed to operate and maintain the dish washing machine per manufacturer's specifications related to the wash cycle not meeting temperature requirements for one machine of one dish washing machine observed. Findings included: During a kitchen tour on 8/11/2025 at 9:49 a.m., the Kitchen Manager indicated the facility operates a High temperature type dish washing machine and revealed the wash should reach at least 160 degrees Fahrenheit (F.) and a final rinse should reach 190 degrees F. He revealed all staff in the kitchen are trained on how to operate the machine and log temperatures. Review of the specification plate on the dish machine revealed the machine was operating as a high temperature dish washing machine and the wash temperature should reach 160 degrees F., and the Rinse temperature should reach 180 degrees F. The Kitchen Manager confirmed the machine's operations specificationsOn 8/11/2025 at 9:52 a.m., the Kitchen Manager and Staff K, Dining Services Technician, both confirmed they had been operating the machine for about ten to fifteen minutes and had already ran many crates of soiled dishes/eating utensils through the machine. The Kitchen Manager confirmed his staff had already primed the machine by running several empty crates through the machine to ensure appropriate wash and rinse temperatures were met.On 8/11/2025 at 9:56 a.m. Staff K was asked to run a crate of soiled dishes through the machine to show operation and temperature demonstration. He turned on and ran the machine through its wash cycle. The machine's wash analog temperature gauge reached a maximum temperature of 145-degrees F. before ending the wash cycle. The machine's analog rinse cycle temperature gauge read 195 degrees F. The Kitchen Manager confirmed both wash and rinse temperature and revealed the internal temperature of the machine is over 160 degrees F., and that is making the machine operate effectively. He confirmed the analog Wash temperature gauge would only reach 145 degrees F. The Kitchen Manager was asked how he was able to determine that, and he lifted the machine door and pointed downward into the machine. There was no thermometer in the inside of the machine. He closed the door and explained the heat booster is set to over 160 degrees F. and stated that was the temperature reaching the dishes that were running through the machine. The Kitchen Manager confirmed himself and his staff use the machine's analog wash and rinse temperature gauges on the topside of the machine, and he confirmed he goes by what the heating booster is set to. The Kitchen Manager was asked how he and his staff take temperatures of the dish machine operation during each meal service, and he only would say that the heating booster is set to 160 degrees F. and that the machine's outside service maintenance person will speak to that. During this observation, the wash temperature was fifteen degrees lower than the requirement.A second wash cycle revealed maximum temperature reached was 139 degrees F. and the rinse was 197 degrees F. It was found the wash cycle was not meeting the dish washing machines' specifications to reach at least 160 degrees F during the wash cycle and the temperature was twenty-one degrees lower than the requirement. During this tour, it was observed the previously washed dishes were not re-ran through the dish washing machine, nor were they properly cleaned though other cleaning/sanitizing methods. The Kitchen Manager revealed should the machine not run at proper specifications, he had other means of washing the dishes/utensils by way of three compartment sink cleaning and he could use paper and plastic. However, he was not observed to use these methods and his staff continued to utilize the dish washing machine to run soiled dishes through the dish machine's wash cycle readings were 139 degrees F.On 8/11/2025 at 3:50 p.m. a telephone interview was conducted with Staff N, an outsourced maintenance personnel. He revealed he received a complaint related to a possible wash temperature not reaching the machine's specifications. Staff N confirmed the machines specification plate was correct, revealing the machine operates at High temperature and that the wash cycle needs to reach at least 160 degrees F., and the Rinse cycle needs to reach at least 180 degrees F. Staff N revealed he had been to the facility and ran the machine. Staff N stated he found the wash cycle was not reaching at least 160 degrees F and stated he had to increase the temperature on the water heater booster for the machine, so the wash cycle can reach at least 160 degrees F. He revealed upon running the machine several times there was a thirty-degree deficit, and he needed to increase the booster to remove the deficit. Staff N explained another reason the machine was not reading the appropriate wash temperature was due to an internal side curtain not operating effectively and that he may need to replace it in the long term. Staff N confirmed staff needed to read the external analog wash and rinse temperature gauges to know what the cycle's temperature is at. He confirmed having the booster set to a certain degree does not mean the actual Wash and Rinse temperature will reach that level. On 8/12/2025 at 8:40 a.m. the Nursing Home Administrator (NHA) provided information about the current status of the kitchen's dish washing machine. He revealed the facility had switched the dish washing machine from a High temperature machine to a now Low temperature machine. The NHA, as well as an earlier interview with the Kitchen Manager, revealed the machine has the ability to do both High temp washing/rinsing process, as well as Low temp washing/rinsing/sanitizing process. The NHA revealed upon verbal interview with Staff N on 8/11/2025, the facility as an abundance of caution will have the dish washing machine work as a Low temperature and Sanitizing option. The NHA revealed they will await physical report from the maintenance company prior to going back to the High temperature option. The Kitchen Manager confirmed they had now switched to the use of a Low temperature dish washing machine due to the wash cycle not reaching the specified temperature.It was determined the facility did not have a specific dish washing machine operation policy and procedure.

Based on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5%. Thirty-two medication opportunities were observed, and six errors were identified for Resident #29 resulting in an error rate of 18.75%.Findings included: On 8/11/25 at 10:45 a.m., Staff P, Registered Nurse (RN) was observed administering medications to Resident #29. Staff P, RN administered the following medications: Pregabalin 25 mg, Amlodipine 5 mg, Aspirin 81mg, Zoloft 50 mg, Potassium chloride ER 10 meq and Tamsulosin 0.4 mg. Following the medication administration observation, a review of Resident# 29's Medication Administration Record (MAR) revealed the Pregabalin, Amlodipine, Aspirin, Zoloft, Potassium Chloride, and Tamsulosin was scheduled to be administered at 9:00 a.m.On 8/13/25 during an interview Staff O, Licensed Practical Nurse (LPN), said nurses are allowed to administer medications between one hour before and one hour after the scheduled medication administration time. On 8/13/25 at 2:56 p.m. during an interview the Director of Nursing interview (DON) said medications are expected to be administered one hour before and one hour after the time the medication is scheduled. Review of the facility's policy titled Medication Administration, reviewed/revised date 7/2023 revealed the following: Policy- Medications are administered by licensed nurses . in accordance with professional standards of practice . Policy Explanation and Compliance Guidelines .11b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician.

Based on interviews and record review, the facility failed to formulate an advance directive and did not ensure a current copy was in the resident's medical record for one resident (#45) of twenty-six residents sampled.Findings included: Review of the admission record revealed Resident #45 was admitted to the facility on [DATE]. Review of the advanced directives revealed the resident was a FULL CODE status and did not have documentation for the designated POA (Power of Attorney) and the primary decision-maker for care. Review of an admission MDS (Minimum Data Set) assessment, dated 7/17/2025, revealed Resident #45 had a Brief Interview for Mental Status (BIMS) assessment that was not scored, but revealed short-term (ST)/long-term (LT) memory problems with Severely Impaired Decision-Making Skills. An interview was conducted with Staff G, a social worker, on 08/12/2025 at 2:50 p.m. She reviewed the social assessment form that was completed for Resident #45. The form was completed by the resident's spouse on July 14, 2025. The documentation revealed that the spouse has a Power of Attorney (POA) document, and that they would provide the facility with a copy of the POA documentation. Staff G could not find the POA documentation or any evidence that the resident's spouse had been contacted any further to provide the document.An interview was conducted with the social services director, Staff H, on 08/13/2025 at 9:00 a.m. When asked about Resident #45's advanced directive, Staff H attempted to find the information in the electronic medical record. She confirmed that Resident #45 did not have a POA in the record. She stated that the resident's spouse was the emergency contact and has been responsible for the resident's care. Staff H confirmed the spouse reported there was a POA, and that no one from the facility had reached out to get the POA documentation.A follow up interview was conducted with Staff G, social worker, on 08/14/2025 at 9:17 a.m. She stated that the social services office could not find any further documentation relating to the Advance Directive or the Power of Attorney. At 9:20 a.m., a follow up interview was conducted with Staff H. She stated that the resident's spouse was called during the survey period, and a voicemail was left on 08/13/25 at approximately 9:30 a.m. to request the POA documentation.A follow up interview was conducted with Resident #45's spouse at 11:01 a.m. The spouse confirmed they had discussed the Advanced Directive and the Power of Attorney documentation during the initial admission session. The spouse confirmed Staff H called on 08/13/2025 to inquire about the POA. The spouse notes that pictures of the POA were texted to the facility on the morning of 08/14/2025.A review of the facility policy and procedure titled Residents' Rights Regarding Treatment and Advanced Directives with a revision date of 6/2025, revealed: On admission, the facility will determine if the resident has executed an advanced directive, and if not, determine whether the resident would like to formulate an advanced directive. Should the resident have an advanced directive, copies will be made and placed on the chart as well as communicated with staff.

Based on record review and staff interview, the facility failed to complete and update the Pre-admission Screening and Resident Reviews (PASARRs) for residents with qualifying mental health diagnoses for two residents (#3 and #10) of 6 residents reviewed for PASARRs. Findings included: Review of the admission record showed Resident #10 was admitted to the facility on [DATE] with a primary diagnosis of dementia on – 4/14/23 and secondary diagnoses with onset dates, mood disorder - 4/14/23, depression - 4/14/23 irritability and anger - 4/14/23 bipolar - 4/14/23 anxiety - 4/14/23 and failure to thrive - 4/14/23. Review of a level I PASARR for Resident #10 dated 5/28/24 revealed all the qualifying diagnoses were not checked. The review showed the Level I PASARR was incomplete, and a level II was not submitted for consideration following qualifying diagnoses. Review of the admission record showed Resident #3 was admitted to the facility on [DATE] with a primary diagnosis of cerebral infarction on – 2/19/25 and secondary diagnoses with onset dates, depression – 2/19/25 dementia – 2/15/25 psychotic disorder - 2/15/25. Review of level I PASARR for Resident #3 dated 5/28/24 revealed the qualifying diagnoses were not checked. The review showed the Level I PASARR was incomplete, and a level II was not submitted for consideration following qualifying diagnoses. An interview was conducted on 8/13/25 at 08:42 a.m. with Staff H, Social Services Director (SSD). After reviewing Resident #10's Level I PASARR, Staff H stated, “If I had reviewed the PASARR, I would have referred the resident for a Level II.” An interview was conducted on 8/13/25 at 11:55 a.m. with Staff H. After reviewing Resident #3's Level I PASARR, Staff H stated, “I should have triggered a level 2.” Review of an unsigned policy dated 5/2025 titled, Resident Assessment-Coordination with PASARR Program, showed the facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs.

