Every finding on record at Westmoreland Care & Rehab CTR

Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff changed the central line dressing as ordered by the physician for 1 (Resident #84) of 5 sampled residents reviewed for medication regime review.Findings included:A facility policy titled, Dressing Change for Vascular Access Devices, dated 08/2021, revealed, Purpose To prevent local and systemic infection related to IV [intravenous] catheter. Policy 1. Short peripheral catheter dressings are changed every 7 days or when the integrity of the dressing is compromised. Change the dressing if moisture, drainage or blood is present or for further assessment if infection is suspected. 2. Central venous access device and midline dressing changes will be done at established intervals and immediately if the integrity of the dressing is compromised, if moisture, drainage or blood is present, or for further assessment if infection is suspected. * Transparent semi-permeable membrane dressings are changed every 7 days and PRN [pro re nata, as needed].A Resident Face Sheet revealed the facility admitted Resident #84 on 03/10/2026. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of surgical aftercare and need for assistance with personal care.An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/16/2026, revealed Resident #84 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated the resident received intravenous (IV) medications and had IV access.Resident #84's Care Plan included a problem statement initiated 03/10/2026, that indicated the resident had a peripherally inserted central catheter. Interventions directed the staff to complete dressing changes as ordered.Resident #84's Physician Order Report revealed an order dated 03/10/2026, for central line dressing change every week on Wednesdays until 03/25/2026.Resident #84's Medication Administration Record [MAR] for the timeframe 03/01/2026 - 03/31/2026, revealed the transcription of a physician's order that directed staff to change the resident's central line dressing every week on Wednesdays. Per the MAR, Licensed Practical Nurse (LPN) #8 initialed the resident's MAR to indicate she changed Resident #84's central line dressing on 03/11/2026 and Registered Nurse (RN) #1 initialed the MAR to indicate she changed the resident's central line dressing on 03/18/2026.During an interview on 03/23/2026 at 2:53 PM, Resident #84 stated they received IV antibiotics as ordered but no one had changed their IV dressing since they arrived at the facility on 03/10/2026. Resident #84 showed the surveyor their IV dressing on their right upper chest and the dressing was 03/10/2026.During an interview on 03/23/2026 at 4:09 PM, RN #1 stated she had not completed any IV dressing changes since 03/02/2026.During an interview on 03/25/2026 at 10:38 AM, LPN #8 stated when she administered IV medication to Resident #84 on 03/11/2026, she noticed the date on the resident's central line dressing was more than a week overdue but did not remember letting anyone know the dressing needed to be changed and did not remember that she initiated the resident's MAR to indicate she changed the central line dressing on 03/11/2026.During a follow-up interview on 03/26/2026 at 7:24 AM, RN #1 stated she accidentally marked (initialed) the dressing change completed on 03/18/2026. RN #1 stated she initiated the dressing change in error.During an interview on 03/25/2026 at 10:56 AM, the Unit Manager stated she expected a RN to change a resident's central line dressing according to the physician's order.During an interview on 03/24/2026 at 2:47 PM, the Director of Nursing stated he expected the nurse to follow the physician's orders.

Based on interview and record review, the facility failed to ensure staff completed and accurately documented the status of resident care to be provided for 2 (Resident #59 and Resident #84) of 21 sampled residents.The findings included:1. A Resident Face Sheet revealed the facility admitted Resident #59 on 08/23/2025. According to the Resident Face Sheet, the resident had a medical history that included dysphagia and protein-calorie malnutrition.A quarterly Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 03/18/2026, Resident #59 had a Staff Assessment for Mental Status (SAMS) that indicated the resident had severely impaired cognitive skills for daily decision making. The MDS indicated the resident had a feeding tube.Resident 59's Care Plan included a problem statement initiated 03/10/2026, that indicated the resident was at risk for complications related to a need for enteral feedings.Resident #59's Physician Order Report revealed an order dated 12/22/2025, for enteral feeding of Jevity 1.5 at 50 milliliters per hours every shift.Resident #59's Observation Detail List Report completed by Registered Nurse (RN) #1 and dated 03/19/2026, revealed the Nutritional interventions section was marked N/A and not Enteral Feedings,Resident #59's Observation Detail List Report completed by RN #1 and dated 03/23/2026, revealed the Nutritional interventions section was marked N/A and not Enteral Feedings,During an interview on 03/25/2026 at 10:50 AM, Licensed Practical Nurse #8 stated the Observation Detail List Report was a nurse's note that should accurately reflect Resident #59's plan of care.During an interview on 03/24/2026 at 2:47 PM, the Director of Nursing stated he expected documentation within the resident's medical record to be accurate and represent the status of the resident.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff wore a gown and gloves when they provided care to residents on enhanced barrier precautions (EBP) for 2 (Resident #23 and Resident #84) of 5 sampled residents reviewed for infection control.The findings included: 1.A facility policy titled, Enhanced Barrier Precautions revised 03/25/2024, revealed This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The policy specified, 5. EBP are indicated for residents who have chronic wounds and or indwelling devices regardless of MRDO [multidrug-resistant organisms]. 2. A Resident Face Sheet revealed the facility admitted Resident #23 on 10/08/2025. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of end stage renal disease and dependance on renal dialysis. An admission Minimum Data Set (MDS) dated [DATE], revealed Resident #23 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident received dialysis. Resident #23's Care Plan included a problem statement initiated 10/08/2025 and edited 02/14/2026, that indicated the resident required enhanced barrier precautions related to a dialysis shunt. Interventions directed staff to use personal protective equipment as indicated (initiated 10/08/2025). Resident #23's Physician Order Report revealed an order dated 02/13/2026, for enhanced barrier precautions every shift due to a dialysis port. During an observation on 03/25/2026 at 10:18 AM, Licensed Practical Nurse (LPN) #4 and Certified Nursing Assistant (CNA) #5 entered Resident #23's room to prepare the resident for a dialysis appointment. CNA #5 pulled back Resident #23's bed linens to allow LPN #4 to perform a full body skin assessment of the resident. LPN #4 put on a pair of gloves and completed an assessment of Resident #23's dialysis port located in the resident's right upper chest. CNA #5 assisted with turning and repositioning the resident. LPN #4 and CNA #5 did not put on a gown when they performed resident care. During an interview on 03/25/2026 at 10:34 AM, LPN #4 stated she had been educated to wear a gown and gloves when caring for residents on enhanced barrier precautions but felt rushed when the paramedics were waiting and forgot to put on a gown. During an interview on 03/25/2026 at 10:38 AM, CNA #5 stated she had been educated to wear a gown and gloves when she provided care to Resident #23 due to the residents' dialysis port. CNA #5 stated she forgot to wear a gown during the provision of care to the resident. During an interview on 03/26/2026 at 9:25 AM, the Staff Development Coordinator (SDC), who also functioned as the Infection Preventionist, stated staff were to wear a gown and gloves when they provided care to residents with internal devices. The SDC stated he expected the staff to put on a gown and gloves when they provided care to Resident #23's dialysis port. During an interview on 03/26/2026 at 10:26 AM, the Director of Nursing stated residents who had a dialysis port should be placed on EBP and staff should wear a gown and gloves when they provided care to the resident's dialysis port or repositioned the resident in bed. During an interview on 03/26/2026 at 10:06 AM, the Administrator stated she expected LPN #4 and CNA #5 to put on a gown and gloves when they provided care to Resident #23's dialysis port. 3. A Resident Face Sheet revealed the facility admitted Resident #84 on 03/10/2026. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of surgical aftercare and need for assistance with personal care.An admission Minimum Data Set (MDS) dated [DATE], revealed Resident #84 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated the resident had three venous and arterial ulcers present and a surgical wound.Resident #84's Care Plan included a problem statement initiated 03/23/2026, that indicated the resident required enhanced barrier/contact precautions related to a wound and a peripherally inserted central catheter line. Interventions directed the staff to wear personal protective equipment (PPE) as indicated.Resident #84's Physician Order Report revealed an order dated 03/10/2026 for contact precautions for wounds and an order dated 03/13/2026 for enhanced barrier precautions related to a wound.During an observation on 03/23/2026 at 11:53 AM, the Activity Director (AD) and Hospitality Aide (HA) #13 entered Resident #84's room, put on gloves, and together they each repositioned the resident in their bed. The AD and HA #13 did not put on a gown when they repositioned Resident #84 in bed.During an interview on 03/23/2026 at 12:25 PM, HA #13 stated she obtained assistance from the AD to reposition Resident #84 in bed. HA #13 l stated she did not need to wear a gown unless she performed care such as changing the resident's incontinence brief. HA #13 stated did not put on a gown when she repositioned Resident #84 in bed.During an interview on 03/25/2026 at 3:16 PM, the AD stated she assisted HA #13 in repositioning Resident#84 in bed. The AD stated she knew she should have worn a gown and gloves but only put on gloves.During an interview on 03/25/26 at 8:20 AM, the Staff Development Coordinator, who also functioned as the Infection Preventionist stated staff were to wear a gown and gloves when they provided care to residents with a wound.During an interview on 03/24/26 at 3:10 PM, the Director of Nursing stated Resident #84 had a wound and staff were expected to wear a gown and gloves when they provided care to the resident.During an interview on 03/26/2026 at 9:29 AM, the Administrator stated she expected staff to wear the PPE when they entered the room of a resident on enhanced barrier and contact precautions.

