Every finding on record at Willow Brooke Court At Park Pointe Village

Based on record review and interviews, the facility failed to ensure residents were informed of their right to have access to names, addresses and telephone numbers of all pertinent state regulatory and informational agencies, resident advocacy groups and information on filing a complaint and or reporting alleged abuse violations. The facility further failed to ensure residents knew where the above information was located within the facility as revealed by 7 of 7 residents during 1 of 1 resident council meetings. The findings included: Record review of the Resident Council Minutes for December 2024, January 2025, and February 2025, no notice of informing residents og their right to have access to names, addresses and telephone numbers of all pertinent state regulatory and informational agencies, resident advocacy groups and information on filing a complaint and or reporting alleged abuse violations. The Resident Council Minutes did not mention the whereabouts of such information within the facility. Interviews on 03/26/25 at 02:17 PM, during a resident council meeting, 4 of 4 residents in attendance confirmed they were not aware of their right to have access to a list of names, addresses and telephone numbers of all pertinent state regulatory and informational agencies, resident advocacy groups and information on filing a complaint and or reporting alleged abuse violations and the whereabouts of this information in the facility. Interview on 03/26/25 at 03:13 PM, the Activities Director revealed, I go through the [Critical Element] CE pathway for resident council every quarter and ask the questions. I do not include this information in the resident council meeting minutes. We play resident's rights Bingo at least yearly. The Ombudsman comes to the facility yearly and reviews their rights with them. No documentation could be found to ensure residents were informed of their right to have access to state regulatory and informational agencies and how to file a complaint and or reporting abuse.

Based on review of the facility policy, observation, interviews and review of the facility assessment, the facility failed to complete and implement a Baseline Care Plan within 48 hours of an admission, for Resident (R)218. Findings include: Review of the facility policy titled, Baseline Care Plan, with a revision date of November 2024 revealed, 1. The licensed nurse will develop a baseline care plan in the electronic application under the assessment tab for each resident within 48 hours of a resident's admission. Review of R218's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses including, but not limited to, displaced fracture of upper end of left humerus, subsequent encounter for fracture with routine healing, history of falling, muscle weakness, difficulty in walking, lack of coordination, Parkinson's disease. Review of R218's Fall Risk Evaluation conducted on 03/20/25 revealed a score of 9. Review of R218's Care Plan with a start date of 03/26/25, revealed [R218] have an ADL self-care performance deficit r/t Limited ROM, Musculoskeletal impairment. I had a fall at home and fractured my left humerus. Interventions include I am training ambulation with therapy with a cane. Sling to left arm. Non-weight bearing to left arm. I am able to: bathe upper body but need asst with lower. Allow me sufficient time for dressing and undressing. R218 I am a fall risk r/t Deconditioning/discomfort secondary to fracture to left arm. I had a fall at home with left humerus fracture initiated on 03/26/25. Interventions include Anticipate and meet my needs. Be sure my call light is within reach and encourage me to use it for assistance as needed. I would like a prompt response to all my requests for assistance. Encourage me to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Ensue that I am wearing appropriate footwear when ambulating or mobilizing in w/c. During an interview on 03/26/25 at 2:40 PM, the Minimum Data Set (MDS) coordinator stated the assessments they perform on admission are as follows: the Braden assessment, the fall assessment, the side rail wander assessment, the skilled evaluation, the baseline care plan, a Covid screening, and a good body audit. She stated that these are the assessments that she could remember off the top of her head. The MDS coordinator stated the baseline care plan must be completed in 48 hours of admission, and the comprehensive care plan is due by day 21. She stated that she is working on completing the care plan for R218. She stated that staff communicates about the resident's care via a walking report system. The MDS coordinator admits that all of the information needs to relayed in the care plan. She stated the purpose of the care plan is to outline the resident's strengths and weaknesses and how to care for the residents. During an interview on 03/26/25 at 3:05 PM, the Director of Nursing (DON) stated the importance of the care plan is to give the staff an outline of the goal for the resident and the plans and interventions to reach those goals. She stated the care plan is initiated on admission. The DON stated that the baseline care plan is continuously updated. The DON expects the MDS coordinator to complete the base line care plan in 48 hours of admission of the resident. During an interview on 03/26/25 at 3:21 PM, Licensed Practical Nurse (LPN)1 stated the importance of the care plan is to establish goals for the residents and the care plan shows whether the resident is progressing or not. LPN1 stated that she follows the care plan to care for the residents. She looks at the care plan daily. LPN1 stated the care plan is very important because it is the basis of how she takes care of the residents.