Based on observations, record review and interviews, the facility failed ensure timely assistance with Activities of Daily Living (ADLs) consistent with the assessed and care planned toileting needs for one resident (#48) of three residents sampled.Findings included: On 8/12/ 2025 at 11:30 a.m., Resident #48 was observed lying down in bed, with no signs of distress. The resident reported concerns with his care because a couple of days ago he was placed on a bed pan and left on it for approximately 45 minutes. An interview was conducted on 08/13/2025 at 2:36 p.m. with Resident #48 stating having had to wait about two hours to receive assistance after being placed on the bed pan. He said Staff T, certified Nursing Assistant (CNA) came to his room around 8:00 a.m. and told the resident she was not able to assist him because she could not find his bed pan and she had to go to the dining room. He said he waited for about 15 minutes then he put his call light back on. Another unidentified CNA answered the call light, but she told him she was not qualified to assist him with the bed pan. Resident #48 stated the nurse came to his room and looked everywhere and they were not able to find a bed pan for him. The resident confirmed not receiving toileting assistance and being placed on the bed pan until 10:00 a.m. Resident #48 waited approximately two hours to receive toileting assistance.Review of Resident # 48 admission record dated 08/14/2025 revealed he was admitted to the facility on [DATE] with diagnoses to include but not limited to encounter for orthopedic aftercare following surgical amputation, acquired Absence of left leg below knee, type 2 diabetes mellitus with hyperglycemia.Review of a Minimum Data Set (MDS) dated [DATE] revealed Resident #48 had a Brief Interview Mental Status (BIMS) score of 15 which indicated intact cognitive abilities.On 08/13/2025 at 3:00 p.m., an interview was conducted with Staff T, CNA. Staff T said she went to Resident #48's room around 8:05 a.m., but she was not able to assist him when he asked her to put him on the bed pan because she had to assist in the dining room. She stated she looked around his room but was not able to find his bed pan. She said she offered to transfer him on the toilet, but he told her he was not comfortable with her transferring him. Staff T stated the facility process is whenever they are assigned to the dining room they have to go, and they cannot leave the dining room until dining is finished. Staff T said while she was in the dining room someone came to tell her Resident #48 still needed to go to the bathroom. She said she told the person she could not leave the dining room. Staff T stated she was able to assist Resident #48 on the bed pan at 10:00 a.m.On 08/13/2025 at 5:30 p.m., an interview was conducted with Staff U, Registered Nurse, RN. Staff U said at approximately 8:30 a.m., Resident #48 told her he asked Staff T, CNA if she could assist him on the bedpan. Staff U stated the resident told him she could not assist him because she was not able to find his bed pan, and she had to assist in the dining room. Staff U, RN said she went to the dining room to ask Staff T if Resident #48 asked her to assist him on the bed pan. She stated Staff T replied, Yes, she told Resident #48 she could not find his bed pan, and she had to assist in the dining room. Staff U said whenever someone is assigned to the dining room they have to go. Staff U, RN said she looked all around Resident #48 room, but she was not able to find his bed pan. Staff U stated, I think someone threw the bed pan in the trash. Staff U said she asked her supervisor to ask if she can bring her a new bed pan for Resident #48 around 9:16 a.m. She stated the supervisor brought the bed pan up to the unit around 9:30 a.m. Staff U said she placed the bed pan in the resident's room and left the room to tell the CNA Resident #48 had a bed pan now and was ready to be assisted. Staff U said there was another CNA on the floor that answered Resident #48's call light, but she did not feel comfortable assisting Resident #48 by herself. Staff U confirmed Resident #48 did not receive timely assistance with toileting due to the bedpan not being found and the CNA having to assist in the dining room.On 08/13/2025 at 5:54 p.m., an interview was conducted with Staff Q, License Practical Nurse (LPN)/ Interim Assistant Director of Nurses (ADON). Staff Q confirmed receiving a text message from Staff U at approximately 9:16 a.m., asking her if she can bring her a bariatric bed pan. Staff U said she went to central supply and brought the bed pan up to Staff U at approximately 9:30 a.m. Staff Q, ADON said she was not aware Resident #48 had to wait so long to be put on the bed pan. Staff Q , ADON stated if an aide has to report to the dining room, then the other aide covering the floor should have assisted the resident with the help of the nurse.On 8/13/2025 at 5:58 pm. an interview was conducted with the Director of Nurses, DON. The DON said the first issue was that the staff did not provide Resident #48 with toileting as requested. The DON stated the second CNA, and the nurse could have assisted Resident #48 on the bed pan while the other aide was in the dining room. The DON said If the aide is assigned to the dining room but is in the middle of patient care ,they can switch with another CNA so they can continue with patient care. The DON said their process is for residents to be toileted before and after meals. The DON stated if a resident had an emergency, then someone should be alerted that a resident needs to go to the bathroom so the resident can be provided with assistance.On 08/13/2025 at 6:14 pm, an interview was conducted with the Therapy Director. The Therapy Director said Resident #48 was currently on therapy case load. She said Resident# 48 cannot transfer on the toilet at this time, so it is recommended that he uses the bed pan.Review of the facility policy titled, Abuse, Neglect, and Exploitation, revised 5/2025, revealed under policy - It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of residents property. Definition: Neglect means failure of the facility, its employees, or services providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Based on observations, interviews and record review, the facility failed to provide meal assistance for two residents (#39 and #45) of thirty-four sampled residents during two of three meal observations on 8/11/2025 and 8/13/2025. Findings included: 1.8/11/2025 at 12:30 p.m. Resident #39 was observed seated in the third-floor dining room at a table and with two other residents. By 12:34 p.m. the other two table mates were served and set up with their lunch meal tray. A staff member was observed to serve one of the three residents at the same table and sat down in a chair and proceeded to assist that resident with eating activities. Resident #39 was still observed at the table and had no meal tray in front of her. The other two were eating as Resident #39 watched. Resident #39 was observed to fall asleep twice but would open her eyes from time to time and looked at her table mates. Resident #39 was not interviewable and would not be able to answer questions related to her medical care and day’s activities. At 12:50 p.m. a staff member then placed an uncovered meal tray in front of Resident #39 and walked away. The other two residents at the table were still eating or being assisted with eating from a staff member. Resident #39 sat at the table with her meal tray in front of her and was not able to self-feed and required eating assistance from staff. At 1:08 p.m., Staff B, Registered Nurse (RN) walked into the dining room and looked around and then grabbed a chair and sat next to Resident #39 and began to assist her with eating. She brought a loaded fork of bites of food items to the resident’s mouth, and the resident accepted the food. Resident #39 sat at a table with no food in front of her while other table mates ate for 24 minutes, from 12:34 p.m. to 12:50 p.m. and then waited 18 minutes with her meal tray placed in front of her with no staff assistance from 12:50 p.m. through to 1:08 p.m. Resident #39 waited a total of 42 minutes at the table while others at the table were eating, and she was not able to eat at the same time. On 8/11/2025 at 12:58 p.m. an interview with Staff B,RN who sat down and assisted the resident with eating, revealed she had just walked into the room to take over for Staff A, Licensed Practical Nurse (LPN)/Supervisor who had to leave the room. Staff B confirmed when she came into the room she noticed Resident #39 had her uncovered meal tray placed in front of her and others at the table were already eating. Staff B stated she was not sure why Resident #39 was not assisted with her meal at the same time as her table mates. Staff B, RN confirmed Resident #39 should not have waited that long to be served and assisted with her meal. On 8/12/2025 an interview with Staff A, LPN revealed he was in the dining room the day before on 8/11/2025 during the lunch meal service and he was overseeing the lunch meal service in the dining room. He confirmed he had sufficient staff to serve and assist with meals, and he had sat down to assist a resident with eating. He confirmed about halfway to the end of the meal service, he had to leave the dining room, and another nurse, Staff B came in the room to supervise. He confirmed he had seen Resident #39 at a table with other table mate’s, and he saw that she was continuing to nod off and had her meal tray in front of her. He confirmed Resident #39 does required eating assistance from staff and he had just missed her and was not able to get to her timely. He confirmed she should not have sat with her meal placed in front of her for a long period of time while others at the table were eating and being assisted with eating. Review of Resident #39’s medical record revealed she was admitted to the facility on [DATE] with diagnoses to include but not limited to: Dementia, Senile Degeneration of the brain, Adult failure to thrive, Weakness, Mood disorder, Anxiety, History of falls, Depression. Review of the current Physician’s Orders dated August 2025 revealed Resident #39 received a regular diet, regular texture, regular thin liquid (order date 9/8/2023). Review of a Significant Change Minimum Data Set (MDS) assessment dated [DATE], revealed the following- Cognition: Brief Interview Mental Status (BIMS) score – Not scored. The MDS revealed the resident had short term and long-term memory problems with severely impaired decision-making skills and required substantial/maximal assistance with eating. Review of the nurses progress notes dated 6/1/2025 through to current 8/12/2025 revealed there were no notes to indicated behaviors of refusing meals, refusing meal assistance. Review of the Therapy screen assessment dated [DATE] revealed; Resident screened in dining room. Resident has food in front of her, however, not awake. Aides demonstrated good understanding of not feeding her when she is not alert. Oral care attempted. No reports of difficulty in chewing or swallowing when awake and alert. No further speech therapy at this time. Review of the current care plan with a next review date 9/19/2025 revealed a focus- Current Functional Performance with interventions to include but not limited to: – Limited assist/two-person physical assist with eating. Focus - Impaired communication related to: Cognitive loss, sometimes makes needs known, sometimes understands others, with interventions in place as reviewed. 2. On 08/11/2025 at approximately 12:25 p.m., Resident #45 was observed seated in the third-floor dining room. Resident #45 appeared slightly agitated and constantly moved the left leg. At 12:35 p.m., Resident #45 received a meal tray and did not attempt to eat any of the food. None of the staff were observed to approach the resident for ten minutes. Staff A, Licensed Practical Nurse (LPN)/Supervisor, began to feed Resident #45 after he was asked about the resident’s status. While assisting Resident #45, Staff A fed the resident several bites and then he would leave and assist other residents. Staff A left the dining area at 1:08 p.m., and he was replaced by Staff B, Registered Nurse (RN). She sat down and began to help another resident. Staff B did not assist Resident #45 with his meal any further. Resident #45 still had over half of the food left to finish on his plate at 1:10 p.m. The resident was not assisted for a total of 25 minutes during this observed mealtime. On 08/13/2025 at 9:15 a.m., an interview was conducted with Staff D, Certified Nursing Assistant (CNA). She stated that the resident needed hands-on care due to dementia. Staff D stated that the resident will self-feed but requires encouragement. On 08/13/2025 at 12:33 p.m. Resident #45 was observed in the third-floor dining room. The resident appeared slightly agitated with a bowl of soup and a disposable juice cup in front of him. He was seated at a table with one other resident. Resident #45 did not attempt to eat the soup. Staff E, Speech Therapist (ST), sat down next to the resident at 12:35 p.m. to assist the other resident. He did not encourage Resident #45 to eat or attempt to feed the resident. At 12:45 p.m., the resident received his tray of food. At 12:52 p.m., the resident reached for his soup spoon and then stopped. At 12:58 p.m., a CNA, Staff F, helped the resident bring the food to his mouth and help cut up his food. At 1:00 p.m., Staff F poured his juice into a glass, and the resident began to drink it. An interview was conducted with Staff F at this time. She stated Resident #45 did not need assistance with his meal, but he does need encouragement to eat. Staff F stated she was unsure about the resident’s care plan, but she was told he needed assistance by one of the therapists. During this observed mealtime, Resident #45 was not assisted for a total of 25 minutes during this observed mealtime. Review of the admission record revealed Resident #45’s diagnoses to include but not limited to: Other Pulmonary embolism without acute COR pulmonale, Aphasia and Dysphagia following cerebral infarction and Unspecified dementia, unspecified severity without behavioral disturbance. Review of the current Physician’s Order Sheet for Resident #45 dated July 2025, revealed related to diet, - No added sugar diet, regular texture, regular thin liquids consistency. (7/11/2025) and Malnourished per Mini Nutritional Assessment (MNA) score of 7, indicates malnourished from stress related to hospital stay. BMI is above 23. A diagnosis of Dementia, CVA, Aphasia, with Albumin level of 3.2 on 7/12/2025, and requires assistance to eat. Review of the current care plan with a next review date 10/11/2025, revealed a focus - Current Functional Performance with Interventions to include but not limited to: Eating – Limited assist/one-person physical assist. A secondary focus revealed Resident #45 has impaired mobility and self-care deficits, with interventions to include the use of task segmentation and verbal cues as needed to promote resident participation and completion of tasks. A review of the current Minimum Data Set (MDS) assessment for Resident #45 dated 7/17/2025, section GG revealed the resident needs assistance with eating – The ability to use utensils to bring food and/or liquid to the mouth- the resident needed supervision or touching assistance. Review of a Speech Therapy Discharge Summary with dates of service 7/14/2025 through 8/13/2025, revealed the resident required set up for meals, and encouragement to initiate self-eating meals. Most of the time, resident required someone to set the fork up for the first few bites, and place the fork in the resident’s hand, and then 50% of the time or greater the resident will continue self-feeding, but not all of the time. On 08/13/2025 at 1:09 p.m. an interview was conducted with Staff C, ST. She stated if she loaded the fork for the resident and used verbal cues, then Resident #45 will begin to feed himself. Staff C stated the verbal cues must be specific. She stated she was unsure about what requirements were listed in the resident’s care plan. Staff C took Staff F’s place in assisting Resident #45 at 1:15 p.m. Staff C began to encourage the resident to eat, and he began to eat more of his meal. An interview was conducted with Staff A, LPN Supervisor, on 8/13/2025 at 1:17 p.m. He stated he wanted Resident #45 to feed himself as much as he could during the meals. He stated he was not sure about the required assistance that was listed in the care plan. When asked who was in charge in the dining room, Staff A stated that he was not in charge. Staff A reviewed Resident #45’s care plan and stated the aides should ask one of the nurses if they were unsure about the residents’ required care. Staff A stated the aides can also use their Kardex (a file that gives a brief overview of each patient), to review the resident’s nutrition care requirements. Staff A reviewed a copy of the Kardex, which showed Resident #45 required limited assistance/one-person physical assistance for eating. A follow-up interview was conducted with Staff C, ST, at 1:30 p.m. She confirmed the resident will often get distracted and may need to be helped during the meal. She stated once she cued Resident #45 to eat during lunch, he then continued to eat. She agreed that the resident should have been cued to eat his meal earlier. A telephone interview was conducted with Resident #45’s spouse on 08/13/2025 at 3:34 p.m. The spouse stated the resident gets distracted when eating. The spouse stated the resident can self-feed but will often lose train of thought. The resident is a slow eater and needs “management” during meals. The spouse stated this had been discussed with the staff. On 08/14/2025 at 9:40 a.m., an interview was conducted with Staff B, RN. She confirmed Resident #45 needs assistance with eating. Staff B said the resident will usually not self-initiate and will need someone to help get the meal started. She confirmed the aides should know the resident’s needs by reviewing the task bar in the record. Staff B stated that the kitchen staff oversees the food and knows the meal plans. She stated that the nurse present in the dining room is the supervisor of the aides and monitoring the residents. She stated the nurses will also assist with feeding residents if help is needed. An interview was conducted with the Director of Nursing (DON) on 08/14/2025 at 10:03 a.m. He stated the nurses and nursing aides can use the Kardex to find out the assistance needs for any resident in the dining room. He confirmed the nurses oversee the residents care in the dining room. Review of the facility policy titled, “Meal Supervision and Assistance” with a revision date of 5/2025 revealed the following under Compliance Guidelines section 4: -Assemble equipment and supplies needed. Do not serve the meal until the attendant is ready to assist the resident.