Based on facility policy review, facility documentation review, observations, and interview, the facility failed to store food at the proper temperature, prevent contamination of food, and ensure the Dietary Department was maintained in a sanitary manner, affecting 89 of 93 residents in the facility. The findings include: Review of the facility's policy titled, Food Storage: Cold Foods, revised 4/2018, revealed, .All perishable foods will be maintained at a temperature of 41' [degrees] F [Fahrenheit] or below, except during necessary periods of preparation and service . Review of the facility's undated policy titled, Food: Preparation, revealed, .All staff will practice proper hand washing techniques and glove use .Dining Services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination .All staff will use serving utensils appropriately to prevent cross contamination . Review of the facility's undated policy titled, Handwashing/Hand Hygiene, revealed, .This facility considers hand hygiene the primary means to prevent the spread of infection .Use an alcohol-based hand rub .m. after removing gloves . Review of the manufacturer's recommendations for testing the efficacy of Oasis 146 Multi-Quat Sanitizer, (the sanitizing solution used in the kitchen for sanitzing surfaces) revealed, .Withdraw and tear off 2 inches of paper (pHydrion Papers QT-40) from dispenser .Testing solution should be at room temperature .Dip paper for 10 seconds .Compare colors immediately with colors on the test strip package to determine ppm (parts per million) .Testing solution should be between 150-400 ppm . Observation in the kitchen on 2/27/2022 at 9:30 AM, revealed the temperature in the walk-in cooler was 43 degrees F. Observation in the kitchen on 2/27/2022 at 11:40 AM, revealed a silver bowl with 2 bread rolls wrapped in a plastic bag on the floor between the steamer and the tilt skillet. Observation in the kitchen on 2/27/2022 at 11:43 AM, revealed the Cook touched a baked potato with her gloved hand, and continued preparing meals on the tray line. Observation in the kitchen on 2/27/2022 at 11:49 AM, revealed the Cook was plating food on the tray line with gloved hands. She left the tray line, retrieved a pan of spinach out of the steamer, placed the pan of spinach on the steam table, removed her gloves and donned new gloves without sanitizing/washing her hands. Observation in the kitchen on 2/28/2022 at 9:00 AM, revealed the temperature in the walk-in cooler was 43 degrees F. Observation in the kitchen on 2/28/22 at 9:05 AM, revealed the Certified Dietary Manager (CDM) tested the sanitizing water for the proper concentration of sanitizing solution, and the test strip read less than 100 ppm. Observation in the Nourishment Room on 2/28/2022 at 9:10 AM, revealed the temperature in the nourishment refrigerator was 44 degrees F. During an interview on 2/27/2022 at 11:40 AM, the CDM confirmed the silver bowl with 2 bread rolls wrapped in a plastic bag on the floor between the steamer and tilt skillet should not be there. During an interview on 2/27/2022 at 11:45 AM, the Cook confirmed she should not have touched the baked potato with her gloved hand. During an interview on 2/27/2022 at 11:50 AM, the CDM confirmed the Cook should not have touched the baked potato with her gloved hand and confirmed the Cook should have sanitized/washed her hands before donning clean gloves. During an interview on 2/28/2022 at 9:05 AM, the CDM confirmed the sanitizing solution should measure between 200-400 ppm and it was registering less than 100 ppm. During an interview on 2/28/2022 at 9:00 AM, the CDM confirmed the temperature in the walk in cooler in the kitchen was 43 degrees F, and should be 41 degrees F or below. During an interview on 2/28/2022 at 9:10 AM, the CDM confirmed the temperature in the Nourishment room refrigerator was 44 degrees F, and it should be 41 degrees F or below.

Based on facility policy review, medical record review, observation, and interview, the facility failed to keep 1 of 93 sampled residents (Resident #8) who was wearing only a brief, covered, and the facility failed to ensure 3 of 7 sampled residents (Resident #33, #43 and #54) indwelling urinary catheter drainage bags were covered with a privacy cover. The findings include: Review of the facility's policy titled, Resident Rights, dated 8/16/18, revealed, .All residents have the right to be treated with respect and dignity .All residents will be treated in a manner and in an environment that promotes maintenance or enhancement of quality of life .The facility will make every effort to support each resident in exercising his/her right to assure that the resident is always treated with respect, kindness, and dignity . Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #8 is rarely/never understood and his cognitive skills for daily decision making is severely impaired. Continued review revealed he rejected care 1 to 3 days in the 7 day evaluation period and he required extensive assistance of 2 or more caregivers for dressing. Observations in Resident #8's room on 2/27/2022 at 12:10 PM, 2:12 PM, and 3:00 PM, revealed the resident laying in bed, uncovered, and only wearing a brief. Observations in Resident #8's room on 2/28/2022 at 7:46 AM, 10:00 AM, 10:25 AM, and 12:45 PM, revealed the resident laying in bed, uncovered, and only wearing a brief. During an interview on 3/1/2022 at 12:15 PM, the Director of Nursing (DON) stated that he (Resident #8) should have been clothed/covered. The DON stated, I told them [nursing staff] to put a gown on him this morning. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment dated [DATE], revealed Resident #33 had an indwelling urinary catheter. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Observations in Resident #33's room on 2/27/2022 at 9:45 AM, 11:31 AM, and 2:55 PM, revealed the urinary drainage bag was not in a privacy bag. Observation and interview in Resident #33's room on 2/27/2022 at 2:55 PM Registered Nurse (RN) #1 confirmed Resident #33's urinary drainage bag was not in a privacy bag. Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment dated [DATE], revealed Resident #43 had an indwelling urinary catheter. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Observation in Resident #43's room on 2/27/2022 at 10:25 AM and 2:23 PM revealed the resident's indwelling urinary catheter drainage bag was hanging on the left side of the bed facing the door and was not in a privacy bag. Observation and interview in Resident #43's room on 2/27/2022 at 2:30 PM, RN #1 confirmed the resident's indwelling urinary catheter drainage bag was not in a privacy bag. She stated, It's not in a privacy bag and it should be. Review of the medical record revealed Resident #54 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Re-entry MDS assessment dated [DATE], revealed Resident #54 had an indwelling urinary catheter. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Observations in Resident #54's room on 2/27/2022 at 10:36 AM and 2:15 PM, revealed the urinary drainage bag was laying on the floor and not in a privacy bag. Observation and interview on 2/27/2022 at 3:00 PM, RN #1 confirmed Resident #54's urinary drainage bag was laying on the floor and not in a privacy bag.