Based on record review and interview, the facility failed to implement timely their Abuse, Neglect and Exploitation policy and procedure related to reporting alleged abuse and neglect incidents for three residents (#1, #2, and #3) of three sampled for Abuse and Neglect. Findings included: 1. A review of the facility's Abuse Log showed Resident #1 had an incident, date notified of allegation was on 05/15/2025, reported to DCF (Department of Children and Families) on 05/15/2025. The incident was documented as Yes to being substantiated, and Yes it was an adverse related to Resident #1 did not receive medications for two days, which was communicated immediately to the Abuse Coordinator on 05/10/25, the date the event started. A review of Resident #1's admission Record documented an admission to the facility on [DATE]. Review of a progress note dated 05/08/2025 showed Resident #1 was transferred to a local hospital on [DATE] at 1312 (1:12 p.m.), for an evaluation and subsequently returned on 05/08/2025 at approximately 2000 (8 p.m.) The resident was transferred back to the hospital again on 05/10/2025. Her diagnoses list included but not limited to: Metabolic encephalopathy; Type 2 Diabetes mellitus without complication; dysphagia; cognitive communication deficit; difficulty in walking; cardiomegaly; elevated white blood cell count; anemia; polyneuropathy and severe chronic kidney disease stage 4. On 06/10/2025 at 1:27 p.m. an interview was conducted with the Nursing Home Administrator (NHA). The NHA stated the Interim Director of Nursing (IDON) became aware of the allegation when the Nurse Practitioner (NP) voiced a concern about Resident #1 not receiving her medications on 05/15/2025. The NHA stated, the IDON reported this to her that day at 1:46 p.m. The NHA said, I reported to DCF on 05/15/2025 at 2:06 p.m. For the investigation, we went back to look at the medical records to determine what happened when she left the building, what medications were ordered, and discussed with the NP her concern with the change in condition for the resident's trip to the hospital on 05/10. The NHA stated there were issues with documentation and their process for placing medications on hold was not followed. 2. A review of the facility's Abuse Log showed Resident # 2 had an incident, date notified of allegation was 06/01/2025 and DCF was notified on 06/03/2025. Incident was documented as not substantiated related to Resident #2's family member voiced an allegation of neglect on 06/01/25 at approximately 2:00 or 3:00 p.m. A review of Resident #2's clinical record, the minimum data set, Significant Change assessment dated [DATE], documented an admission of 01/24/2025. Her diagnoses list included but not limited to: Anemia, atrial Fibrillation, Coronary Artery Disease, and heart failure. An interview was conducted on 06/10/2025 at 12:03 p.m. with the NHA. The NHA stated the allegation for Resident #2 was that the resident was not given medication when she had a high blood pressure. The NHA said, I received the allegation by way of a text on 06/01/2025 at approximately 2:00 p.m. or 3:00 p.m. Resident #2's family member reported the resident's blood pressure was high, a reading of 186, and he was concerned the nurse was not going to do anything. The NHA said, Yes, he used the word neglect. A review of the reportable event submitted by the NHA reflected the NHA reported online to the DCF the allegation of neglect on 06/03/2025 at 5:00 p.m. The NHA confirmed she was the abuse coordinator. She stated the expectation was to report immediately which means within 2 hours but, no later than 24 hours. The NHA confirmed the allegation for Resident #2 was reported late. 3. A review of the facility's Abuse Log showed Resident #3 had an incident, date notified 06/05/2025. DCF was notified on 06/08/2025. The incident was documented as in progress. The review showed the resident self-reported an allegation on 06/06/2025 at approximately at 7p.m. Documentation revealed the allegation was not reported until 06/08/2025 at 4:02 p.m. with the facility not implementing protection for the resident. A review of Resident #3's admission Record documented an admission of 06/05/2025. Her diagnoses list included but not limited to displaced communicated fracture of shaft of humerus, right arm, subsequent encounter for fracture with routine healing, repeated falls, difficulty in walking and unspecified atrial fibrillation. An interview was conducted on 06/10/2025 at approximately 11:45 a.m. with the NHA regarding Resident #3. The NHA stated, Resident #3 was admitted on [DATE]. The allegation was the resident did not get any pain medication until the next day. The NHA stated Resident #3 reported the allegation to her on 06/06/2025. The NHA stated the resident was not satisfied with the care up to that point and the pain was not being addressed with the medication she was taking. The NHA stated she spoke to Staff A, Licensed Practical Nurse (LPN) who reported he had worked on a Percocet prescription for Resident #3. Staff A, LPN reported Resident #3 came from the hospital with orders for the Percocet. The NHA stated the prescription did not come with her from the hospital and the provider wrote a new prescription which was not sent to the pharmacy due to a fax machine issue. The NHA reported she had asked for the medication at 8:00 a.m., and it was around noon that the staff could retrieve it from the Emergency Drug kit. The NHA stated the reportable event was a work in progress and she had not had a chance to speak with Staff B, Registered Nurse (RN) who was the admitting nurse. The NHA stated, No, I have not had the chance to talk to her. I do not know if she worked in the days after the 06/05/2025 shift. A review of the reportable event submitted by the NHA, reflected that she had reported online DCF the allegation of neglect on 06/08/2025 at 4:02 p.m., which was more than 24 hours after she had received the allegation. An interview was conducted on 06/10/2025 at 4:23 p.m. with Staff C, LPN. while reviewing Resident #3's clinical chart. Staff C, LPN confirmed she had worked on 05/10/2025 and Resident #1 was running a temperature. Staff C stated she called the NP who gave orders for Augmentin confirmed at 8:50 p.m. Staff C stated she found out Resident's #1 medications had been placed on Hold. Staff C stated Resident #1's family member was at the facility and was upset about the medications being on Hold. Staff C said, I was not going to tell the [family member] the medications that were not given to the resident for the last couple of days. Staff C stated she notified the NP. She reported the NP stated, Nobody ever puts medications on hold. If there was an issue, then the DON (Director of Nursing) needs to be notified. A review of the facility Abuse, Neglect and Exploitation policy and procedure, last reviewed/ revised 05/2025, documented the policy: it is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Included in the definitions: Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Policy Explanation and Compliance Guidelines: .2. The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law. 3. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. In section VI. Protection of Resident: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation. B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed. C. Increased supervision of the alleged victim and residents. D. Room or staffing changes, if necessary to protect the resident(s) from the alleged perpetrator. E. Protection from retaliation. In section VII. Reporting/ Response: A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specific time frames: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on observations, interviews and record review, the facility failed to ensure eating assistance and adaptive eating equipment was provided for one resident (#83) out of twenty-two sampled residents. Findings included: On 4/24/2023 at 12:40 p.m. Resident #83's room was approached and from the hallway, the resident could be seen in his room seated in a high-back wheelchair next to his bed, with the over the bed table positioned in front of him. The resident was noted to be alone in the room with his meal tray placed in front of him. The floor beneath him was observed with what appeared to be a puddle of red liquid. The resident was able to confirm he had dropped some liquid on the ground. Resident #83 was interviewed; he was noted to have to take time to answer general questions about his day. The resident was noted to have some food pocketed within his mouth on both sides. While in the room with Resident #83 from 12:40 p.m. through to 12:52 p.m., no staff were observed to enter the room to assist the resident with his meal. The meal tray was observed to be a non divided plate and both of his eating utensils were regular silverware. A review of the meal ticket on the tray, revealed; Resident #83, Diet - No Added Salt Mechanical Soft texture and Nectar Thick liquids, and AE Curved Utensil/Divided plate. No adaptive eating utensils were observed on the meal tray. Photographic evidence was taken. On 4/26/2023 at 12:40 p.m. Resident #83 was noted in his room and seated in his high back wheelchair next to the bedside. The over-the-bed table was positioned in front of him, and he had his lunch meal tray placed on the table. Staff A, Certified Nursing Assistant (CNA) was observed in the room and standing up in front of the resident with a spoonful of food being brought to his mouth. Staff A was asked if the resident had any adaptive equipment and she explained, No they took that away because he now requires assistance with feeding. The resident was not provided with a divided plate and was not provided with any adaptive built-up eating utensils per the current meal ticket. Photographic evidence was taken. Staff A stated she could not remember the last time he had the eating adaptive equipment. She continued to scoop food from his plate and tried to bring the spoon to his mouth, while standing in front of him. Resident #83 shook his head in a yes manner when asked if he could self-feed. Staff A gave him the spoonful of food item and allowed him to grip the spoon and he brought it to his mouth himself. She explained she needs to make sure she has her hand very close to the eating utensil as he really cannot eat on his own and needs assistance. While Resident #83 brought the spoon to his mouth, there was not any immediate concerns. Staff A was asked if speech therapy was working with the resident and she revealed, Yes, but I forgot her name. The resident then said, Staff B was the speech therapy member, and Staff A then confirmed the same name. On 4/26/2023 at 12:55 p.m. Resident #83's was observed seated in his room with his lunch meal tray placed in front of him. He had already started his meal with assistance from Staff A at 12:40 p.m., however, Staff A was not in the room. Resident #83 was not attempting to eat on his own. His meal tray still had approximately 50% uneaten food items on it. Staff A was observed in the room next door, seated in a chair, and assisting another resident with eating needs. At 1:00 p.m. Staff A was observed to get up from assisting the other resident and go over to Resident #83's room and begin to assist him with his meal. She brought forkfuls of food to his mouth, while allowing him to take bites slowly, and then chew and swallow slowly. At 1:15 p.m., Staff A was no longer in Resident #83's room, and she was again noted in the room next door seated in a chair and assisting the other resident with eating needs. There was no other staff member noted to be assisting Resident #83's during the meal. Resident #83 was not observed to try and eat on his own, but his meal tray was still observed with uneaten food items on it. At 1:20 p.m. Staff A stopped assisting the other resident in the next room and walked back to Resident #83's room to continue to assist him with his eating needs. Resident #83 accepted the food that was brought to his mouth. An interview with Staff A revealed, Resident #83 wanted a break so I ran over to start feeding the other resident and then I will go back and assist him. She stated, There are not a lot of staff on this hallway, and I do the best that I can with all those who require eating assistance. She stated the residents who require eating assistance should have staff in the room during the entire time of the meal service, and to not leave to help others. A review of Resident #83's medical record revealed he was admitted to the facility on [DATE]. The advance directives revealed Resident #83 had a Power of Attorney in place to make his medical and financial decisions. A review of the diagnosis sheet revealed diagnoses to include but not limited to: Parkinson's, dementia, seizures, Alzheimer's, dysphagia, depression, cognition communication deficit, and age-related physical debility. A review of the current Minimum Data Set (MDS) Quarterly assessment, dated 3/9/2023, revealed the following. Speech: Speech clarity section revealed - Unclear Speech, usually understood, understands others; Cognition/Brief Interview Mental Score/BIMS score - 15 of 15; Activities of Daily Living/ADL: EATING activities = Limited Assistance with One person assistance; Swallowing/Nutrition: Not checked for holding food, not checked for loss of liquids, not checked for coughing, or choking, not checked for complaints of pain or problem swallowing; Oral/Dental - Not checked for difficulty with chewing. A review of the 4/2023 order sheet, revealed the following but not limited to: - Extend speech therapy for dysphagia, daily x 3 days x one week x four weeks with order date 4/12/2023. - Please ensure additional assistance to self-feed is provided for resident at meal times. Is able to self-feed but very slowly (also wife's request), x shift with order date 3/24/2023. - No Added Salt diet, Mechanical soft texture, Nectar thick liquids with built up curved utensils and divided plate with order date 3/13/2023. - Speech therapy to evaluate and treat as indicated speech therapy to treat daily x 4 days x one week x four weeks for dysphagia therapy. Downgrade liquid to nectar thick liquid. Continue mechanical software, with order date 3/13/2023. A review of the therapy screen, dated 3/9/2023, revealed the following: Range of Motion/ROM, decreased strength, transfers; Self-care revealed not checked for needing assistance and is self-feed; Safety section revealed - not checked for choking or swallowing. Notes indicated - Recently discontinued from Physical Therapy on 2/14/2023, with no significant change in functional mobility status, no skilled therapy indicated this time. A review of the nurse progress notes revealed the following: 3/9/2023 09:26 mini nutrition - Not suffered psychological stress or acute disease in past three months. Has severe dementia. 3/9/2023 11:44 ADL only - Revealed EATING = Self performance, supervision, support provided and set up help only. 3/14/2023 16:16 Nutrition - Low risk malnutrition. Mech soft and had been eating well +75% some slight decrease in intakes noted past two days. SLP will be working with him. He continues to receive the built-up curved utensil and divided plate and is able to feed self after setting up with minimal assist. 3/19/2023 20:37 - Health status note - CNA updated on oral intake. Able to self-feed his cheesecake on his own but requires assistance to feed any other meals. 3/28/2023 22:14 - Resident has trouble swallowing meds, meds are crushed and placed into pudding to facilitate swallowing, resident holds meds in his mouth until they begin to drool from the mouth. Staff assist with meals, which is very long process related to the time it takes for the resident to swallow. 4/13/2023 19:36 - RD Nutrition note/assessment - Resident had diet downgraded. Diet is NAS mech soft with nectar thick liq. He does receive adaptive equipment for self-feeding efficiency. Has self feeding deficits. 4/21/2023 17:31 Communication with family - Resident requires assist with eating, able to feed self, but slow. A review of the comprehensive care plan, with next review date of 6/7/2023, revealed the following but not limited to problem areas: - Current Functional Performance with interventions in place to include but not limited to: Resident performance EATING - Limited assist/one-person physical assist. - Potential for Aspiration related to diagnosis dysphagia with difficulty chewing and swallowing. Resident is on a modified consistency diet related to history of pocketing food and medication with difficulty swallowing, with interventions in place to include but not limited to: All staff to be informed of special dietary and safety needs, Built up curved utensils and divided plate for all meals. Check mouth after meal for pocketing food and debris. Report to the nurse. Provide oral care to remove debris, Supervise and assist at mealtimes and with nutrition and fluid intake as need, instruct to eat in an upright position, to eat slowly, and to chew each bit thoroughly, Monitor for choking, drooling, holding food in mouth, several attempts at swallowing, appears concerned during meals, Refer to speech therapist for swallowing eval. - Self Care deficit, needs extensive assist with ADL related to Parkinson's needs assist with meals and adaptive equipment with interventions in place to include but not limited to: Allow for rest periods between ADL tasks, Divided plate, and built-up curved utensils for all meals, provide physical assistance to resident as needed to complete tasks. - Risk for malnutrition due to dementia, limited mobility and elevated BMI potential for weight variance and decline in intake due to Parkinson's, dementia, Alzheimer's, and depression. Significant wt. loss is noted. Needs assistance with set up help for all meals and feeding. Needs adaptive equipment to assist with self-feeding, with interventions in place to include but not limited to: Allow resident ample time to consume food, provide adaptive equipment as ordered each meal. The above listed care plan problem areas indicated Resident #83 should receive both Eating assistance and also the use of adaptive Eating equipment during meals. However, staff were not consistent with following the care plan interventions. On 4/26/2023 at 2:10 p.m. an interview was conducted with Staff B, Speech Therapist, and the Director of Rehabilitation Services (DOR). Staff B stated she was well acquainted with Resident #83 since his admission and was able to state his primary diagnosis of Parkinson's as a condition that will have periodic changes in presentation for his care. Staff B mentioned Resident #83 as a [NAME] that loves to eat. Staff B stated the resident would need ques to close his mouth at times in order to remind the patient to swallow. Staff B denied pocketing of food was an issue for the resident, and stated the resident had a strong cough response. Staff B stated assistive devices during meals for Resident #83, such as lipped plate with dividers and built-up eating utensils, was an Occupational Therapy plan and not a Speech Therapy plan. On 4/27/2023 at 9:15 a.m. an interview was conducted with Staff C, MDS Coordinator and Staff D, MDS Coordinator. Both were aware of the resident and needs in relation to care and services. Staff C stated she knew Resident #83 was assessed and care planned for Eating- Activities of Daily Living (ADL) and was coded for Limited Assistance with One-person Assistance. She stated a resident who was coded for Limited Assistance with One person Assistance would mean the staff member would indeed need to be present in the room or dining room during the entire time the resident was eating. Staff C and Staff D confirmed Resident #83 was on swallowing and chewing precautions and was being seen on case load from Speech Therapy. Staff C stated Resident #83 should be provided with Limited Assistance with Eating but also should be supervised at all times during his meal service. Staff C and Staff D confirmed Resident #83 was ordered, and care planned for Adaptive Eating equipment to include Built Up Eating utensils and a Divided Plate. They were not aware he did not receive adaptive equipment and he should have and still should receive the equipment with meals. On 4/27/2023 at 10:00 a.m. the Director of Nursing (DON) provided the Activities of Daily Living (ADL) policy and procedure with a revised date of 4/2022 which revealed the following: The Policy stated, the facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. (#4) of the policy revealed; Eating to include meals and snacks. The Policy Explanation and Compliance Guidelines revealed the following but not limited to: (#1) Conditions which may demonstrate unavoidable decline in ADLs include: a. Natural progression of the resident's disease state with known functional decline, b. Deterioration of the resident's physical condition associated with the onset of an acute physical or mental disability while receiving care to restore or maintain functional abilities, c. Refusal of care and treatment by the resident or his/her representative to maintain functional abilities after efforts by the facility to inform and educate about the benefits/risks of the proposed care and treatment; counsel and/or offer alternatives to the resident or representative. (#3) A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal oral hygiene.

Based on observations, interviews and record review, the facility failed to ensure care planning interventions were implemented related to; 1) Not providing adaptive eating equipment during meal service, and 2) Not offering and assisting with braces/splinting for contracture management for two residents (#83 and #36) out of twenty-two sampled residents. Findings included: 1) On 4/24/2023 at 12:40 p.m. Resident #83's room was approached and from the hallway, the resident could be seen in his room seated in a high-back wheelchair next to his bed, with the over the bed table positioned in front of him. The resident was noted to be alone in the room with his meal tray placed in front of him. The floor beneath him was observed with what appeared to be a puddle of red liquid. The resident was able to confirm he had dropped some liquid on the ground. Resident #83 was interviewed; he was noted to have to take time to answer general questions about his day. The resident was noted to have some food pocketed within his mouth on both sides. While in the room with Resident #83 from 12:40 p.m. through to 12:52 p.m., no staff were observed to enter the room to assist the resident with his meal. The meal tray was observed to be a non divided plate and both of his eating utensils were regular silverware. A review of the meal ticket on the tray, revealed; Resident #83, Diet - No Added Salt Mechanical Soft texture and Nectar Thick liquids, and AE Curved Utensil/Divided plate. No adaptive eating utensils were observed on the meal tray. Photographic evidence was taken. On 4/26/2023 at 12:40 p.m. Resident #83 was noted in his room and seated in his high back wheelchair next to the bedside. The over-the-bed table was positioned in front of him, and he had his lunch meal tray placed on the table. Staff A, Certified Nursing Assistant (CNA) was observed in the room and standing up in front of the resident with a spoonful of food being brought to his mouth. Staff A was asked if the resident had any adaptive equipment and she explained, No they took that away because he now requires assistance with feeding. The resident was not provided with a divided plate and was not provided with any adaptive built-up eating utensils per the current meal ticket. Photographic evidence was taken. Staff A stated she could not remember the last time he had the eating adaptive equipment. She continued to scoop food from his plate and tried to bring the spoon to his mouth, while standing in front of him. Resident #83 shook his head in a yes manner when asked if he could self-feed. Staff A gave him the spoonful of food item and allowed him to grip the spoon and he brought it to his mouth himself. She explained she needs to make sure she has her hand very close to the eating utensil as he really cannot eat on his own and needs assistance. While Resident #83 brought the spoon to his mouth, there was not any immediate concerns. Staff A was asked if speech therapy was working with the resident and she revealed, Yes, but I forgot her name. The resident then said, Staff B was the speech therapy member, and Staff A then confirmed the same name. On 4/26/2023 at 12:55 p.m. Resident #83's was observed seated in his room with his lunch meal tray placed in front of him. He had already started his meal with assistance from Staff A at 12:40 p.m., however, Staff A was not in the room. Resident #83 was not attempting to eat on his own. His meal tray still had approximately 50% uneaten food items on it. Staff A was observed in the room next door, seated in a chair, and assisting another resident with eating needs. At 1:00 p.m. Staff A was observed to get up from assisting the other resident and go over to Resident #83's room and begin to assist him with his meal. She brought forkfuls of food to his mouth, while allowing him to take bites slowly, and then chew and swallow slowly. At 1:15 p.m., Staff A was no longer in Resident #83's room, and she was again noted in the room next door seated in a chair and assisting the other resident with eating needs. There was no other staff member noted to be assisting Resident #83's during the meal. Resident #83 was not observed to try and eat on his own, but his meal tray was still observed with uneaten food items on it. At 1:20 p.m. Staff A stopped assisting the other resident in the next room and walked back to Resident #83's room to continue to assist him with his eating needs. Resident #83 accepted the food that was brought to his mouth. An interview with Staff A revealed, Resident #83 wanted a break so I ran over to start feeding the other resident and then I will go back and assist him. She stated, There are not a lot of staff on this hallway, and I do the best that I can with all those who require eating assistance. She stated the residents who require eating assistance should have staff in the room during the entire time of the meal service, and to not leave to help others. A review of Resident #83's medical record revealed he was admitted to the facility on [DATE]. The advance directives revealed Resident #83 had a Power of Attorney in place to make his medical and financial decisions. A review of the diagnosis sheet revealed diagnoses to include but not limited to: Parkinson's, dementia, seizures, Alzheimer's, dysphagia, depression, cognition communication deficit, and age-related physical debility. A review of the current Minimum Data Set (MDS) Quarterly assessment, dated 3/9/2023, revealed the following. Speech: Speech clarity section revealed - Unclear Speech, usually understood, understands others; Cognition/Brief Interview Mental Score/BIMS score - 15 of 15; Activities of Daily Living/ADL: EATING activities = Limited Assistance with One person assistance; Swallowing/Nutrition: Not checked for holding food, not checked for loss of liquids, not checked for coughing, or choking, not checked for complaints of pain or problem swallowing; Oral/Dental - Not checked for difficulty with chewing. A review of the 4/2023 order sheet, revealed the following but not limited to: - Extend speech therapy for dysphagia, daily x 3 days x one week x four weeks with order date 4/12/2023. - Please ensure additional assistance to self-feed is provided for resident at meal times. Is able to self-feed but very slowly (also wife's request), x shift with order date 3/24/2023. - No Added Salt diet, Mechanical soft texture, Nectar thick liquids with built up curved utensils and divided plate with order date 3/13/2023. - Speech therapy to evaluate and treat as indicated speech therapy to treat daily x 4 days x one week x four weeks for dysphagia therapy. Downgrade liquid to nectar thick liquid. Continue mechanical software, with order date 3/13/2023. A review of the therapy screen, dated 3/9/2023, revealed the following: Range of Motion/ROM, decreased strength, transfers; Self-care revealed not checked for needing assistance and is self-feed; Safety section revealed - not checked for choking or swallowing. Notes indicated - Recently discontinued from Physical Therapy on 2/14/2023, with no significant change in functional mobility status, no skilled therapy indicated this time. A review of the nurse progress notes revealed the following: 3/9/2023 09:26 mini nutrition - Not suffered psychological stress or acute disease in past three months. Has severe dementia. 3/9/2023 11:44 ADL only - Revealed EATING = Self performance, supervision, support provided and set up help only. 3/14/2023 16:16 Nutrition - Low risk malnutrition. Mech soft and had been eating well +75% some slight decrease in intakes noted past two days. SLP will be working with him. He continues to receive the built-up curved utensil and divided plate and is able to feed self after setting up with minimal assist. 3/19/2023 20:37 - Health status note - CNA updated on oral intake. Able to self-feed his cheesecake on his own but requires assistance to feed any other meals. 3/28/2023 22:14 - Resident has trouble swallowing meds, meds are crushed and placed into pudding to facilitate swallowing, resident holds meds in his mouth until they begin to drool from the mouth. Staff assist with meals, which is very long process related to the time it takes for the resident to swallow. 4/13/2023 19:36 - RD Nutrition note/assessment - Resident had diet downgraded. Diet is NAS mech soft with nectar thick liq. He does receive adaptive equipment for self-feeding efficiency. Has self feeding deficits. 4/21/2023 17:31 Communication with family - Resident requires assist with eating, able to feed self, but slow. A review of the comprehensive care plan, with next review date of 6/7/2023, revealed the following but not limited to problem areas: - Current Functional Performance with interventions in place to include but not limited to: Resident performance EATING - Limited assist/one-person physical assist. - Potential for Aspiration related to diagnosis dysphagia with difficulty chewing and swallowing. Resident is on a modified consistency diet related to history of pocketing food and medication with difficulty swallowing, with interventions in place to include but not limited to: All staff to be informed of special dietary and safety needs, Built up curved utensils and divided plate for all meals. Check mouth after meal for pocketing food and debris. Report to the nurse. Provide oral care to remove debris, Supervise and assist at mealtimes and with nutrition and fluid intake as need, instruct to eat in an upright position, to eat slowly, and to chew each bit thoroughly, Monitor for choking, drooling, holding food in mouth, several attempts at swallowing, appears concerned during meals, Refer to speech therapist for swallowing eval. - Self Care deficit, needs extensive assist with ADL related to Parkinson's needs assist with meals and adaptive equipment with interventions in place to include but not limited to: Allow for rest periods between ADL tasks, Divided plate, and built-up curved utensils for all meals, provide physical assistance to resident as needed to complete tasks. - Risk for malnutrition due to dementia, limited mobility and elevated BMI potential for weight variance and decline in intake due to Parkinson's, dementia, Alzheimer's, and depression. Significant wt. loss is noted. Needs assistance with set up help for all meals and feeding. Needs adaptive equipment to assist with self-feeding, with interventions in place to include but not limited to: Allow resident ample time to consume food, provide adaptive equipment as ordered each meal. The above listed care plan problem areas indicated Resident #83 should receive both Eating assistance and also the use of adaptive Eating equipment during meals. However, staff were not consistent with following the care plan interventions. On 4/26/2023 at 2:10 p.m. an interview was conducted with Staff B, Speech Therapist, and the Director of Rehabilitation Services (DOR). Staff B stated she was well acquainted with Resident #83 since his admission and was able to state his primary diagnosis of Parkinson's as a condition that will have periodic changes in presentation for his care. Staff B mentioned Resident #83 as a [NAME] that loves to eat. Staff B stated the resident would need ques to close his mouth at times in order to remind the patient to swallow. Staff B denied pocketing of food was an issue for the resident, and stated the resident had a strong cough response. Staff B stated assistive devices during meals for Resident #83, such as lipped plate with dividers and built-up eating utensils, was an Occupational Therapy plan and not a Speech Therapy plan. On 4/27/2023 at 9:15 a.m. an interview was conducted with Staff C, MDS Coordinator and Staff D, MDS Coordinator. Both were aware of the resident and needs in relation to care and services. Staff C stated she knew Resident #83 was assessed and care planned for Eating- Activities of Daily Living (ADL) and was coded for Limited Assistance with One-person Assistance. She stated a resident who was coded for Limited Assistance with One person Assistance would mean the staff member would indeed need to be present in the room or dining room during the entire time the resident was eating. Staff C and Staff D confirmed Resident #83 was on swallowing and chewing precautions and was being seen on case load from Speech Therapy. Staff C stated Resident #83 should be provided with Limited Assistance with Eating but also should be supervised at all times during his meal service. Staff C and Staff D confirmed Resident #83 was ordered, and care planned for Adaptive Eating equipment to include Built Up Eating utensils and a Divided Plate. They were not aware he did not receive adaptive equipment and he should have and still should receive the equipment with meals. 2) On 4/26/2023 at 7:40 a.m. Resident #36 was observed in his room. lying in bed with Head Over Bed (HOB) approximately 25 degrees, with his head on a pillow. The bed covers were pulled up to his neckline but both hands were exposed. There were no splints or braces on either of his hands. The room was visually free from any splints/braces. On 4/26/2023 at 9:40 a.m. Resident #36 was noted in his bed and lying under the covers with both his hands and arms exposed. Resident #83 was awake and alert. He was not observed with any type of splint or brace on his left hand. Resident #36 was asked about his left hand and if he had any pain. He denied any pain and said, I'm fine. He was asked if he had any special device he wears on his hand and he said, I'm fine. It was noted that the resident had cognitive deficits and could not be interviewed with relation to his care and services. The room was not observed with any type of splints/braces out in the open, nor placed on his Left hand. On 4/26/2023 at 11:35 a.m. the resident was observed in his room and was in bed. His eyes were observed closed and both of his hands were exposed. He was not observed wearing splint/brace on his Left or Right hand. On 4/26/2023 at 1:30 p.m. and 2:40 p.m. Resident #36 was noted in room and lying in bed. He was not wearing a splint/brace on his Left hand. There were no visible signs of a brace/splint in his room. On 4/27/2023 at 8:10 a.m. Resident #36 was again observed in his room and lying in bed. He was not observed with any splint/brace on his Left hand. The resident was not able to speak with relation to his medical care and services. A brace or any type of splints were not visible within the resident's room. On 4/27/2023 at 9:57 a.m. Resident #36 was noted in his room and seated upright in bed with the covers pulled up to his neckline. An interview was conducted with Staff F, CNA who was assigned to Resident #36. Staff F stated she was familiar with Resident #36 but normally works on another floor stating, I know of Resident, but I work on a different floor. Staff F was able to say Resident #36 was on a Nectar diet and was total care. She stated she was not aware Resident #36 had a contracture. Staff F stated she was not aware of Resident #36 requiring a splint on his left hand. Upon entering Resident #36's room, Staff F greeted the resident and demonstrated that a splint was on his left hand. Staff F did not remember if the splint was on or not when she came on shift this a.m. She also did not know who offered and donned the splint or when it was placed on. Staff F was unable to answer the schedule for splint. Staff F stated the therapy team notifies the nursing staff when a splint is needed. On 4/27/2023 at 10:04 a.m. an interview with Staff E, CNA who also worked with Resident #36 was conducted. She stated she was not aware of who assisted Resident #36 with the split this a.m. She stated perhaps the previous shift placed it on. The resident was observed on 4/27/2023 from 8:10 a.m. through 9:50 a.m. without any splints on his left hand. A review of Resident #36's medical record revealed he was admitted to the facility on [DATE]. A review of the advance directives revealed the resident had a Power of Attorney/POA in place to make his medical and financial decisions. A review of the diagnosis sheet revealed diagnoses to include but not limited to dementia, dysphagia, depression, Alzheimer's, contracture left hand, and peripheral vascular disease. A review of the current Minimum Data Set (MDS) Quarterly assessment, dated 3/30/2023 revealed the following; Cognition/Brief Interview Mental Status/BIMS score - 3 of 15 which indicated the resident would not have been able to speak with relation to his care and services; Activities of Daily Living/ADL - BED MOBILITY = Extensive assist with one person, TRANSFERS = Extensive assist with Two person, EATING = Extensive assist with one person, TOILET USE = Extensive assist with one person, PERSONAL HYGIENE = Extensive assist with one person; Health Condition - Not checked for falls prior to or upon admission; Active dx. Contracture Left hand; Nutrition - not documented for wt. loss, has mechanically altered diet. A review of the current Physician's Order Sheet for the month of 4/2023, revealed the following but not limited orders: Skin tear to Left elbow cleanse with wound wash, pat dry. Xeroform to wound bed and cover with foam dressing x night shift for wound care with order date 4/26/2023. Skin tear on left arm-Betadine swab to wound bed x evening shift for wound care 7 days with original order 4/26/2023. OT to treat QD x 2 days per week for 30 days for contracture management, orthotics/subsequent, therapeutic exercises, ROM/Strength, patient/caregiver education with original order date 3/30/2023. Resident to wear left hand functional position splint up to 4 hours daily on day shift as tolerated to prevent further contractures with original date 9/13/2022. A review of the nurse's progress notes revealed the following: - 3/23/2023 14:28 - Health Status Note - Resident noted to be having some contractures to bilateral hands, having difficulties in picking up items and needs help with other ADLs and feeding, referral made to OT. - 3/26/2023 11:58 Order note - Resident to wear left hand functional position splint up to 4 hours a day during day shift as tolerated and then palm protector all other times, excluding bathing/hygiene every day shift A review of the nurse's progress notes dating back from 1/30/2023 through to current notes on 4/27/2023, did not indicate any documentation that reflected Resident #36 ever refusing the use of a Left-hand splint. Nor were there any notes reflecting Resident #36 was not comfortable wearing the device. A review of the Occupational Therapy Certification period of 3/29/2023 through to 4/26/2023 assessment and plan of treatment revealed Resident #36 had a preexisting Left-hand contracture and that OT had a plan of treatment for. The assessment revealed treatment approaches may include Subsequent encounter, orthotics/prosthetics use. The goal revealed Resident #36 will improve ability to safely and efficiently perform eating tasks with supervision or touching assistance with use of built-up utensils to ensure adequate nutrition and hydration. The Plan of Treatment section Functional Skills Assessment revealed under Eating; Partial/moderate assistance is able to feed self, however, has difficulty holding regular utensils due to decreased joint flexibility and coordination. The Musculoskeletal System Assessment section Test/UE strength revealed use of Left-hand grip strength, NT due to contracture. The assessment summary revealed; Patient has presence of multiple joint contractures in left hand, elbow, right elbow, wears a palm protector daily which applies. The summary also indicated that Splint/Orthotic Recommendations are to continue with replacement splint for left hand, combined with hand hygiene to maintain skin integrity. The Occupational Therapy Discharge summary, dated 4/26/2023, revealed the resident had been seen on case load for contracture management for the left hand. The Discharge summary revealed the resident met the highest practical level, with interventions to include Contracture management, staff is educated on providing adequate hand hygiene and to don/doff palm protector which is least aggressive to provide partial ROM and maintain skin integrity of left hand to prevent skin breakdown. A review of the current care plans with next review date 6/8/2023 revealed the following areas: (1.) Impaired mobility and self-care deficit related to weakness, cognitive impairment due to dementia, decreased balance and endurance left hand, with interventions in place to include but not limited to: Palm protector and splint to right hand as tolerated. Note: It was clarified through interview with the Director of Nursing and Interview with the MDS/Care Plan Coordinator Staff C, that the care plan should have indicated the Left hand, not Right hand as the problem area. (2.) Risk for skin impaired skin integrity related to decreased mobility, muscle weakness, incontinence, depression, psychotropic med use, cognitive impairment, repeated falls, Malignant neoplasms right forearm and left dorsal hand, declines further biopsy, contracture left hand, with interventions to include but not limited to: Palm protector and splint to Right hand as ordered. Note: It was clarified through interview with the Director of Nursing and Interview with the MDS/Care Plan Coordinator Staff C, the care plan should have indicated the Left hand, not Right hand as the problem area. On 4/27/2023 at 9:15 a.m. Minimum Data Set/Care Plan Coordinators Staff C and D were interviewed with relation to Resident #36, and both confirmed he had a left-hand contracture and has been seen on case load from OT/PT. Staff C and Staff D the resident does utilize a left hand/palm splint orthotic, and it is the responsibility of the aide to don and doff per the order and care plan. Staff C and Staff D confirmed if a resident refuses to wear the device, it should be noted in progress notes and brought to the attention of the nurse and then ultimately to MDS/Care Planning staff, so they can update with relevant interventions. They were not aware Resident #83 was not offered or assisted with his left-hand splint. Staff C and Staff D confirmed the resident did not currently have any care plan problem areas with regards to refusal of care and treatment, specifically with relation to his contracture management device. On 4/27/2023 at 11:00 a.m. the Director of Nursing provided the Comprehensive Care Plan policy and procedure with a revised date 4/2022, for review. The policy revealed the following: It is the policy of this facility to develop and implement comprehensive person-centered care plan for each resident, consistent with resident rights, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Under the Policy Explanation and Compliance Guidelines section of the policy revealed, (3) The Comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. b. Any services that would otherwise be furnished but are not provided due to the resident's exercise of his or her right to refuse treatment. (8) Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