Based on facility policy review, observations, and interviews, the facility failed to ensure 1 of 93 sampled residents (Resident #63) had clean and groomed fingernails. The findings include: Review of the facility's policy titled, Nail Grooming, dated 5/18/2018, revealed, .Regular fingernail care will promote cleanliness and prevent infection. The nursing staff will provide observation and care of nails for all residents daily and as necessary . Observation on 2/27/2022 at 9:51 AM, revealed Resident #63 sitting in his wheelchair in his room. Continued observation revealed the resident had long fingernails with dried brown debris noted under his nails on both hands. Observation and interview on 2/27/2022 at 11:39 AM, Resident #63 was sitting in his wheelchair in his room. The resident had different clothes on but his nails on both hands continued to be long with dried brown debris noted under his fingernails. Resident #63 confirmed he had received a bath. Observation and interview in Resident #63's room on 2/27/2022 at 12:15 PM, Certified Nurse Aide (CNA) #1 confirmed Resident #63's nails on both hands were dirty and long. He stated, We use an orange stick to clean them when we give them a bath and when they need it done, but I didn't clean them today. Observation and interview in Resident #63's room on 2/27/2022 at 12:30 PM, Licensed Practical Nurse (LPN) #1 looked at Resident #63's hands and confirmed Resident #63's nails were dirty and long. She stated residents' nails were supposed to be cleaned with showers and baths and whenever they are dirty and clipped when needed.

Based on facility policy review, medical record review, observation, and interview the facility failed to have a call light in reach for 1 of 93 sampled residents (Resident #27) observed. The findings include: Review of the facility policy titled, Resident Rights, revised 8/16/2018, revealed, .The facility provides equal access to quality of care regardless of diagnostic and severity of condition . Review of the medical record revealed Resident #27 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #27 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Continued review revealed Resident #27 required total assistance with two staff members for Bed Mobility and Transfers. Continued review revealed Resident #50 had upper and lower impairments of the extremities bilaterally. Observations in Resident #27's room on 2/27/2022 at 11:44 AM and 2:32 PM, revealed Resident #50's flat call light was not in reach for her to touch and call for help. Observation in Resident #27's room on 2/28/2022 at 10:42 AM revealed Resident #50's flat call light was not in reach for her to touch and call for help. Observation and interview in Resident #27's room on 2/28/2022 at 10:44 AM, Certified Nurse Aide (CNA) #7 confirmed Resident #27 was not able to reach her call light. During an interview on 3/2/2022 at 10:33 AM, the Unit Manager also known as LPN #5 confirmed the call light should be placed near Resident #27's face so she can reach it.

Based on facility policy review, medical record review, and interview, the facility failed to implement a person-centered care plan for 3 of 93 sampled residents (Resident #14, #43, and #50) for respiratory care for Resident #14, anticoagulant for Resident #43, and elopement for Resident #50. The findings include: Review of the facility's policy titled, Comprehensive Care Plan, revised 7/19/2018, revealed, .A person-centered Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The care plan will include how the facility will assist the resident to meet their needs, goals and preferences .10. The resident's Comprehensive Care Plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS [Minimum Data Set]/ CAA [Care Area Assessment]). Review of the medical record revealed Resident #14 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Scheduled 5-Day Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #14 received oxygen therapy. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Oxygen Therapy: Oxygen via NC [nasal cannula] to keep sats [saturation] above 88% .Oxygen therapy: Change tubing every week .change on Thur [Thursday] .[MEDICATION(S)] aerosol inhaler; 90 mcg [micrograms]/actuation; amt [amount]: 2 puffs; inhalation Every 6 Hours - PRN [as needed] .[MEDICATION(S)] ([MEDICATION(S)]-umeclidin-vilanter) blister with device; 100-62.5-25 mcg; amt: 1 inhalation; inhalation Once A Day .Inhaler use: following inhaler medication administration, have resident rinse mouth with water .Oxygen Weaning- wean as tolerated .Oxygen therapy: Check humidification bottle every shift, change when empty . Review of the Care Plan for Resident #14 dated 1/3/2022, revealed Resident #14 had no Care Plan for Respiratory Care. Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS dated [DATE] revealed Resident #43 received anticoagulant medication 7 out of 7 days of the lookback period. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] ([MEDICATION(S)]) 5 mg twice a day .Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan for Resident #43 dated 2/18/2022, revealed the resident had no care plan for anticoagulants. Review of the medical record revealed Resident #50 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan for Resident #50 revised 2/7/2022, revealed the resident had no care plan for elopement risk. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Check placement of Wander Guard every shift . Review of the Elopement Risk Assessments for Resident #50 dated 4/20/2021 and 2/11/2022 revealed the resident was considered a high elopement risk. During an interview on 3/1/2022 at 9:34 AM, MDS Coordinator #1 confirmed risk for elopement was not on Resident #50's care plan. During an interview on 3/1/2022 at 1:39 PM, Director of Nursing (DON) confirmed elopement was not on Resident #50's care plan. During an interview on 3/1/2022 at 1:40 PM, MDS Coordinator #2 confirmed Resident #14 had no Care Plan for Respiratory Care. During an interview on 3/2/2022 at 8:34 AM, MDS Coordinator #1 confirmed Resident #43 was taking anticoagulant medication and did not have a care plan for anticoagulants.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to revise a care plan for 1 of 93 sampled residents (Resident #8) reviewed. The findings include: Review of the facility's policy titled, Comprehensive Care Plans, dated 4/6/15 and revised 7/19/18, revealed, .A person-centered Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident .The nurse/Interdisciplinary Team (IDT) develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain .Each resident's Comprehensive Care plan is designed to: a. incorporate identified problem areas; .j. Reflect currently recognized standards of practice . Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #8 is rarely/never understood and his cognitive skills for daily decision making is severely impaired. Continued review revealed he rejected care 1 to 3 days in the 7 day evaluation period and he required extensive assistance of 2 or more caregivers for dressing. Review of the Care Plan for Resident #8 did not address the resident preferred to only wear a brief and would remove the gown, sheet, or blanket while in bed. Observations on 2/27/2022 at 12:10 PM, 2:12 PM, and 3:00 PM in Resident #8's room, revealed him laying in bed, uncovered, and wearing only a brief. Observations on 2/28/2022 at 7:46 AM, 10:00 AM, 10:25 AM, and 12:45 PM in Resident #8's room, revealed him laying in bed, uncovered, and wearing only a brief. During an interview on 2/28/2022 at 10:25 AM, Certified Medication Assistant (CMA) #2 stated, He [Resident #8] doesn't like to be clothed or covered up with a blanket or sheet. He will take his gown off and throw it. He doesn't like a pillow under his head either. During an interview on 3/1/2022 at 8:46 AM, Licensed Practical Nurse (LPN) #4 stated, He [Resident #8] appears more comfortable wearing only a brief. During an interview on 3/1/2022 at 8:55 AM, MDS Coordinator #1 confirmed the Care Plan for Resident #8 should include the fact he prefers to wear only a brief, and it was not. During an interview on 3/1/2022 at 9:25 AM, the Director of Nursing confirmed Resident #8 should be care planned for preferring to wear only a brief, and was not.