Based on observations, record review, and interviews, the facility failed to provide care consistent with professional standards of practice related to following physician orders for oxygen therapy for one resident (#52) out of two sampled residents for respiratory care. Findings included: A review of the Admission Record for Resident #52 showed she was initially admitted into the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease with acute exacerbation and chronic respiratory failure with hypercapnia. A review of the Minimum Data Set (MDS) assessment, dated 04/11/23, revealed in Section C Cognitive Patterns, Resident #52 had a Brief Interview for Mental Status (BIMS) score of 15 out of fifteen indicating cognitively intact. Section O Special Treatments, Procedures, and Programs indicated Resident #52 was on oxygen while a resident. A review of the Order Summary Report with active orders as of 04/27/23 revealed the following order: -continuous oxygen at 2 liters per minute via nasal cannula every shift (01/17/23). A review of the Treatment Administration Record (TAR) for 04/01/23 to 04/30/23 revealed continuous oxygen was administered at 2 liters per minute via nasal cannula every shift. A review of the care plan for oxygen therapy initiated 12/13/22 showed an intervention to apply oxygen as ordered. On 04/24/23 at 11:52 a.m., Resident #52 was observed in bed in her room with the oxygen nasal cannula below her nose. She adjusted the nasal cannula when asked if she was breathing ok and stated no. The oxygen concentrator was observed at 3.5 liters per minute. On 04/25/23 at 1:56 p.m., Resident #52 was observed in bed in her room. She was wearing the oxygen nasal cannula appropriately and the oxygen concentrator was observed at 3.5 liters per minute. On 04/26/23 at 11:26 a.m., Resident #52 was observed in bed in her room. She was wearing the oxygen nasal cannula appropriately and the oxygen concentrator was observed at 3.5 liters per minute. On 04/26/23 at 11:28 a.m., Staff G, Licensed Practical Nurse (LPN), stated the oxygen concentrator should be set at 2 liters per minute per orders. She had never observed the resident adjusting the oxygen concentrator. Staff G, LPN, went into the room and confirmed the oxygen concentrator was set at 3.5 liters per minute and should have been set at 2 liters per minute. 04/27/23 09:15 a.m., the concern was presented to the Director of Nursing (DON). She did not state her expectations when asked but voiced that it would be fixed immediately. On 04/27/23 at 9:20 a.m., a policy related to following physician orders was requested, but not provided.

Based on observations, interviews, and review of facility policy, the facility failed to ensure proper labeling and storage of drugs and biologicals for two (Resident #77 and Resident #66) of eight residents observed for medication administration, in three of three medication carts observed, and in one of two medication storage rooms observed. Findings included: A medication cart inspection was conducted on 05/26/21 at 10:56 a.m. with Staff F, Licensed Practical Nurse (LPN) on the 200 unit of the facility. A container of glucose monitoring test strips was observed in the top drawer of the medication cart. The glucose monitoring test strips did not have a date labeled on them to indicate when they were opened. Staff F, LPN was not able to state whether or not the glucose monitoring test strips should have been dated upon opening and stated that she would not normally put a date on the bottle. Two small brown bottles of [MEDICATION(S)] 0.4 milligram (mg) tablets was observed in the medication cart. One of the small brown bottles of [MEDICATION(S)] 0.4 mg tablets was stored inside of the manufacturer's box, but did not have a lid. The bottle also did not have a date labeled on it to indicate when it was opened. Staff F, LPN was not able to state why the [MEDICATION(S)] tablet bottle did not have a lid and stated that it may have come that way from the pharmacy. A second bottle of [MEDICATION(S)] 0.4 mg tablets was observed to be stored inside of the manufacturer's box with a yellow label that read Date Opened. No date was documented on the label to indicate when the bottle was opened. Staff F, LPN was not able to state why the bottle of [MEDICATION(S)] 0.4 mg tablets did not have a documented date of when it was opened. Staff F, LPN addressed that if a medication came from the pharmacy with a Date Opened label on it, then it should be dated with the date that it was opened by the nurse. During the inspection of the medication cart, 4 loose medication pills were observed throughout the medication cart. Staff F, LPN stated that the medication cart should not have loose medications in it and that the 11:00 p.m. to 7:00 a.m. shift nurse would normally inspect the medication carts to ensure that medications were properly labeled and that there were not any loose medications in the medication carts. An inspection of a medication storage room was conducted on 05/27/21 at 7:50 a.m. with Staff C, Assistant Director of Nursing (ADON) on the 300 unit of the facility. An observation was made during the inspection of a small yellow bin, just inside of the entrance to the medication storage room, which contained several medication cards, boxes, and plastic storage sleeves full of medications inside of it. Located on the left side of the sink in the medication storage room was a large red plastic container, which was filled with various medications and was not able to be properly closed. One large brown paper bag full of medications sat on top of the large red bin and a large brown paper bag full of medications was also sitting next to the large red bin on the counter of the medication storage room. A two tiered black storage bin was also observed to be full of various medications on the counter next to the brown paper bags and large red bin full of medications. The right side of the sink in the medication storage room contained another large brown paper bag full of various medications and two clear plastic bins full of medications next to it. Staff C, ADON stated that education needed to be conducted with the nursing staff related to proper procedures for returning medications to the pharmacy. Medications should be returned to the pharmacy using the large red bins and should be taken down when the pharmacy delivery came on the 11:00 p.m. to 7:00 a.m. shift. Staff C, ADON stated that the facility was having some staffing issues on the 11:00 p.m. to 7:00 a.m. shift and that the agency nurses may not have been aware of the proper procedure for returning medications to the pharmacy. The 11:00 p.m. to 7:00 a.m. nurse should also be conducting audits of the medication carts to ensure that there were no expired medications, medications were properly labeled, and to ensure that there were no loose medications in the medication carts. An interview was conducted on 05/27/21 at 8:05 a.m. with the facility's Director of Nursing (DON). The DON stated that the pharmacy would make a delivery on the 3:00 p.m. to 11:00 p.m. shift and that the nursing staff should be returning any medications to the pharmacy during that pharmacy run. The DON stated that the nursing staff may be forgetting to take the red bin down to return to the pharmacy when they pick up new medications that were delivered. The DON also addressed that the medication storage room should not contain a large number of medications to be returned to pharmacy and stated this never happens. A medication cart inspection was conducted on 05/27/21 at 10:45 a.m. with Staff A, Registered Nurse (RN) on the facility's 300 unit. During the inspection, a total of 5 loose medications were observed throughout the drawers of the medication cart. Staff A, RN stated that she did not routinely check the medication cart for the presence of loose medications but stated that there should not be any loose medications in the medication cart. An observation was made of the medication [MEDICATION(S)] via inhaler with a white label reading Expires 42 Days After Date Opened. No date was documented on the label, but hand written documentation on the box revealed that the medication was opened on 03/28/2021. Staff A, RN addressed that the inhaler was considered expired since it had been over 42 days since it was opened. An observation was made on 05/27/21 at 11:07 a.m. of a medication cart on the 300 unit of the facility. The medication cart was observed to be unlocked. No staff members were observed in the immediate area of the medication cart and the medication cart was able to be inspected without staff being present. Shortly after beginning the medication cart inspection, Staff D, LPN returned to the medication cart. Staff D, LPN addressed that she should have locked the medication cart before stepping away from it. During the inspection of the medication cart, 2 loose pills were observed in the top drawer of the medication cart. Staff D, LPN stated that the medication cart should not have loose medications in the drawers, but she did not check for loose medications when she took responsibility of the medication cart. Staff D, LPN stated that she just hoped that the previous nurse checked for any issues with the medication cart because she was an agency nurse. Staff D, LPN also stated that she checked the expiration date of the medications as she gave the medications. A container of glucose monitoring test strips were observed in the top drawer of the medication cart. The glucose monitoring test strips did not have a date labeled on them to indicate when they were opened. An observation was made of a package of [MEDICATION(S)] 0.4 milliliter (ml) single use eye drop vials. A yellow label on the package read Date Opened. No date was documented on the yellow label to indicate when the package was opened. A bottle of [MEDICATION(S)] 0.005% eye drops were observed inside of a brown plastic bag in the medication cart. The bag and vial of eye drops both had a white label that read Expires 42 days from date opened. No date was documented on the bag or the vial to indicate when the vial was opened. A [MEDICATION(S)] inhaler was observed in the manufacturer's box inside of the medication cart. A white label was observed on the box which read Expires 90 Days From Date Opened. No date was documented on the label to indicate when the inhaler was opened. Staff D, LPN stated that medications that have a label to document the date that it was opened should have a date documented on the label by the nurse. Staff D, LPN was not able to state why the medications were not dated properly. A follow up interview was conducted on 05/27/21 at 1:25 p.m. with the facility's DON. The DON stated that the cart audits that were supposed to be conducted on the 11:00 p.m. to 7:00 a.m. shift were not being followed properly and that the 11:00 p.m. to 7:00 a.m. shift should be checking for expiration dates of medications and the cleanliness of the medication cart. The DON also stated that nurse's should not walk away from the medication carts without first locking the cart. Photographic evidence was obtained. 2. On 05/24/2021 at 12:00 p.m., Resident #66 was observed in her bed asleep. On the left side of her bed, three medications were located on top of the bedside table. A closer look revealed a Breo Ellipta 200-25 MCG Inhaler, a clear medication cup with a white round tablet in it, and [MEDICATION(S)] Prop 50 MCG Spray. The Resident was observed to wake up, and then looked at the clear medication cup containing the white round pill and stated Hi! what is that? (Pointing to the medication cup with the white round pill in it) I don't know, I don't know what it is A further interview was attempted with Resident #66, but she was unable to answer any questions related to the medications. Photographic Evidence Obtained. On 05/24/2021 at 12:02 p.m., an interview was conducted with Resident #66's nurse, Staff A, Registered Nurse, (RN) who was sitting at the nurse's station typing on the computer. Staff A was asked about the three medications observed on Resident #66's bedside table, and if the resident had an active physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff A confirmed the presence of the medications left out and then asked Resident #66 to take the white round pill, handing her a Styrofoam cup filled with water. Staff A, then stated, I left the meds here. The resident across the hall's alarm on his chair went off and I forgot the medications were in the room, it's my fault I forgot them. I know I am not supposed to leave it in a resident room. She was observed to take the other two medications off the table and leave the room. Record review for Resident #66 indicated she was admitted on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly Minimum Data Set (MDS) dated [DATE], identified in Section C, that Resident #66's Brief Interview for Mental Status (BIMS) score was 0, which indicated severe cognitive impairment. On 05/24/2021 at 12:30 p.m., an observation was conducted of Resident #77 sitting in a recliner chair in his room. The resident appeared to be sleeping as his eyes were closed. Observation of [MEDICATION(S)] 0.1% Ointment medication was on a shelf near the resident's closet. A record review for Resident # 77 indicated he was admitted on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Minimum Data Set (MDS) dated [DATE], identified in Section C, that Resident #77's Brief Interview for Mental Status (BIMS) score was 3, which indicated severe cognitive impairment. An interview was conducted with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on 05/26/2021 at 10:32 a.m. During the interview, the DON and NHA were informed of the observations made of Resident #66 and Resident #77 and were shown two photographs of medications left out in both resident rooms. The DON revealed that Staff A (RN), informed him of the white round pill she left on the bedside table. The DON indicated that the nurses should store all medications properly and stay in the resident's room during administration. The NHA stated, The nurses should follow the facility policy and they should not leave medications at bedside, in a resident room. On 05/27/2021 at 12:39 p.m., a telephone interview related to the observations was attempted with the Pharmacy Consultant, without success. A facility provided policy titled, Medication Storage, with Revision Date 07/2020, Page 01 of Page 02, was reviewed and read under Policy Heading It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure the proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy Explanation and Compliance Guidelines: 1. General Guidelines a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms, under proper temperature controls. c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.

Based on observation, interview, and policy review, the facility failed to follow their policy to appropriately store and maintain food in for a safe and sanitary manner in one of four refrigerators and one freezer. Findings included: During the initial kitchen tour on 05/29/2021 at 9:30 a.m., an observation of the freezer revealed two large white plastic buckets of cornbread batter on the floor of the freezer. The Certified Dietary Manager (CDM) confirmed the presence on the floor, and indicated they need to be stored on a shelf. The CDM further indicated that they were moved there due to inventory process and placed each bucket on the bottom shelf. Observation of the walk-in refrigerator included on the side second shelf, a cardboard box that contained two moldy lemons. On the first shelf at the back of the refrigerator, a large bottle was seen without a cover, that contained garlic. The CDM, confirmed the presence of both moldy lemons, and asked an unidentified kitchen staff to remove the bottle of garlic, that she quickly threw away into a nearby garbage receptacle. (Photographic Evidence Obtained) A review of the facility's policy Westminster Communities of Florida Dining Services Standards and Guidelines, titled Food and Supplies Storage, Revised 9/2011, Pages 01-02 of Page 03, included under Guidelines reads: 4. All foods stored in walk-in refrigerators and freezers will be stored on shelves, on racks, dollies, or other surfaces that facilitate thorough cleaning. All food items shall be stored a minimum of 6 from the floor. 5. Food shall be rotated as delivered and used in a First In, First Out Method. 6. Prepared or opned foods stored in the refrigerator until served, shall be covered. Such food stored in a refrigerator must be placed in a storage container and tightly sealed with a tight fitting lid marked with the name o the item, and date of expiration (5 days after preparation or opening), or wrapped tightly with foil or plastic wrap and labeled.

Based on interviews and record review, the facility did not ensure the common and safe nursing practice of verifying medications for accuracy prior to administration was performed, and failed to identify four (4) incorrect medications that were administered for one (1) (Resident #1) of three (3) Residents in the sample group. The facility failed to follow their protocols regarding new admission/transfer orders, medication reconciliation, medication administration, and the prevention of medical errors. Findings included: 1. A review of the medical chart for Resident #1 indicates the resident was admitted to the facility on [DATE] at 2:23 p.m., from the facility's Assisted Living Facility (ALF) Towers, with [DIAGNOSES REDACTED]. A review of Admission record for Resident #1 for transfer/admissions process revealed the following paperwork, Resident Medical Information and Medications listed was observed to be on a paper dated January 14, 2006, Resident Medication Administration Record (MAR) and 3008 form provided by the ALF. The following medications read [MEDICATION NAME] 500 mg, [MEDICATION NAME] 125 mcg , [MEDICATION NAME] XL 100 mg, Hydroclorot 25 mg, [MEDICATION NAME] 5mg and [MEDICATION NAME] 20 mg. Further record review of nursing progress notes for Resident #1 revealed no documentation on 4/1/2020 recorded for contacting the resident's daughter to confirm a current medication list, the attending physician or the ALF related to medication verification/reconciliation. Review of the MAR for dated 4/1/2020 and 4/2/2020 was conducted, revealing that there were four (4) medications errors administered to Resident #1 on 4/2/2020 between 06:00 a.m. and 09:00 a.m. Nursing staff administered two (2) incorrect dosages as follows: 1. At 6:00 a.m. [MEDICATION NAME] 125 MCG 1 Tablet given by mouth, instead of the correct dosage of [MEDICATION NAME] 112 MG Tablet. 2. At 9:00 a.m., [MEDICATION NAME] ER 100 MG 1 Tablet given by mouth instead of correct dosage of [MEDICATION NAME] ER 50 mg tablet. The other two (2) other medications administered but not physician ordered was not listed on the transfer MAR from the ALF. They are as follows: 3. [MEDICATION NAME] HCL ER 500 MG 1 Tablet By Mouth Daily administered at 9:00 a.m. 4. [MEDICATION NAME] 20 MG 1 Tablet 1 Tablet by Mouth Daily administered at 9:00 a.m. On 7/02/2020 at 4:06 p.m., an interview was conducted with Staff B, Unit Manager (UM) for Resident #1. Staff B, UM confirmed she noticed medication errors while reviewing Resident #1's physician orders on 4/2/2020. The UM stated here is the paper I used with my writing on it, I put a x on the two medications that she should not have had, and look at the other two, the [MEDICATION NAME] should have been 112 MCG and the nurses already gave it to the her (Resident #1) along with [MEDICATION NAME] 100 mg instead of 50 mg. The order was inaccurate, they looked at the 2006 medications that was given to us when she was transferred to our unit, and it was a transcription error. The UM revealed that the physician was not called for clarification of orders at the time of admission. An investigation was conducted on 4/4/2020 by Staff B (UM). The write up read The medication record used was old and not relevant to this admission, even though it was sent up with her current records, the date was old and the form, and should have been questioned. Procedure is to call physician and confirm the medications and doses at time of admission or by next day if office is not open. This transcription error led to wrong drug and dose administration. On 07/6/2020 at 2:57 p.m. a telephone interview was conducted with Staff A, Licensed Practical Nurse (LPN). Staff A was informed that the DON and UM gave her name and permission to contact her for an interview regarding Resident #1. Staff A was asked about medication order sets that her name was observed to handwritten on, and signature under NURSE: Please Initial the Documentation Record as performed, for Resident #1's transfer admission. Staff A, (LPN) stated I don't recall transposing any orders. I did not have any dealings with the resident on admission, and she came in from the ALF to the admission (transmission) unit. She came in on the 3-11 p.m. shift that I do not work. Staff A, (LPN) revealed that she never had education training or an Inservice related to transcribing medications and or medication errors from the UM. She further indicated she did not remember speaking to the UM about Resident #1's medications or anyone else including the DON. 2. During a phone interview with Resident #1's daughter on 7/6/20 at 1 p.m., the daughter said When I got the bill from the facility, I saw all these medications that were given, and shouldn't have been given. My mother had been off the [MEDICATION NAME] for 2-3 years. The doctor stopped it because my mother lost so much weight, and her blood sugar was within normal parameters. Same thing for the Rosuvastatin and the [MEDICATION NAME], she'd been off those meds for some time. Then I saw that she had been given 100 milligrams (mg) of [MEDICATION NAME] instead of 50 mg, and they gave her 125 mcg (micrograms) of [MEDICATION NAME] instead of 112 mcg. Those were the wrong doses. I called the Nursing home up and told them that these were all wrong medications . She also stated I saw my Mother on March 29, 2020 at the ALF (Assisted Living Facility). She was very lethargic and completely out of it. She was wearing her underwear, a velour jacket, and a blanket on top of her, and she was very sleepy. The weekend nurse agreed with me, and she told me my mother had not been eating, and that my mother had been complaining of stomach pain. Review of the Medication Administration Record (MAR) from 4/2/2020 revealed that [MEDICATION NAME] HCL ER 500 milligrams had been administered to Resident #1 at 9:00 a.m. even though Resident #1 did not eat her breakfast and had less than 25% of her dinner the night before. Review of the Meals/Snack Roster from 4/1/20 through 5/2/20 revealed that Resident #1 did not have breakfast the morning of 4/2/20: Breakfast: percentage eaten: 0% Breakfast fluid intake: 0% Lunch: percentage eaten: 25% Lunch: fluid intake: 200 ml Dinner: percentage eaten: 25% Dinner: fluid intake: 120 ml Snack: percentage eaten: 1-25% Furthermore, a nursing progress note written the night before on 4/1/2020 at 9:58 p.m. revealed Resident remained in bed this evening, appetite poor, ate less than 25% of supper meal. Review of Bristol(NAME)Squibb (BMS) (manufacturer of [MEDICATION NAME] ER/[MEDICATION NAME] XR) dosing and administration for [MEDICATION NAME] showed that [MEDICATION NAME] should be administered with meals. [MEDICATION NAME] XR: Starting dose: 500 mg once orally daily with the evening meal. Under BMS dosage and administration instructions, all indicated that [MEDICATION NAME] and [MEDICATION NAME] extended release should be taken with meals. (https://packageinserts.bms.com/pi/[MEDICATION NAME].pdf). An interview was conducted on 7/2/2020 at 4:10 p.m. with the Unit Manager (Staff B). When asked about the medications, Staff B said When I looked at the medications on the MAR, I saw that the resident was on [MEDICATION NAME] and had been given [MEDICATION NAME]. She was [AGE] years old and hardly eating anything. I asked the doctor if she should be on that, and she said it was discontinued a while back. Review of the Facility's policy titled Medication Administration, revised in June 2019, revealed Policy Explanation and Compliance Guidelines: 14: Administer medication as ordered in accordance with manufacturer specifications. A) Provide the appropriate amount of food and fluid. During the interview on 7/2/20 at 4:10 p.m., Staff B also confirmed that the March ALF MAR and the 2006 medical record document were the papers used to transcribe the admission orders [REDACTED] Westminster Communities of Bradenton Date: 1/14/2006 Resident medical information (Date of birth, Social security #, Insurance, etc.) Medications: [MEDICATION NAME], [MEDICATION NAME], and [MEDICATION NAME] Allergies and physician information Emergency contacts There was no April 2020 Medication Administration Record (MAR) from the ALF for the morning of 4/1/20, to indicate which medications were given prior to discharge to the Nursing Home in the late afternoon (2:30 p.m. per the Nursing Home nurse progress note written on 4/1/20 at 3:30 p.m.). Review of the Facility policy titled Medication Reconciliation, revised in June 2019, revealed Policy: This facility reconciles medication frequently throughout a resident's stay to ensure that the resident is free of any significant medication errors, and that the facility's medication error rate is less than 5 percent. Policy Explanation and Compliance Guidelines: 3) Pre-Admission Processes: a. Obtain current medication list from the referral source (i.e.; hospital, home health, hospice, or primary care provider). B. Obtain current medication/admission orders [REDACTED]. Compare orders to hospital records, etc. Obtain clarification orders as needed. C. Transcribe orders in accordance with procedures for admission orders [REDACTED]. Have a second nurse review transcribed orders for accuracy and cosign the orders, indicating the review. Additionally, a review of the Routine Medications Westminster Point Pleasant ALF- March 2020 (handwritten) revealed the following scheduled pain medication, which was given for pain. Aleve 220 mg (2) tablets by mouth twice a day for pain (dated 3/9/20); 9 a.m. and 5 p.m. [MEDICATION NAME] administered from 3/9/20-3/31/20 (23 days). This order was not transcribed onto to the Nursing Home April 2020 MAR, and the medication was not given as ordered. There were no physician orders to discontinue the Aleve, until 4/2/20. Review of the Hospice physician orders faxed over on 4/2/20 revealed Discontinue [MEDICATION NAME] orders. (Additionally, Staff A, obtained clarification of meds on 4/2/20 and wrote the order for the correct doses of [MEDICATION NAME] (112 mcg) and [MEDICATION NAME] (50 mg) ). An interview was conducted on 7/2/2020 at 4:10 p.m. with the Unit Manager (Staff B). When asked if the admitting nurse should have clarified the orders with the doctor before reconciling the medications, Staff B said Yes, but when I spoke to her she said that she just took the handwritten medications from the ALF MAR because they have a different format for orders in the ALF, and she didn't notice the 2006 date on the other sheet. She confirmed that the orders were clarified on 4/2/2020. When asked about the double question marks next to [MEDICATION NAME] on the physician orders, Staff B said Well, I saw that she was [MEDICATION NAME] pain while she was in the ALF. The doctor was called, and [MEDICATION NAME] discontinued. When a resident is admitted , the procedure is to call the physician and confirm the medications and doses. It was a transcription error that led to a medication error. During a phone interview with Resident #1's daughter on 7/6/2020 at 1 p.m., the daughter was asked if she was informed by the Nursing Home that [MEDICATION NAME] been discontinued. The daughter stated No, I didn't know until I received the bill for the medications. Review of the Facility policy titled Medication Orders, revised in June 2019, revealed Policy: This facility shall use uniform guidelines for the ordering of medication. 4) Documentation of Medication Orders: B. Clarify the order. F. When a new order changes the dosage of a previously prescribed medication, discontinue the previous entry by writing DC'd and the date. G. Enter the new order on the MAR. H. Notify resident's sponsor/family of the new medication order. 5) Specific Procedures for Medication Orders: C. Written Transfer Orders (sent with a resident by a hospital or other health care facility) .If the order is unsigned, or signed by another physician, or the date is other than the date of admission, the receiving nurse should verify the order with the current attending, before medications are administered. The nurse should document verification on the admission order record, by entering the time, date, and signature. Example: Order verified by the phone with Dr. Smith/M.(NAME) R.N. Review of the Facility's policy titled Medication Errors, revised in June 2019, revealed Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors. Policy explanation and Compliance Guidelines: 1) The facility shall ensure medications will be administered as follows: A) according to the physician's orders. B) Per manufacturer's specifications regarding the preparation and administration of the drug or services. 7) To prevent medication errors and ensure safe medication administration, nurses should verify the following information: A. Right medication, dose, route, and time of administration. B. right resident and right documentation.