Based on facility policy review, medical record review, observation, and interview, the facility failed to follow Physician's Orders for 3 of 93 sampled residents (Resident #38, #43, and #59) reviewed regarding wound dressing changes for Resident #38, Midline dressing changes for Resident #43, and medication administration for Resident #59. The findings include: Review of the facility's policy titled, Skin Tears-Abrasions and Minor Breaks, Care of, revised 9/2013, revealed, .The purpose of this procedure is to guide the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .Steps in the Procedures: 18. Apply the ordered dressing and secure with tape or bordered dressing per order .Label with date and initials to top of dressing . Review of the facility policy titled, Guidelines for Preventing Intravenous Catheter-Related Infections, revised August 2014, revealed, .Change TSM [transparent, semi permeable membrane] dressings on CVADs [Central Venous Access Device] every 5-7 days or PRN [as needed] if damp, loosened, or visible soiled . Review of the facility's policy titled, General Medication Order, revised 6/26/2018, revealed, .The purpose of this procedure is to establish uniform guidelines in the receiving and recording of the medication orders .Recording Orders: 6. Treatment Orders- When recording treatment orders, specify the treatment, location, frequency and duration of the treatment . Review of the medical record revealed Resident #38 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan for Resident #38 dated 2/16/2022, revealed, .Elder has skin tear to left shin area . Appropriate goals and interventions in place. Review of the Physician's Orders for Resident #38, dated 2/16/2022, revealed, .skin tear left shin, clean with normal saline, apply petroleum gauze and border gauze dressing, change every 3 days . During an interview on 2/27/2022, at 3:56 PM, Licensed Practical Nurse (LPN) #1 confirmed the dressing on Resident #38's left lower leg was dated 2/22/2022. LPN #1 also confirmed the physician's order was that wound care with dressing change to be performed every 3 days. She stated, It should have been changed on the 25th [2/25/2022]. During an interview on 2/28/2022 at 7:41 AM, LPN #2 confirmed she did not change the dressing to Resident #38's left lower leg on the due date of 2/25/2022. She stated she thought LPN #5 had performed the wound care and changed the dressing on 2/25/2022, because LPN #5 was assisting with wound care on the floor that day. During an interview on 3/1/2022 at 9:18 AM, LPN #5 stated she did work on the floor and assist with wound care on 2/25/2022. LPN #5 confirmed she did not change the wound dressing to Resident #38's left lower leg on 2/25/2022. She stated, I did not see that it was due to be changed. Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician's Orders for Resident #43 dated 2/18/2022, revealed, .Midline extension, connector and dressing change weekly . Review of the Care Plan for Resident #43 dated 2/18/2022, revealed, .Elder has midline in place for IV [intravenous] infusion .midline dressing change as ordered . Observation in Resident #43's room on 2/27/2022 at 10:25 AM and 2:23 PM, revealed a midline to the resident's right upper arm. The midline dressing was dated 2/17/2022. Observation and interview in Resident #43's room on 2/27/2022 at 2:30 PM, Registered Nurse (RN) #1 confirmed the resident's midline dressing was dated 2/17/22. She stated, It's out of date; it should have been changed on the 24th [2/24/2022]. Review of the medical record revealed Resident #59 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #59 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. Continued review revealed Resident #59 received 7 days of insulin injections. Review of Resident #59's Care Plan dated 2/18/2020, revealed, .Elder has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #59's Physician's Orders dated 2/19/2022, revealed, .[MEDICATION(S)] U [units]-100 Insulin (insulin [MEDICATION(S)]) insulin pen; 100 unit/mL [milliliter] (3 mL); amt [amount]: 37 units; subcutaneous Special Instructions: 37 units SQ [subcutaneous] every morning . Review of Resident #59's Physician's Orders dated 08/02/2021, revealed, .Blood sugar checks AC + HS Before Meals and At Bedtime 06:00 [6:00 AM], 12:00 [12:00 PM], 17:00 [5:00 PM], 21:00 [9:00 PM] . Review of Resident #59's Physician's Orders dated 6/29/2021, revealed, .[MEDICATION(S)] (HCl [[MEDICATION(S)]]) Emergency Kit ([MEDICATION(S)] hcl) recon soln [reconstitute solution]; 1 mg [milligram]; amt: 1 MG; injection Special Instructions: Reconstitute & GIVE 1 mg IM [intramuscular] As Needed For Blood Glucose Less Than 60 . Review of Resident #59's vitals dated 3/1/2022 recorded at 6:37 AM, revealed Resident #59 had a blood glucose of 34mg/dl (milligram per deciliter). During an interview on 3/1/2022 at 8:00 AM, Resident #59 stated her blood glucose was 31 this morning and she was given chocolate pudding and crackers. During an interview on 3/1/2022 at 8:00 AM, LPN #3 confirmed she did not administer the ordered [MEDICATION(S)]. During an interview on 3/1/2022 at 1:39 PM, the Director of Nursing (DON) confirmed he expected the nurse to follow the physician orders.

Based on facility policy review, medical record review, observation, and interview, the facility failed to prevent the spread of infection for 2 of 93 sampled residents (Resident #54 and #60) reviewed, regarding indwelling urinary catheter drainage bag and tubing was laying in the floor for Resident #54, oxygen tubing was touching the floor for Resident #60. The facility also failed to ensure staff donned appropriate Personal Protective Equipment (PPE) prior to entering a Transmission Based Precaution (TBP) room. The findings include: Review of the facility policy titled, Urinary Tract Infections (Catheter-Associated), Guidelines for Preventing, dated September 2017, revealed, .The purpose of this procedure is to provide guidelines for the prevention of catheter-associated urinary tract infections (CAUTIs) .Do not place the drainage bag on the floor . Review of the facility policy titled, Policies and Practices-Infection Control, dated October 2018, revealed, .This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections . Review of the facility policy titled, Isolation-Categories of Transmission-Based Precautions, dated October 2018, revealed, .Transmission-Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents .Droplet Precautions .Gloves, gown and goggles should be worn if there is risk of spraying respiratory secretions . Review of the medical record revealed Resident #54 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Reentry Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #54 had an indwelling urinary catheter. Review of Resident #54's Physician's Order dated 2/26/2022, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Observations in Resident #54's room on 2/27/2022 at 10:36 AM and 2:15 PM, revealed the urinary drainage bag and tubing was laying on the floor. Observation and interview in Resident #54's room on 2/27/2022 at 3:00 PM, Registered Nurse (RN) #1 confirmed Resident #54's urinary drainage bag and tubing was laying on the floor. Review of the medical record revealed Resident #60 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual MDS assessment dated [DATE] revealed Resident #60 required oxygen. Review of Resident #60's Physician's Order dated 1/13/2022 for [MEDICATION(S)]-[MEDICATION(S)] solution for nebulization three times a day as needed and an order dated 8/13/2021 for Oxygen therapy at 2 liters per minute for shortness of breath as needed. Observation in Resident #60's room on 2/27/2022 at 9:45 AM and 11:09 AM, revealed the oxygen tubing was touching the floor on the right side of her bed and a nebulizer mask and nebulizer machine was in the bed with her. Observation and interview in Resident #60's room on 2/27/2022 at 11:28 AM, the Director of Nursing (DON) confirmed the nebulizer mask and nebulizer machine should not be in the bed and the oxygen tubing should not be touching the floor. Observation on 2/27/2022 at 11:42 AM, revealed Certified Nurse Aide (CNA) #5 took a meal tray into a resident's room who was on TBP without donning gloves or a gown. During an interview on 2/27/2022 at 11:43 AM, CNA #5 confirmed he took a meal tray into a TBP room and didn't wear appropriate PPE. He stated, I should have put a gown and gloves on, but I didn't. During and interview on 3/2/2022 at 8:24 AM, Licensed Practical Nurse (LPN) #6 stated when staff were delivering and picking up meals from a resident that's on TBP they must wear a mask, goggles, gown, and gloves. Review of the medical record for Resident #60 revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] for Resident #60 revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment. Continued review revealed the use of oxygen. Review of the Physician's Orders for Resident #60 revealed an order dated 1/13/2022 for [MEDICATION(S)]-[MEDICATION(S)] solution for nebulization three times a day as needed, and an order dated 8/13/2021 for Oxygen therapy at 2 liters per minute for shortness of breath as needed. Review of the current Care Plan for Resident #60 revealed assessments for risk for respiratory distress related to [CONDITION(S)] and Chronic Respiratory Failure with appropriate goals and interventions including administering medications as ordered and using oxygen as ordered. Observation on 2/27/2022 at 9:45 AM in Resident #60's room, revealed the oxygen tubing was touching the floor on the right side of her bed and a nebulizer mask and nebulizer machine in the bed with her. Observation on 2/27/2022 at 11:09 AM in Resident #60's room, revealed the oxygen tubing was touching the floor on the right side of her bed and a nebulizer mask and nebulizer machine was in the bed with her. During an observation and interview on 2/27/2022 at 11:28 AM with the Director of Nursing in Resident #60's room, he confirmed the nebulizer mask and nebulizer machine should not be in the bed with the resident, the nebulizer mask should be in a bag, and the oxygen tubing should not be touching the floor.