Based on interviews, observations, and record review, the facility failed to provide respiratory care in accordance with professional standards of practice related to not performing post lung assessments following respiratory treatments and not rinsing equipment after use for two residents (#259 and #260) and not administering a respiratory treatment as ordered, and directed by manufacturer instructions for one resident (#259) out of a total of three residents sampled for respiratory treatments. Findings included: 1. A review of Resident #259's Face Sheet revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The (MONTH) 2019 Medication Administration Record [REDACTED]. Resident #259's care plan initiated on 8/22/19, included a problem/need as, at risk for respiratory distress related to [MEDICAL CONDITION] and sleep apnea. Uses oxygen at 2 liters continuously. The approaches included to administer prescribed medications, observe for effectiveness, possible adverse effects, and notify MD (medical doctor) as needed. Review of the Assessment of Self Administration of Medication, dated 8/12/19, revealed that Resident #259 had no desire to self-administer medication, and there were no physician orders for self-administration. An observation of the medication administration for Resident #259 was conducted on 8/29/19 at 10:35 a.m. Staff B, Registered Nurse (RN) took his vital signs, and then administered his crushed oral medications. Resident #259 then asked for a sip of water, and Staff B handed him his water cup. After taking a sip, he handed the cup back to Staff B to put on the bedside table. She then handed the resident the HANDIHALER, which contained one capsule of [MEDICATION NAME]. Staff B said, You know what to do, inhale. Resident #259 inhaled deeply one time, and then handed the HANDIHALER back to Staff B. She emptied the capsule into the garbage. Staff B did not ask the resident to exhale fully before inhalation, she did not ask him to hold his breath for ten seconds after inhalation to allow the medication to deposit in his airways, and she did not instruct the resident to inhale a second time. Staff B did not offer the resident water to rinse his mouth. Instead, she checked the resident's lung sounds, and stated, Yes, you need treatment, you are pretty congested. She then opened and placed the [MEDICATION NAME]-[MEDICATION NAME] vial into the nebulizer cup and placed the mask over the resident. At 10:40 a.m., she turned the nebulizer machine on, and told the resident, Okay, I'll be back. She left the room. Staff B returned to Resident #259's room at 10:52 a.m. and checked to make sure there was no medication left in the vial, shut off the nebulizer machine, and put the equipment away. She then left his room. Staff B did not ask Resident #259 how he felt, and she did not conduct a post lung sound assessment or rinse the nebulizer cup and mask. An interview was conducted with Staff A, Unit Manager for the 3rd floor, on 8/29/19 at 11:15 a.m. Staff A said, Yes, I would expect the nurse to follow the directions on the inhalant and the orders; and to allow the resident to rinse his mouth after he inhaled the medication. When asked about lung assessments for nebulizer treatments, Staff A said, Yes, I would expect the nurse to stay in the room, do pre lung sounds for a baseline, and then do post lung sounds to see if it helped. A review of the MAR for (MONTH) 2019 for Resident #259 showed listed next to the nebulizer medication (IPRAT-ALBUT) the following instructions, lung sounds, respirations per minute, lung sounds. A review of the manufacturer specifications for the [MEDICATION NAME] capsules, (Pharmaceutical Company Name), revealed, Instructions for use: [MEDICATION NAME] HANDIHALER: .Step 4) Breathe out completely in 1 breath, emptying your lungs of any air, then breathe in deeply until your lungs are full. You should hear or feel the [MEDICATION NAME] capsule vibrate. Hold your breath for a few seconds, then breathe normally again. Take your full daily dose (2 inhalations from the same [MEDICATION NAME] capsule). 2. A review of Resident #260's Face Sheet revealed that he was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The (MONTH) 2019 MAR for the resident showed, IPRAT-ALBUT0.5-3 (2.5) MG/3 ML Inhale 1 [MEDICATION NAME] Via Nebulizer four times a day at 9AM/1PM/5PM/9PM for Congestion. Resident #260's care plan initiated on 8/20/19 included a problem/need as, at risk for respiratory distress related to [MEDICAL CONDITION] and [MEDICAL CONDITION], requires the use of O2 (oxygen) at 2 liters continuously. The approaches included, monitor lung sounds if indicated, monitor for changes in breathing pattern and observe for any shortness of breath, and notify MD as needed. An observation of the medication administration for Resident #260 was conducted on 8/29/19 at 10:25 a.m. Staff B, RN finished administering Resident #260's oral medications and then listened to his lung sounds, set up his nebulizer treatment, and started his nebulizer machine. She informed Resident #260 that she would be back. Staff B left the room and began to dispense medications for the next resident. At 10:42 a.m., Staff B, RN returned to Resident #260's room, shut off the nebulizer machine, and stored the nebulizer equipment. Staff B, RN left the room. She did not conduct a post lung sound assessment or rinse the nebulizer cup and mask. A review of the MAR for (MONTH) 2019 for Resident #260 showed listed next to the nebulizer medication (IPRAT-ALBUT) the following instructions, lung sounds, respirations per minute, lung sounds. Review of Resident 260's Initial Assessment, dated 8/9/19, revealed in the Safety Assessment section that Resident #260 had no desire to self-administer medications, and there was no physician order for [REDACTED].>An interview was conducted with the Director of Nursing (DON) on 8/29/19 at 1:00 p.m. The DON said, I would expect the nurse to do lung assessments before and after the nebulizer treatment. The nurse should remain in the room for the treatment. When asked about the hand-held inhaler, the DON stated, I would expect the nurse to administer the inhalant as ordered by the physician, so if it said to rinse his mouth after the inhalant, the nurse should make sure the resident rinses his mouth. A review of the facility's policy titled, Administration of Metered Dose Inhaler, revised in (MONTH) 2019, revealed, Policy: It is the policy of this facility to ensure medications are administered as prescribed and in accordance with professional standards of practice . Policy Explanation and Guidelines: 1) Verify practitioner's order . 9c) Position inhaler in mouth, close lips around inhaler. 10) Instruct resident to exhale fully. 11) Press down on inhaler to release the medication as the resident starts to breathe in slowly. 12) Instruct resident to hold breath and slowly count to ten, if possible, to allow medication time to deposit in airways. 13) Instruct resident to slowly exhale through pursed lips. 14) Repeat puffs as directed, waiting at least one minute between puffs, or per manufacturer's specifications. 15) Allow resident to gargle with water if desired, to remove medication from mouth and back of throat. A review of the facility's policy titled, Nebulizer Therapy, revised in (MONTH) 2019, revealed, Policy: It is the policy of this facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed, using proper technique and standard precautions. Policy Explanation and Guidelines: .1f) Obtain resident's vital signs and perform respiratory assessment to establish a baseline .1l) Turn the machine on .n) Observe the resident during the procedure for any change in condition . o) When medication is complete, turn the machine off . p) Disassemble and rinse the nebulizer with water and allow to air dry. 2) Care of the Equipment: d) Rinse the nebulizer cup and mouthpiece with sterile or distilled water. 3) Documentation: a) date, time, and duration of therapy. d) Vital signs and respiratory assessment. e) Resident's response to the treatment.

Based on observation, interviews, and policy review the facility did not ensure appropriate infection control measures were followed during medication administration for 3 residents (#4, 5, and 6) of 4 residents observed during blood glucose monitoring. Findings included: On 12/27/2018 at 6:15 AM an observation was conducted during blood glucose monitoring with Staff A, RN (Registered Nurse). Resident #4 was admitted to the facility with a [DIAGNOSES REDACTED]. Staff A gathered a lancet, alcohol preps, and a test strip and placed them in a medication cup. She prepared medications and placed them in medication cup as well. Staff A sanitized her hands. After putting on a pair of gloves, she took the supplies and medications, along with an Assure Prism glucometer she had retrieved from the medication cart, and knocked on Resident #4's door. She entered the resident's room and placed the supplies and glucometer on the bedside table in front of the resident. She gave Resident #4 his medications with a cup of water after explaining that she had medications for him. Next she took an alcohol prep pad and cleaned Resident #4's right index finger with it. Then she took the lancet out of the cup and pierced his finger. She applied a droplet of blood to the test strip she had placed in the glucometer. She set the glucometer on his bedside table. Then she removed another alcohol prep and cleaned Resident #4's left upper outer arm. After administering his scheduled insulin, she disposed of the needle and lancet in a sharps container. She removed the gloves and performed hand hygiene. She exited the room and placed the glucometer on top of the medication cart. She did not clean the glucometer. Resident #5 was admitted to the facility with a [DIAGNOSES REDACTED]. At 6:21 AM Staff A prepared another medication cup with alcohol preps, a lancet, and a test strip. Then she prepared medications. She picked up the supplies and medications she had prepared, along with the glucometer and went to Resident #5's room. She announced herself before entering the room. She placed the supplies, medications, and glucometer on the bed side table. Then she raised the head of the bed. She gave Resident #5's medications with some water after explaining she had his medications. Then Staff A put on a pair of gloves. She placed a test strip in the glucometer and turned it on. Then she used an alcohol prep to clean Resident #5's right fourth finger. She used the lancet to poke his finger and applied the blood droplet to the test strip. Then she disposed of the lancet in the sharps container and put the used supplies in the trash along with the gloves. Then she performed hand hygiene and returned the glucometer to the top of the medication cart. Again, she did not clean the glucometer. Resident #6's admission record indicated he was admitted to the facility with a [DIAGNOSES REDACTED]. At 6:32 AM Staff A prepared another medication cup with an alcohol prep, lancet, and test strip. She picked them up along with the glucometer and announced herself before entering Resident #6's room. She explained that she was going to check his blood sugar. Then she placed the supplies on the bed side table and set the glucometer next to them. Next she put on a pair of gloves and placed the test strip in the glucometer. Then she put the glucometer on Resident #6's bed. She removed an alcohol prep and cleaned his left pinky finger with it. Then she took the lancet and poked his finger with it. She applied the blood droplet to the test strip. After noting the reading, she disposed of the gloves and supplies. Then she performed hand hygiene. She returned the glucometer to the top drawer of the medication cart. Once again, she did not clean the glucometer. In an interview with Staff A at 6:40 AM she said she probably should have cleaned the glucometer after each resident. Then she took the glucometer out of the drawer, removed an alcohol prep and proceeded to clean the glucometer with it. She returned it to the drawer and explained that the medication cart doesn't have the right kind of wipes in it to clean the glucometer with. Policy, Infection Prevention and Control Program, dated 6/2018 Policy: It is the policy of this facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Policy Explanation and Compliance Guidelines: 8. Equipment Protocol: a. All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment. Policy, Glucometer Disinfection, dated 6/2018 Policy: The purpose of this procedure is to provide guidelines for the disinfection of capillary-blood sampling devices to prevent transmission of blood borne diseases to residents and employees. Policy Explanation and Compliance Guidelines: 1. The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for mutli-resident use. 3. The glucometers should be disinfected with a wipe pre-saturated with an EPA registered healthcare disinfectant that is effective [MEDICAL CONDITION].[MEDICAL CONDITION] and [MEDICAL CONDITION] virus. 4. Glucometers should be cleaned and disinfected after each use and according to manufacturer's instructions regardless of whether they are intended single resident use or multiple resident use. Assure Prism multi Blood Glucose Monitoring System, User Instruction Manual, dated 11/2015 Page 38 Cleaning and Disinfecting: The cleaning procedure is needed to clean dirt as well as blood and other body fluids on the exterior of the meter and lancing device before performing the disinfection procedure. The disinfection procedure is needed to prevent transmission of blood-borne pathogens. The meter should be cleaned and disinfected after use on each patient. This Blood Glucose Monitoring System may only be used for testing multiple patients when Standard Precautions and the manufacturer's disinfection procedures are followed. We have validated Clorox Germicidal Wipes, Dispatch Hospital Cleaner Disinfectant Towels with bleach, Caviwipes 1, and PDI Super Sani-Cloth Germicidal Disposable Wipe for disinfecting the Assure Prism multi meter. At 1:27 PM an interview was conducted with the ADON (Assistant Director of Nursing) for the third floor of the facility. She said definitely after you use the glucometer, you wipe it off with a saniwipe, then you wrap it in the saniwipe and stick it in a cup for a couple of minutes. That is, after each use.

Based on observation of the dish machine in operation, review of the service call report and temperature log for the dish machine, and interview with the Director of Dining Services and the dish machine Technician, the facility failed to ensure the dish machine was working and staff were trained per manufacturers guidelines . The facility also failed to ensure the can opener and housing were kept free from residue build-up and metal shards from opening cans; and failed to ensure the floor was kept clean related to mopping after meals and ensuring all crumbs and residue were not swept into corners and allowed to remain on the floors between and under counters. Findings included: On 05/08/2018 at 9:35 a.m., the dish machine was noted to be processing dishware from the prior meal. The dietary aide reported that it was a high temperature machine and the wash temperature should be at a minimum of 160 degrees Fahrenheit and the rinse temperature should be at a minimum of 180 degrees Fahrenheit (F). The surveyors watched the temperature gauges for approximately 5 minutes without the wash temperature rising above 150 degrees F or the rinse temperature rising above 170 degrees F. Observation of the face plate stating the manufacturer's guidelines attached to the dish machine revealed hot water for the wash cycle must be at a minimum of 160 degrees F and the hot water for the rinse cycle must be at a minimum of 180 degrees F. The Dining Services Supervisor (DSS) reported at 9:45 a.m. that the booster heater had recently been dropped on the floor and the dish machine temperatures fluctuated. He reported the machine was set up for chlorine as a low temperature machine. He tested the level of chlorine at that time, even though the machine was described as a high temperature machine, and it was noted to test at approximately 200 parts per million. Review of the (MONTH) Dishmachine Temperature Log revealed no column on the log on which levels of sanitizer could be documented, even though the DSS commented that the chlorine was set up to be dispensed. At 11:00 a.m., the dish machine technician reported that he checked the machine and because the hot water was not consistently above the required wash and rinse temperatures, the booster heater was disconnected and the chlorine solution would provide the sanitizing. The DSS confirmed that the chlorine had been connected to provide chlorine as a sanitizer even though the dish machine was operating as a high temperature machine providing hot water as the sanitizer. The DSS confirmed that there had not been formal inservicing of his staff on the new concerns with the dish machine identified on 04/19/2018. He reported temperatures had been maintained above the required minimums and the chlorine had not been necessary. He confirmed that the chlorine sanitizing solution was connected and was dispensing even though it was not necessary. Review of the dish machine Technicians initial report, dated 04/19/2018 at 4:27 p.m., revealed the comment: Point of Observation: Final Rinse Temperature; Condition: Too Low; Cause: Equipment; Action & Benefits: Adjusted to ensure proper product usage. The DSS and Technician were questioned as to what the Action and Benefits statement meant. The Technician reported that he attached the chlorine line so chlorine would be dispensed as the temperatures were not high enough to sanitize the dishes. The DSS reported that he had not inserviced all of his staff who used the dish machine as to the change from a high temperature machine to a low temperature machine requiring testing of the chlorine to ensure adequate levels of a minimum of 50 parts per million. The DSS referred to the (MONTH) and (MONTH) temperature logs indicating that the temperatures had not dropped below the required minimum, therefore the staff did not need to test the chlorine to ensure its proper level for sanitation. Review of the log for (MONTH) and (MONTH) (up to 05/08/2018 Breakfast) revealed there was no column on the log to document chlorine levels and the Directions read: Take temperatures at the beginning of each change of wash water . record temp and write your initials. Notify your supervisor immediately if your dishmachine wash and rinse temperatures are lower or higher than allowed. The allowed temperatures were not provided on the log, for either a high or low temperature. There was no column to document the chlorine reading. Review of the 05/08/2018 report provided by the Technician revealed the level of sanitizer in the dish machine tested at 250 ppm, whereas the manufacturer requirement was a minimum of 50 ppm. Comments on the report read: As stated in previous report, the D/M (dish machine) is currently running on Chemical sanitizer at 100 ppm. Booster heater is going to be replaced due to failure to maintain constant 180 F water temp at final rinse. We have turned off Booster heater to avoid random readings above 160 F that may cause sanitizer to evaporate. Machine is currently operating under all requirements stated by NSF (National Science Foundation) on its date plate. An observation of the dish machine on 05/09/2018 beginning at 3:35 p.m. revealed a sign posted on the dish machine which read, machine sanitizes using chemical sanitizer. Also the log had been revised and it included Directions for required temperatures and a column to document chlorine ppm. An observation of the dish machine on 05/09/2018 at approximately 4:00 p.m. revealed that the wash water temperature was above 140 degrees F, the rinse water temperature was above 120 degrees F and the parts per million of the sanitizer was at 100. All appropriate readings for a low temperature machine. During the initial tour of the main kitchen, beginning at 7:10 a.m. on 05/08/2018, the can opener was observed in the housing, with metal shards attached to black residue on the pincer blade. During the second visit to the kitchen at 9:30 a.m. on 05/08/2018, the can opener had been removed from the housing, exposing a build-up of a sticky black residue around the housing base with metal shards from opening cans attached to the residue. An observation of the main kitchen floor, on 05/08/2018 beginning at 7:10 a.m. revealed a build up of crumbs along the base boards and between tables. Around the base of the large standing kettle, on the floor, was a circle of red residue. Next to the kettle was the fryer with a circle of splashed grease around its base. In an interview with the DSS on 05/08/18 during the second visit to the main kitchen, beginning at 9:30 a.m., revealed that each evening at closing the floor was washed and after each meal the floor was swept and washed if there were spills during meal preparation. During the observations made beginning at 7:10 a.m. and again beginning at 9:30 a.m., there was not a red sauce or soup being made in the standing kettle and nothing was being fried in the fryer.