Based on observation and interview, the facility dietary department failed to maintain dietary equipment in a sanitary manner in 2 of 5 observations. Findings include: Observation on 5/8/18 between 11:53 AM to 12:00 PM, at 1:53 PM, and 2:25 PM, with the Certified Dietary Manager (CDM) present, revealed the floor mixer had multiple splatters of various colored dried debris on the underside of the beater arm and the mixer bowl holder arms had dried accumulation of brown colored debris around the 3 connection sites to the bowl. Further observation revealed the stacked convection oven interior had a heavy accumulation of blackened debris. Further observation in the walk-in freezer revealed the condenser fan grate and blade had an accumulation of blackened debris. Interview with the CDM on 5/8/18 at 12:00 PM and 1:55 PM in the dietary department confirmed the floor mixer, stacked convection oven, and the walk-in freezer condenser grate and blades were not maintained in a sanitary manner. Observation on 5/8/18 at 2:25 PM in the dietary department dish room, with the CDM present, revealed the dish machine was in operation. Further observation revealed silverware and multiple racks with dishes and mugs had been washed, air dried, and stored. Further observation revealed a wall mounted fan in operation positioned on the dirty side of the dish machine. Further observation revealed the fan was in operation and directed at the dirty side of the dish machine, therefore contaminating the cleaned dishes. Interview with the CDM on 5/8/18 at 2:25 PM in the dietary department dish room confirmed the fan blades and grate were dirty and not maintained in a sanitary manner.

Based on medical record review, observations, and interview, the facility failed to follow Physician's Orders for 1 of 24 sampled residents (Resident #73) related to application of heel floats. Findings include: Medical record review revealed Resident #73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set (MDS) for Resident #73 dated 4/17/18 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 6 indicating moderate cognitive impairment. Medical record review of Physician Telephone Orders for Resident #73 dated 4/18/18 revealed .Heel floats to bilateral heels while in bed . Medical record review of the Physicians orders for Resident #73 dated (MONTH) (YEAR) revealed .Heel floats to bilateral heels while in bed . Medical review of the Treatment Administration Record (TAR) for Resident #73 dated 5-1-18 through 5-31-18 revealed .Heel floats to bilateral heels while in bed . Observation of Resident #73 on 5/9/18 at 7:27 AM and again at 8:17 AM in the resident's room revealed the resident lying in bed with his feet exposed from under the cover and no heel floats were in place. Interview with Licensed Practical Nurse (LPN) #1 on 5/8/18 at 3:25 PM in the common area room revealed Resident #73 had a Suspected Deep Tissue Injury (SDTI) to his right heel and she stated .he has heel floats when he's in bed . Interview with Registered Nurse (RN) #1 on 5/9/18 at 1:49 PM in the Willow Brook nurses station confirmed he expected heel floats to be placed on residents when in bed, he stated .It wouldn't do them any good if they didn't have them on in bed, that's supposed to help protect them .

Based on facility policy review,medical record review and interview, the facility failed to monitor behavior and assess pain correctly and completely for 4 residents (#21, #45, #47, #51) of 5 residents reviewed for unnecessary medications of 28 residents reviewed in Stage 2. The findings included: Review of facility policy, Behavior Monitoring, revealed .Specific behaviors identified for the use of [MEDICAL CONDITION], mood stabilizers, anti-depressants, anti-anxiety, and hypnotics/sedatives will be reviewed .The Interdisciploinary Team will identify pharmacological interventions in the care plan .The licensed nurse will report to the physician the identified symptoms, possible contributing factors, and request for the appropriate medication . Review of the Medication Administration Record [REDACTED]= behavior monitored; 9 = behavior outcome; 11 = no behavior. Continued reivew revealed medications such as antidepressants, were to be documented as follows: 9 = behavior outcome; 13 = no side effects. Further review revealed medications were to be documented as follows: 0 = administered; 2 = blood pressure/pulse too low; 3 = refused; 6 = dose not due; 7 = self administered; Medical record review revealed Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Medication Administration Record [REDACTED]. Continued review revealed the resident was ordered .Monitor elder for behaviors such as delusions, cursing, yelling, combativeness, anxiousness, paranoia, frightful distress. Please note type of behavior . Medical record review of the Behavior Monitoring (assessment used to monitor targeted behavior symptoms for residents on psychoactive medications) on the MAR for 2/2017 revealed no documentation for 2 of 84 opportunities. Medical record review of the Behavior Monitoring on the MAR for 2/2017 revealed 80 of 84 incorrectly coded opportunities marked with a 0 indicating, Administered. Continued review for 3/2017 revealed 61 of 93 incorrectly coded opportunities marked with a 0 indicating, Administered. Continued review for 4/2017 revealed 35 of 59 incorrectly coded opportunities marked with a 0 indicating, Administered. Medical record review revealed Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #51 scored 15 on the Brief Interview for Mental Status (BIMS) indicating she was alert, oriented, and able to make her needs known. Continued review of the MDS revealed Resident #51 required extensive assistance of 2 people with transfers, dressing, and toileting; extensive assistance of 1 person with grooming; was dependent on 2 people for bathing; and was frequently incontinent of bowel and bladder. Medical record review of the MAR for 2/2017 revealed behavior monitoring was ordered each shift to .Monitor elder for behaviors such as delusions, cursing, yelling, combativeness, anxiousness, paranoia, frightful distress . Continued review revealed 84 opportunities for documentation of behaviors and for 43 shifts behaviors were marked with a 0 indicating administration according to the code printed at the top of the page. Medical record review of the MAR for 2/2017 for pain assessment revealed 3 shifts were marked with an 11 indicating no behavior while 1 shift was marked with a 13 indicating no side effects. Medical record review of the MAR for 3/2017 for behavior revealed 93 opportunities with 35 shifts marked with a 0 indicating administration and 2 shifts marked 13 indicating no side effects. Medical record review of the MAR for 3/2017 for pain assessment revealed 9 shifts marked with a 9 indicating no behavior. Medical record review of the MAR for 4/2017 for behavior monitoring revealed 58 opportunities with 3 shifts marked 0 indicating administration and 2 shifts marked with a 13 indicating no side effects. Medical record review of the MAR for 4/2017 for pain assessment revealed 3 shifts were marked with an 11 indicating no behaviors and 1 was marked with a 13 indicating no side effects. Interview with Licensed Practical Nurse (LPN) #4 on 4/20/17 at 10:10 AM on the 200 hall revealed a 0 indicated no behavior; an 8 indicated behavior occurred; and an 11 she didn't know what it referred to. Interview with Registered Nurse (RN) #1 on 4/20/17 at 10:20 AM on the 200 hall revealed a 0 indicated no behavior; an 8 indicated the number of times the resident had behaviors; and an 11 also indicated the number of times a resident had behaviors. Interview with LPN #5 on 4/20/17 at 10:35 AM on the 100 hall revealed a 0 indicated no behaviors; an 8 indicated extreme behavior; and an 11 she did not use. Interview with LPN #6 on 4/20/17 at 10:45 AM on the 300 hall revealed a 0 indicated no behaviors; an 8 indicated behaviors; and an 11 indicated no behaviors. Interview with RN #2 on 4/20/17 at 11:00 AM on the 300 hall revealed a 0 indicated no behaviors; an 8 indicated a behavior occurred; and an 11 she did not know what it was. Resident #45 was admitted to the facility on 1/17/16 from the hospital with [DIAGNOSES REDACTED]. Medical record review of the Significant Change MDS dated [DATE] revealed the resident received antianxiety and antidepressant medication in the last 7 days of the 7 day look back period. Medical record review of the MAR for 2/2017 revealed the facility failed to document a pain assessment for 83 of 84 opportunities. Medical record review of the MAR for 3/2017 revealed the facility failed to document a pain assessment for 72 of 93 opportunities. Medical record review of the MAR for 4/2017 revealed the facility failed to document a pain assessment for 55 of 57 opportunities. Medical record review of the MAR for 2/2017 revealed the facility failed to document behavior monitoring for 15 of 84 opportunities. Medical record review of the MAR for 3/2017 revealed the facility failed to document behavior monitoring for 53 of 93 opportunities. Medical record review of the MAR for 4/2017 revealed the facility failed to document behavior monitoring for 15 of 57 opportunities. Resident #47 was admitted on [DATE] to the facility with [DIAGNOSES REDACTED]. Medical record review of the 14 day MDS dated [DATE] revealed medications given for the 7 day look back period was antidepressant for 7 days and antianxiety for 1 day. Medical record review of the MAR for 2/2017 revealed the facility failed to document a pain assessment for 104 of 104 opportunities. Medical record review of the MAR for 3/2017 revealed the facility failed to document a pain assessment for 112 of 124 opportunities. Medical record review of the MAR for 4/2017 revealed the facility failed to document a pain assessment for 59 of 59 opportunities. Medical record review of the MAR for 2/2017 revealed the facility failed to document behavior monitoring for 32 of 76 opportunities. Medical record review of the MAR for 3/2017 revealed the facility failed to document behavior monitoring for 37 of 93 missed opportunities. Medical record review of the MAR for 4/2017 revealed the facility failed to document behavior monitoring for 20 of 59 opportunities.