Based on observations, interviews with residents, family members and facility staff, and review of staffing schedules, assignments and filed grievances the facility failed to ensure sufficient nurse staffing was in place to address resident care needs, for 5 (#110, #95, #52, #18, #64) of 40 sampled residents and failed to ensure residents needs were met timely during meal times. Findings included: 1- Interview with a family member of Resident #52 , on 05/09/2018 beginning at 11:30 a.m. revealed that sometimes agency aides were working with the residents and they didn't seem to know anything about the residents and what they needed. The family member confirmed she had filed a grievance in (MONTH) which included this concern. In an interview with the Assistant Director of Nurses, Staff C on 05/10/2018 beginning at 9:20 a.m., it was revealed that the facility uses agency nurses and aides. She reported that the shift supervisor was to ensure the agency staff were familiar with their assignment and knew what residents on their units needed. She confirmed that for the aides, it was all verbal communication, nothing was written about each resident for the agency aide. In an interview with Aide O (on 05/11/2018 at 10:40A.M.), when asked how agency staff know their assignments, she reported that she verbally tells the agency aide about each resident and may write some details down on the assignment sheet for the aide. She said that the aides have been told that they are to fill in the assignment sheets with information about each resident during rounding with the outgoing aide, but that takes a long time. She also reported that the ADON (Staff C), had told the aides she was going to create a document listing each residents' needs, but it hadn't been completed yet. 2-On 5/11/18 at 10:23 a.m. an interview with Staff H, Certified Nursing Assistant (CNA) revealed the staff on the second floor work together as a team during lunch. She stated there were no set assignments during meal times. She said, Around lunch time it gets busy and after lunch. We have it to where we have a few people in the hall while the rest are in dining. She said, No, when asked if assignments were made for staff to be in dining room or on the floor. She said, We all just help, one that does the steam table line, then some serve trays, then come back to dining room. She confirmed no one in particular is assigned to answer call lights during meal times she said, No. We just all answer them together. On 5/11/18 at 10:43 a.m., an interview with Staff E, Registered Nurse (RN) stated, As far as I know they do have assignments. To my knowledge, they know what to do. On 5/11/18 at 10:53 a.m., an interview with Staff I, CNA confirmed the assignment sheets for the CNAs are found in the sign in book at the nurses' station and on the wall. She shared that only the room numbers are provided. She said, The assignment with our names and the assignments are on the wall. It just has room numbers and which nurses to which side. On 5/11/18 at 12:31 p.m. and interview with Staff J, Staffing Coordinator, CNA confirmed the staffing assignment sheets are placed in the sign in book at the nurses' station and on the wall. She explained the Unit Managers would fill in the assignments for the CNAs on the assignment sheets each shift. She said, If not typed in then the Unit Manager will assign them. She explained that all staff are hands on deck for call lights. A review of the staff assignment sheets for 5/7/18 for the 7:00 a.m. - 3:00 p.m. and 3:00 p.m. - 11:00 p.m. shift on the second floor documented the room numbers and tasks assigned to the staff to include passing trays, dining room and lights. A review of the staff assignment sheets for 5/8/18 for the 7:00 a.m. - 3:00 p.m. shift on the second floor revealed a typed form that documented the room numbers assigned to the staff. The staff assignment sheets for 5/8/18 for the 3:00 p.m. - 11:00 p.m. shift on the second floor was typed and documented the room and task assignments to include passing trays, dining room and lights. A review of the staff assignment sheets for 5/9/18 for the 7:00 a.m. - 3:00 p.m. shift on the second floor only documented the room numbers assigned to the staff. The staff assignment sheets for 5/9/18 for the 3:00 p.m. - 11:00 p.m. shift on the second floor documented the room and task assignments to include passing trays, dining room and lights. A review of the staff assignment sheets for 5/10/18 for the 7:00 a.m. - 3:00 p.m. shift on the second floor only documented the room numbers assigned to the staff. The staff assignment sheets for 5/10/18 for the 3:00 p.m. - 11:00 p.m. shift on the second floor documented the room and task assignments to include passing trays, dining room and lights. A review of the staff assignment sheets for 5/7/18 - 5/10/18 for the 7:00 a.m. - 3:00 p.m. and 3:00 p.m. - 11:00 p.m. shift on the third floor documented the room numbers only for staff assignments. Observations of dining on 5/9/18 and 5/10/18 during lunch in the second floor dining room revealed seven to eight staff members assisting residents with serving the lunch. The staffing schedule for 5/9/18 and 5/10/18 during the 7:00 a.m. - 3:00 p.m. shift on the second floor and third floor indicated eight CNAs scheduled for the shift. On 5/11/18 at 1:59 p.m., an interview with the Executive Director and Director of Nursing revealed the facility initiated on 5/10/18 a plan to address call light response. They noticed a trend in grievances related to call light response time. They will be in-servicing staff, reinstituting a pager system. The staffing quality plan in place since (MONTH) of (YEAR) identified a shortage in direct care staff. Their goal was to stabilize and have reduced the number of open positions. 3-Review of filed grievances with the Social Services Director on 05/09/2018 beginning at 2:40 p.m. revealed on 05/02/2018, two grievances were filed by residents or their families, related to long wait times in response to call bells, with the date of resolution for both documented on 05/03/2018. Discussion with the Social Services Director and Staff C revealed that neither staff investigated the grievances in depth to address why the residents had to wait for a response. On 05/02/2018, Resident #110 filed a grievance reporting she had to wait too long for staff to respond to her needs. Also on 05/02/2018, Resident #95 called her daughter to report she was waiting too long for a response to call lights and aide talking to resident attempting to excuse why it takes them so long. Review of the two resolutions revealed the Assistant Director of Nurses, Staff C, provided an inservice on customer service and answering call bells timely. Review of the grievance paperwork, per the Social Services Director, revealed Resident #110 was referring to a long wait time during the 3-11 shift. There were no aides' names documented on the grievance paperwork. Resident #95 reported it was two aides on the 11p to 7a shift that were working with the resident and the grievance paperwork revealed that the two aides spoke to the resident about the wait and apologized. Interview with Staff C, on 05/10/2018 at 9:20 a.m., revealed she had not pulled the schedules or assignments for 05/02/2018 to determine who had worked with either resident. Staff C confirmed she had not investigated why the delay in response, but felt inservicing the staff would be the best resolution. 4-On 5/08/18 at 9:12 a.m., an interview with Resident #18 revealed her concern with the facility not having enough staff to care for her needs. She said, No not really, there are times I'm left sitting on the commode. On 5/08/18 at 12:13 p.m., an interview with Resident #64 revealed the facility has been short-staffed. She said, It goes up and down. I would say, all the time they have a problem. On 5/10/18 at 2:04 p.m., in a meeting held with members of the Resident Council, a concern was revealed regarding the facility having enough staff during meal times. Multiple residents expressed concern. One Resident stated, Sometimes they get real busy. My concern is not against staff at all. Every time I ask for help, they do. Sometimes it takes a little longer than comfortable. Sometimes I'm left sitting on the commode during the day during the lunch hour or change of shift. Another Resident said, If you're on water pills and they're short-handed, well the other night they only had two here and it was a disaster. I think we are short staffed. 5-On 05/10/2018 at 12:30 p.m., the third floor dining room was noted to be in the middle of the lunch meal with most of the tables occupied by residents and facility staff assisting them. One table of four residents was noted to have three facility staff seated alongside three of the four residents. These three facility staff were identified as activity assistants (AA). They were directly assisting the residents with their lunch and all three residents were noted to have mechanically altered meals, not regular consistency diets. Resident #52 was holding her own beverage cup and able to drink independently with an AA encouraging her. Once she drank some of the milk and put her cup down, the AA was observed to offer a spoonful of her meal. The resident took the offered bite, and several after that one. The AA encouraged her to drink after several bites. The other two AA's were observed directly assisting the two residents they were sitting next to with their modified consistency diets. In an interview with the Speech Therapist on 05/11/2018, beginning at 1:20 p.m., she confirmed she had not 'certified' the activities assistants in assisting residents with their meals. She confirmed she had only shared 'pointers' with them when they assist residents with meals. 6-Based on an observation of a call light activated on 5/11/18 at 8:45 a.m., revealed the call light had been on for five minutes when a resident was observed coming down the hallway with the hairdresser. The resident was observed wearing ted hose and no socks. The hairdresser stated to the resident that she would find someone to put socks on him so he could go get a haircut. The dining room revealed 8 staff members assisting residents at 8:45 a.m The four hallways revealed no staff members at the time. At 8:50 a.m. one of the CNAs approached the resident and the hairdresser stated he needed socks. The CNA went to his room and put socks on the resident at the elevator. During an interview with the hairdresser on 5/11/18 at 8:52 a.m. she stated, I should not have removed the resident from his room but the call light was on for so long that I took him to the elevator to wait for someone to put socks on the resident. The hairdresser stated that it is difficult at meal times to get staff to assist since they are assisting the residents that need help eating in the dining room and that is why she took him to the elevator.

Based on observations and interviews, the facility failed to ensure residents were treated in a dignified manner related to staff not announcing themselves prior to going in occupied resident rooms on two of two floors, during four of four days observed (5/8/18, 5/9/18, 5/10/18 and 5/11/1) and taking a pulse oximeter reading of Resident #9 and removing a Resident from the Resident Council meeting. Findings included: The following observations were made of staff not knocking, or announcing, or waiting for permission prior to going into occupied resident rooms and interrupting a Resident Council meeting to take a vital sign and remove a resident: 1. On 5/8/18 at 8:33 a.m., a nurse entered the private room of Resident #66 during an interview with surveyor without knocking, announcing or waiting for permission from the Resident to enter. She apologized and said, I am here just to give her medicine. Following the interruption of the interview the Resident told the nurse she did not want to continue the interview. An additional observation at 9:30 a.m. revealed a staff member entering the room of Resident #66 with towels in hand and did not knock or announce herself. 2. On 5/8/18 at 9:10 a.m., a staff member entered the private room of Resident #18 during an interview with surveyor without knocking, announcing or waiting for permission from the Resident to enter. She came into the room and proceeded to discuss with Resident #18 items on her breakfast tray. 3. On 5/8/18 at 10:05 a.m., a staff member answered a call light for Resident #9. She entered the private room without knocking, announcing or asking for permission to enter Resident #9's room. 4. On 5/9/18 at 12:30 p.m., a staff member walked past surveyor, and entered room [ROOM NUMBER] and delivered a lunch tray to Resident residing at 241A. She did not knock, announce herself or wait for permission to enter the room. 5. On 5/9/18 at 12:33 p.m., in the dining room on the second floor, a staff member was observed to assist a resident with drinking cranberry juice by standing over the resident. 6. On 5/10/18 at 2:05 p.m., Staff A, Registered Nurse walked into the Resident Council meeting and proceeded to place a pulse oximeter on the finger of Resident #9. Sixteen other residents were in attendance at the meeting. Residents seated next to Resident #9 stared at the resident and nurse while the oxygen saturation level was taken. Additionally, a staff member interrupted the meeting at 2:14 p.m. and announced she needed a Resident and called her by name. She then proceeded to take the Resident from the meeting and stated, They need you over there now. 7. On 5/11/18 and at 12:08 p.m. a staff member slightly knocked on the door to room [ROOM NUMBER]. The knock was inaudible. She did not announce herself or wait for permission to enter the room. 8. On 5/11/18 at 12:50 p.m., a staff member walked into room [ROOM NUMBER]A and delivered the lunch tray without knocking, announcing self or waiting for permission to enter the room. A review of a facility provided policy titled, Promoting/Maintaining Resident Dignity, Date Reviewed/Revised 6-17, revealed a policy description to promote resident rights and treat each resident with respect and dignity to maintain or enhance the resident's quality of life. The policy did not include compliance guidelines related to knocking and announcing prior to entering a resident's room. The Director of Nursing and ADON confirmed the facility did not have a policy related to knocking on the door to resident's rooms prior to entering. An interview on 5/11/18 at 12:31 p.m. with Staff J, Staffing Coordinator, and CNA confirmed staff should knock and announce themselves prior to entering a resident's room. She said, Always knock and wait on the resident. We have to realize this is their home. An interview on 5/11/18 at 3:43 p.m. with Staff C, Assistant Director of Nursing confirmed her expectation is the staff would knock and announce themselves prior to entering a resident's room. She said, Knock and then announce.

Based on review of the resident's medical record and interview with the Facility staff, the facility failed to ensure the Physician was informed of one resident (#170) of a sample of 39 residents, for late administration of insulin, not receiving insulin on one day, and having a blood glucose accucheck result of 345 the day that she did not receive the insulin. Findings included: Resident #170 was admitted on [DATE] from a hospitalization for a hip joint replacement, per the face sheet located in the resident's medical record. Review of Physician's notes revealed on 05/03/2018 the physician documented that the resident had DM II (Diabetes Mellitus II), Uses (illegible) [MEDICATION NAME] 22 u + 16 u and under A/P (Assessment/Plan), it was documented DM - insulin clarified with her own pharmacy. A review of the Physician's note dated 05/08/2018 revealed high (arrow up) accuchecks, getting wrong insulin, will change to [MEDICATION NAME] 70/30 as she uses at home. Review of the resident's (MONTH) Medication Administration Record (MAR) revealed on 05/04/ the morning dose of insulin was documented as given at 11:49 a.m. for a dose ordered at 10:00 a.m. Review of the resident's (MONTH) MAR revealed the insulin ordered to start on 05/06/18 at 8:00 a.m. was discontinued on 05/07/2018. The MAR for 05/07/2018 for the insulin dose at 8:00 a.m. was marked with a N which was documented as refused in the end notes of the MAR. The MAR listed an order for [REDACTED]. The insulin was not documented as given at 5 p.m. for this order. Further review of the MAR revealed no order and no documented administration of insulin in the afternoon on 05/07/2018. No insulin was documented as being given on 05/07/2018, and no nurses note or end note in the MAR documented that insulin had not been given for the 5:00 p.m. dose. In an interview with the Assistant Director of Nurses, Staff C, on 05/11/2018 beginning at 10:40 a.m., she confirmed that there was no documentation of the administration of insulin on 05/07/2018 as the resident had refused the morning dose and the evening dose was not documented as given. Staff C located the telephone order, dated 05/07/2018, but not timed, for the [MEDICATION NAME] 70/30, 22 u at 7 a.m. and 16 u at 5 p.m. She surmised that the 11p to 7a nurse had 'picked up' the order, transcribed it to the MAR and sent it to the Pharmacy for filling. The resident received this order of insulin at 6:23 a.m. on 05/08/2018. Staff C confirmed that there were no nurses notes written to document why the changes in insulin had been made during the resident's admission. She also confirmed that there were no nurses notes indicating the physician had been notified that the resident had received no insulin on 05/07/2018, had an accucheck at 5:00 p.m. of 345, and that the resident received a late morning dose of insulin ordered to be given at 10:00 a.m., but received it at 11:49 a.m.

Based on observation, interview and record review, the facility failed to maintain privacy and confidentiality for one Resident (#371) of nine residents observed during medication administration by throwing away the pre-printed medication packets labeled with the resident's name and medication. Findings included: After observation of Staff D, Licensed Practical Nurse LPN, preparing medications, the nurse was observed at 8:51 a.m. on 5/10/18 discarding the resident's 2 pre-filled medication pouches in the trash. During an interview with Staff D, LPN on 5/10/18 at 8:51 a.m., she stated that she always throws pre -printed medication pouches in the garbage and does not see why they need to be kept until the end of the day. The nurse stated, she did not realize that throwing them in the trash with the resident information was an issue. She stated that she never thought that was a problem. During an interview with Staff C, Assistant Director of Nursing (ADON), at 9:20 a.m. on 5/10/18, she stated the nurse after opening meds should dispose of the prefilled medication pouches in the shredder, not the garbage. During an interview on 5/11/18 at 1:00 p.m., with the Director of Nursing (DON), she stated that the pre-filled medication pouches should be shredded and not thrown away due to them having resident information. Review of the policy for HIPAA dated 6/17, page one of two revealed: It is the policy of this facility to comply with all policies and procedures regarding the protection of personal identifiable health information of our residents.