Based on medical record review and interview, the facility failed to promote and facilitate resident self-determination through support of resident bathing choice for 2 residents (#51, #107) of 2 reviewed for choices of 28 residents reviewed in stage 2. The findings included: Medical record review revealed Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #51 scored 15 on the Brief Interview for Mental Status (BIMS) indicating she was alert, oriented, and able to make her needs known. Continued review of the MDS revealed Resident #51 required extensive assistance of 2 people with transfers, dressing, and toileting; extensive assistance of 1 person with grooming; was dependent on 2 people for bathing; and was frequently incontinent of bowel and bladder. Interview with Resident #51 on 4/18/17 at 9:15 AM in the resident's room revealed she preferred a shower but .had fallen and broken a lot of bones so she could not do it by herself . Continued interview revealed Resident #51 did not know her shower schedule but went to the shower whenever they came and took her to the shower. Review of the Bathing Report for 3/2017 and 4/2017 revealed 22 opportunities for possible baths/showers to be given in the 2 months with 12 completed bed baths; 7 half baths given instead of full bath; 2 occasions where bathing did not occur; and no documentation of a shower being given. Interview with CNA #6 on 4/19/17 at 1:30 PM on the 100 hall, revealed a half bath included arm pits, perineal area, and buttocks. Interview with the Director of Nursing (DON) on 4/19/17 at 5:50 PM, in the common area revealed a shower was not indicated on the Bathing Record. Continued interview revealed the DON was asked if a half bath on shower day meant the resident did not get a shower or a complete bath. Further interview revealed the DON stated a half bath to one Certified Nursing Aide (CNA) may mean the important parts while to another it may mean a full bath. Continued interview revealed there was no protocol on what areas to wash. Continued interview revealed there was also no way to document on the Bathing Record if the resident refused a shower. Further interview revealed Resident #51 was scheduled for showers on Tuesday, Thursday, and Saturday on second shift. Interview with the DON on 4/20/17 at 7:30 AM in the conference room revealed the facility was striving to become more homelike so residents .can have a shower whenever they want and they don't have to stick to scheduled shower days . Continued interview revealed a shower will not show up on the bathing record and she didn't know if the shower button worked on the kiosks on each hall where the CNAs documented. Further interview revealed the only way to find out if a resident had a shower was to ask the resident. Continued interview revealed the DON talked to all CNAs and all were in agreement as to what constituted a half bath so everyone was documenting the same thing. Interview with CNA #7 on 4/20/17 at 8:15 AM on the 200 hall revealed Resident #51 was given a bed bath only and had never refused a bed bath. Continued interview revealed it was easier to do a bed bath since Resident #51 was bedridden and incontinent of bowel and bladder. Further interview confirmed CNA #7 had never given Resident #51 a shower. Interview with the LPN on the 100 hall on 4/20/17 at 9:30 AM confirmed Resident #51 had not been given any showers and it was her choice to receive showers. Medical record review revealed Resident #107 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an unscheduled MDS dated [DATE] revealed Resident #107's BIMS was 12 indicating the resident was moderately impaired. Continued review revealed bed mobility and transfer required extensive assistance with 2 person physical assist. Further review revealed Resident #107 participated in the assessment. Medical record review of an Annual MDS dated [DATE] revealed Resident #107's Preferences for Customary and Routine Activities, .How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? . The resident response was coded 1 which is interpreted as very important. Medical record review of the Initial Social Service History dated 2/20/2017 revealed Resident #107's preference for bathing is a shower. Medical record review of CNA Skin Care Alert Document (CNA records skin alerts as well as bathing and personal hygiene performed on their shift and then gives to nurse) dated 4/5/17 revealed Resident #107 .Refused said didn't want to get up this early . Medical record review of the Bathing Report for 3/1/17 to 4/19/17 revealed during the 50 total days for the time period, Resident #107 received 8 full baths and 27 half baths, (2 of those days the resident had a full and half bath on the same day, 1 day the resident had 3 half baths on the same day,1 day the resident had 2 full baths on the same day), no bath of any type occurred from 3/12/17 to 3/15/17. Interview with Resident #107 on 4/18/17 at 9:18 AM in her room revealed the resident did not choose how many times a week she gets a bath or shower. Continued interview revealed she does not choose whether she takes a shower, tub, or bed bath. Further interview revealed the resident wants a shower and all she ever gets is a bed bath. Interview with CNA #4 on 4/19/17 at 11:32 AM on the 200 hall revealed the resident required a lift for transfer. Continued interview revealed the staff gets the resident up on Monday, Wednesday, Friday, and any other time she requests. Further interview revealed the resident does not like to get up early so they usually wait until after breakfast to get her up on those days. Interview with CNA #5 on 4/19/17 at 11:35 AM on the 200 hall confirmed the shower schedule for Resident #107 is Monday, Wednesday, and Friday on the 11:00 PM to 7:00 AM shift. Continued interview confirmed she gave the resident a full bed bath that morning before she got her up. Interview with LPN #4 on 4/19/17 at 11:40 AM at the 200 nurses station revealed Resident #107 gets up on Monday, Wednesday, and Friday after breakfast and stays up until after lunch. Continued interview revealed the resident has arthritic pain but the staff will get her up any time she wants. Further interview revealed the resident's shower schedule is Monday, Wednesday, and Friday on the 11:00 PM to 7:00 AM shift. Interview with CNA #6 on 4/20/17 at 7:25 AM in the facility parking lot revealed she has been working at the facility for about a year, and she currently works the 3rd shift on the hall on which Resident #107 resides. Continued interview revealed the shower schedule for Resident #107 is on the 3rd shift. Further interview revealed the resident required a 2 person mechanical lift for transfer and there was not always 2 staff available to operate the lift. Continued interview revealed Resident #107 had refused showers with the reason being she didn't want to get up that early. Further interview confirmed that CNA #6 had never given Resident #107 a shower.

Based on medical record review and interview, the Consultant Pharmacist failed to conduct an in-depth Medication Regimen Review which would have revealed evidence of inadequate monitoring of behaviors and assessment of pain for 4 residents (#21, #45, #47, #51) of 5 residents reviewed for behavior monitoring and pain assessment of 28 residents reviewed in Stage 2. The findings included: Medical record review revealed Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Medication Administration Record [REDACTED]= behavior monitored; 9 = behavior outcome; 11 = no behavior. Continued reivew revealed medications such as antidepressants, were to be documented as follows: 9 = behavior outcome; 13 = no side effects. Further review revealed medications were to be documented as follows: 0 = administered; 2 = blood pressure/pulse too low; 3 = refused; 6 = dose not due; 7 = self administered; Medical record review of the Medication Administration Record [REDACTED]. Also ordered were Behavior Monitoring every shift. Medical record review of the Behavior Monitoring (assessment used to monitor targeted behavior symptoms for residents on psychoactive medications) on the MAR for 2/2017 revealed no documentation for 2 of 84 opportunities. Medical record review of the Behavior Monitoring on the MAR for 2/2017 revealed 80 of 84 incorrectly coded opportunities marked with a 0 indicting, Administered. Continued review for 3/2017 revealed 61 of 93 incorrectly coded opportunities marked with a 0 indicating, Administered. Continued review for 4/2017 revealed 35 of 59 incorrectly coded opportunities marked with a 0 indicating, Administered. Medical record review revealed Resident #21 was admitted to the facility with Left Above the Knee Amputation (AKA), Chronic Obstructive Pulmonary Disorder (COPD), Depressive Disorder, Diabetes Mellitus (DM) Type 2, Chronic Kidney Disease-Stage 4, Fluid Retention, Arteriosclerotic Heart Disease (ASHD), Esophageal Reflux, Anxiety Disorder Anemia, Peripheral Vascular Disease (PVD) Resident #45 was admitted to the facility on [DATE] and re-admitted on [DATE] from the hospital with [DIAGNOSES REDACTED]. Medical record review of the Significant Change MDS dated [DATE] revealed resident received antianxiety and antidepressant medication in the last 7 days of the 7 day look back period. Medical record review of the MAR for 2/ 2017 revealed the facility failed to document a pain assessment for 83 of 84 opportunities. Medical record review of the MAR for 3/2017 revealed the facility failed to document a pain assessment for 72 of 93 opportunities. Medical record review of the MAR for 4/2017 revealed the facility failed to document a pain assessment for 55 of 57 opportunities. Medical record review of the MAR for 2/2017 revealed the facility failed to document behavior monitoring for 15 of 84 opportunities. Medical record review of the MAR for 3/2017 revealed the facility failed to document behavior monitoring for 53 of 93 opportunities. Medical record review of the MAR for 4/2017 revealed the facility failed to document behavior monitoring for 15 of 57 opportunities. Resident #47 was admitted to the facility with [DIAGNOSES REDACTED]. Medical record review of the 14 day MDS dated [DATE] revealed medications -7 day look back revealed antidepressant was given for 7 days and antianxiety was given for 1 day. Medical record review of the MAR for 2/2017 revealed the facility failed to document a pain assessment for 104 of 104 opportunities. Medical record review of the MAR for 3/2017 revealed the facility failed to document a pain assessment for 112 of 124 opportunities. Medical record review of the MAR for 4/2017 revealed the facility failed to document a pain assessment for 59 of 59 opportunities. Medical record review of the MAR for 2/2017 revealed the facility failed to document behavior monitoring for 32 of 76 opportunities. Medical record review of the MAR for 3/2017 revealed the facility failed to document behavior monitoring for 37 of 93 missed opportunities. Medical record review of the MAR for 4/2017 revealed the facility failed to document behavior monitoring for 20 of 59 opportunities. Medical record review revealed Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #51 scored 15 on the Brief Interview for Mental Status (BIMS) indicating she was alert, oriented, and able to make her needs known. Continued review of the MDS revealed Resident #51 required extensive assistance of 2 people with transfers, dressing, and toileting; extensive assistance of 1 person with grooming; was dependent on 2 people for bathing; and was frequently incontinent of bowel and bladder. Medical record review of the MAR for 2/2017 revealed behavior monitoring was ordered each shift. Continued review revealed 84 opportunities for documentation of behaviors and for 43 shifts behaviors were marked with a 0 indicating administration according to the code printed at the top of the page. Medical record review of the MAR for 2/2017 for pain assessment revealed 3 shifts were marked with an 11 indicating no behavior while 1 shift was marked with a 13 indicating no side effects. Medical record review of the MAR for 3/2017 revealed 84 opportunities for behavior monitoring with 35 shifts marked with a 0 indicating administered while 2 were marked with a 13 indicating no side effects. Medical record review of the MAR for 3/2017 for behavior revealed 93 opportunities with 35 shifts marked with a 0 indicating administration and 2 shifts marked 13 indicating no side effects. Medical record review of the MAR for 3/2017 for pain assessment revealed 9 shifts marked with a 9 indicating no behavior. Medical record review of the MAR for 4/2017 for behavior monitoring revealed 58 opportunities with 3 shifts marked 0 indicating administration and 2 shifts marked with a 13 indicating no side effects. Medical record review of the MAR for 4/2017 for pain assessment revealed 3 shifts were marked with an 11 indicating no behaviors and 1 was marked with a 13 indicating no side effects. Interview with Licensed Practical Nurse (LPN) #4 on 4/20/17 at 10:10 AM on the 200 hall revealed a 0 indicated no behavior; an 8 indicated behavior occurred; and an 11 she didn't know what it referred to. Interview with (Registered Nurse (RN) #1 on 4/20/17 at 10:20 AM on the 200 hall revealed a 0 indicated no behavior; an 8 indicated the number of times the resident had behaviors; and an 11 also indicated the number of times a resident had behaviors. Interview with LPN #5 on 4/20/17 at 10:35 AM on the 100 hall revealed a 0 indicated no behaviors; an 8 indicated extreme behavior; and an 11 she did not use. Interview with LPN #6 on 4/20 17 at 10:45 AM on the 300 hall revealed a 0 indicated no behaviors; an 8 indicated behaviors; and an 11 indicated no behaviors. Interview with RN #2 on 4/20/17 at 11:00 AM on the 300 hall revealed a 0 indicated no behaviors; an 8 indicated a behavior occurred; and an 11 she did not know what it was. Telephone interview with the Consultant Pharmacist on 4/20/17 at 9:50 AM revealed he monitors MARs monthly. Continued interview revealed he was told staff does not consistently monitor pain and behavior and he responded he had not seen behavior monitoring. Further interview revealed the Consultant Pharmacist reviewed the MAR indicated [REDACTED]. Continued interview revealed pain assessment was up to nursing judgement since they interact with the residents. Further interview revealed he would have to see the sheet to determine if the coding was correct for behavior monitoring. Continued interview revealed when told Pharmacy was to monitor pain and behaviors to determine if medications were still needed and absent or incorrect documentation by nursing would affect the decision, he stated he tried Gradual Dose Reduction (GDR) on all medications whether there had been behaviors or not and whether or not nursing was monitoring the resident. Further interview revealed the GDR was done every 6 months across the board. Continued interview revealed when the Consultant Pharmacist was asked if staff monitoring of behavior and assessing pain was important he stated not from his standpoint and he does not touch pain since each resident was an individual and so specialized.

Based on facility policy review, medical record review, review of facility grievance log, and interview the facility failed to make prompt efforts to resolve a grievance for 1 resident (#80) of 28 residents reviewed. The findings included: Review of facility policy, Investigate Complaint/Grievance, revealed .Residents have the right to present a concern or complaint about his/her care and treatment .and any other concerns regarding their facility stay .Residents have the right to file grievances orally or in writing .All grievances or complaints will be documented on the Grievance and Complaint Report by the person receiving the report . Medical record review revealed Resident #80's original admitted was 2/6/12 and the current admitted was 5/27/15. Continued review of the Quarterly Minimum (MDS) data set [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) of 15 indicating the resident was cognitively intact. Review of facility grievance log revealed a report was communicated from Resident #80 to the Social Services Director on 4/18/17 regarding the resident had lost his lower dentures. Findings of the investigation were reported as .dentures are missing and have not been found . No other reports were found in the log regarding this resident and his missing dentures in the past 3 months. Interview with Resident #80 on 4/17/17 at 3:35 PM, outside the facility front door revealed the resident had lost his lower dentures over a week ago and it was difficult to chew. Further interview revealed the resident had told a staff member his lower dentures were missing and it was difficult to chew. Continued interview revealed Resident #80 was unsure of the name of the person he had told. Further interview revealed the staff were not taking care of the problem to his satisfaction and he had not heard any resolution from the staff. Interview with Resident #80 on 4/19/17 at 2:19 PM, outside the facility front door revealed Resident #80 still did not remember who he had told regarding his lost dentures and it was about 5 days ago. Interview with the Social Services Director on 4/19/17 at 3:04 PM, in her office revealed she was first made aware of the missing dentures for Resident #80 on 4/18/17 when the resident was sitting outside near the front door. Continued interview revealed she was passing by and he called her over and told her. Further interview revealed Resident #80 reported to her he had told a staff member about 5 days prior but couldn't remember who it was. Further interview revealed staff are to report complaints and concerns immediately and document on the Complaint/Grievance Report. Continued interview revealed she filled out the report on 4/18/17. The Social Services Director confirmed she did not receive a Complaint/Grievance Report from any staff member regarding the missing dentures.

Based on observation and interview, the facility failed to post staffing requirements for 79 of 79 days reviewed. The findings included: Observations on 4/17/17 to 4/20/17 revealed the Daily Staffing Form posted on the large bulletin board in the hallway near the commons area. Continued observation revealed the actual hours worked were not documented on any of the forms for these dates. Further review of the Daily Staffing Forms for February, March, and April 2017 revealed the actual hours worked were not documented on any of the forms. Interview with the Administrator and the Director of Nursing on 4/20/17 at 8:34 AM, in the Administrator's office, when shown the daily staffing forms and the actual hours worked column was not completed, confirmed the facility had failed to complete the hours worked because they did not realize it was required.

Based on policy review, observations, and interviews, the facility failed to ensure food was stored and served in a sanitary manner as evidenced by opened food items in the freezer, staff members did not perform hand hygiene during dining and returning a tray that had been taken into a resident's room to the cart with food trays that had not yet been served. This had the potential to effect 91 residents receiving trays from the kitchen of the 97 residents residing in the facility. The findings included: 1. The facility's Storage of Foods and Supplies stated, .All items must be covered . Observations in the kitchen on 4/11/16 at 1:26 PM, revealed containers of opened cookie dough, opened mixed vegetables, and opened green beans in the freezer. Interview with the Dietary Manager (DM) on 4/11/16 at 1:42 PM, in the kitchen office, the DM was asked if the food items should be stored opened in the freezer. The DM stated, It shouldn't be. 2. The facility's Serving Resident Food-Resource policy stated, .Employees must wash their hands before serving food to residents . If there is contact with soiled dishes, clothing or the residents (resident's) personal effects, the employee must wash their hands before serving the next employee (resident) . Observations in the dining area on 4/11/16 at 5:00 PM, revealed certified nursing assistant (CNA) #1 assisted residents with wheelchairs and seating. CNA #1 held Resident #120 under the arm while walking around the dining area to find the chair of her choice. CNA #1 did not wash her hands before serving beverages or meals to the residents in the dining area. Interview with the DM on 4/12/16 at 4:30 PM, the DM confirmed that staff should wash their hands before serving meals. 3. Observations in room 209B on 4/11/16 at 4:54 PM, revealed CNA #2 took a dinner meal tray to Resident #133's room. CNA #2 set the tray on the over bed table in front of the resident and removed the lid to reveal the meal to the resident. The resident requested an alternate. CNA #2 placed the served tray back into the cart with the trays that had not been served to other residents. Interview with the Director of Nursing (DON) and the Administrator on 4/13/16 at 4:20 PM, in the Administrator's office, the DON was asked what should be done with a meal tray that was taken into a resident's room, lid removed, and the resident asked for an alternate. The Administrator stated, Well, I wouldn't want them to contaminate the other trays by putting it back on the meal cart. They need to put it on the top of the meal cart.

Based on policy review, observation and interview, the facility failed to ensure insulin was not stored past the expiration date, insulin was labeled with resident's name and narcotic medication cards were not taped on the back in 2 of 4 (200 and 100 hall medication carts) medication storage areas. The findings included: 1. Review of the facility's Medication Storage policy revealed, .Medications and biological's are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration . 2. Observations on the 200 hall on [DATE] beginning at 8:30 AM, revealed the 200 hall medication cart contained the following: a. Resident #97's Levemir Flextouch insulin pen had expired with an open date of [DATE]. b. Resident #118's Hydrocodone-Acetaminophen ,[DATE] milligram (mg) #6 and #20 blister was broken and there was tape on the back of the card. c. Resident #32's Hydrocodone-Acetaminophen 7XXX,[DATE] mg #4 blister was broken and there was tape on the back of the card. 3. Observations on the 100 hall on [DATE] beginning at 8:50 AM, revealed the 100 hall medication cart contained the following: a. Resident #40's bubble pack of Tramadol 50 mg, had 20 pills and #10 pill had been punched out and taped with clear tape on the back. Interview with Licensed Practical Nurse (LPN) #1 on [DATE] at 8:55 AM, on the 100 hall, LPN #1 was asked if the pills were supposed to be taped in the pack. LPN #1 stated, No ma'am, but I guess they were scared that the pill would fall out but we are not suppose to use tape. b. Resident #189's bubble pack of Zolpidem Tartrate 5 mg had 14 pills and #14 was open and taped on the back. Interview with LPN #1 on [DATE] at 9:10 AM, at the 100 hall medication cart, LPN #1 was asked if the #14 pill was taped. LPN #1 stated, Yes ma'am. it is taped. I personally would have wasted it with another nurse. 4. Telephone interview with the pharmacist on [DATE] at 5:40 PM, the pharmacist was asked if was acceptable to put medications back into the bubble packs and tape them in. The pharmacist stated, No, they should be destroyed.