Based on observation, interview, and record of professional reference information, the facility failed to maintain a safe, sanitary, functional environment by assuring that the drainage pipes from the juice bar table and the ice machine were above floor level. In the event of a sewer back-up, drainpipes at or below floor level which do not have an air gap of at least one inch can be contaminated by the dirty sewer liquid backup, creating the potential to affect any of the current ten residents. Findings include: During an initial tour of the kitchen on 12/29/21 at 9:50 AM with the Registered Dietician (RD), an observation of the drain area between the ice machine and the beverage bar area (coffee machine, juice machine on stainless table table) revealed that two of three drains (both approximately 1-inch PVC pipes, the third was approximately a 2.5-inch PVC pipe) were draining below floor level with the PVC tubing lying on the floor. At 9:52 AM, the RD confirmed two of the drainpipes were discharging lower than floor level. At 9:58 AM on 12/29/21, the Maintenance Foreman (MFM) entered the kitchen and confirmed the pipes were below the floor level. When asked what the consequences could be of discharge pipes below floor level, the MFM responded, If sewer backed up it would go into the [water] system. On 12/29/21 at 1:45 PM, the RDDC stated one of the below-floor level drainpipes was from the ice machine, while the other was from the drain under the juice machine. A review of a professional reference material from the Pennsylvania State University College of Agricultural Sciences titled, Understanding and Preventing Backflow in Your Food Facility is Critical to Ensure Safe Food for Your Customers updated 02/01/19 and retrieved on 07/21/21 from https://extension.psu.edu/safe-water-and-your-foodservice-operation, revealed in pertinent part, One of the greatest safety risks to water in an establishment is the creation of cross-connections. A cross-connection is a direct link between safe and unsafe water .Cross-connections are dangerous because they create an opportunity for backflow. Backflow occurs when contaminants from dirty water flow back into the stream of safe water, making it unsafe to use . An air gap is a 100% [percent] sure way to prevent backflow. This is a physical space between a safe water outlet and a source of unsafe water. Review of professional reference material from the International Association of Plumbing & Mechanical Officials titled, Air Gap and Air Break Required retrieved on 07/21/21 from http://forms.iapmo.org/email_marketing/codespotlight/2017/July13.htm, revealed in pertinent part that for a plumbing air gap, the the minimum vertical distance as measured from the lowest point of the indirect waste pipe or the fixture outlet to the flood-level rim of the receptor shall be not less than 1 inch. In an interview on 12/31/21 at 3:15 PM, the Director of Culinary and Nutrition Services (DCNS) stated, There is no specific policy regarding air gaps.

Based on interview, record review, and review of facility policy, the facility failed to ensure a coordinated/integrated plan of care was developed for one (Resident (R) 112) of one residents reviewed for Hospice care out of the total census of 10 residents. R112's care plan failed to describe the coordination of care between the facility and the Hospice provider, including which services each party would provide for the resident. Findings include: During an interview on 12/29/21 at 10:27 AM, R112 stated she was not on Hospice care and that I'm just happy here in my chair. Review of R112's printed Admission Record from the electronic medical record (EMR) Profile tab, showed a facility admitted [DATE]. Review of R112's Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R112's admission Minimum Data Set [MDS] assessment with an Assessment Reference Date (ARD) of 12/10/21 revealed R112 was enrolled in and receiving hospice services both prior to and after admission to this facility on 12/03/21. A review of R112's care plan, initiated 12/03/21, (from the EMR Care Plan tab) revealed that R112 was on Hospice care but included no information as to how often Hospice was providing services such as personal care by a certified nurse aide (CNA) or how often a Registered Nurse, Social Services, or Ministerial services would be available. Review of the care plan revealed no coordination of care regarding what services the facility would provide versus what services Hospice would provide. A review of R112's EMR Progress Notes tab for 12/15/21 showed a late entry by the Social Services Coordinator (SSC) which was not completed until 12/30/21 at 8:51 AM, after initiation of the recertification survey. It stated, Social Services Note: Late Entry: Note Text: Comprehensive POC [Plan of Care] Review: IDT [Interdisciplinary] and Hospice team met with [name of R112's Heath Care Power of Attorney (HCPOA)] on 12/15/2021-- to discuss res [resident] POC needs and concerns. Concerns were voiced and addressed by appropriate team members. Res is alert, verbal with confusion noted. Res has adjusted well to change in the environment. Res has been pleasant and cooperative with staff and others. Res preferences have been honored by staff to promote Life enrichment and engagement living too. Res has continued with routine. Her family has made her environment homelike and accessible. Res is very comfortable in the new environment. [HCPOA] expressed to IDT that she is very pleased with the res adjustment at WBC [facility name]. Res enjoys her routine activities for meals, ADL [activities of daily living], and for leisure time. Res is a delight to work with. Res is stable for mood and behavior. Staff continues to honor res preferences when appropriate. Staff continues to honor res rights and choices. Review of this note revealed no information as to coordination of care as to the services the facility would provide versus the services for which Hospice was responsible. On 12/30/21 at 2:30 PM, MDS Coordinator/Licensed Practical Nurse (LPN) 1 stated the person identified as the Hospice Coordinator in the entrance conference documentation was the facility Social Services Coordinator (SSC), who was currently out of the office. A request was made for evidence of a coordinated care plan related to the resident's Hospice services. A care plan from the assisted living facility where R112 previously resided was provided. Review of this Hospice Interdisciplinary [IDT] Care Plan, dated 08/20/21, revealed the approaches listed were to assess and instruct for spiritual care; assess, perform, and instruct for counseling; and assess, perform, and instruct for grief management. The care plan from the assisted living revealed no coordination of services detailing which party (the facility or Hospice) was responsible for the delivery of each service. During an interview on 12/31/21 at 10:03 AM, the SSC stated R112 came over from an assisted living unit and was admitted to this facility for long term services on hospice care. The SSC stated that when admitted , a new hospice nurse was assigned, and they (hospice) should be sending an integration (plan of care) from the new nurse since she was transferred here. The SSC stated that the Hospice IDT care plan came with her record to us [from the assisted living where R112 previous resided] and the coordination would be from the new admission here. When evidence of coordination of care with hospice services was requested for the 12/03/21 admission to this facility, the SSC indicated that it had not yet been received, stating, That is coming to us. When asked how she coordinates care between hospice services and the facility, the SSC stated, We have the letter that we send to them, clarifying that this was a letter sent to hospice to invite them to the care plan conference. The SSC stated the facility's nursing disciplines for care were not initially included in the facility care plan, so I added that, but the rest of it was there. The SCC stated that her only coordination involved care plan meetings, and coordination of nursing staff care was the responsibility of the MDS Coordinator. Interview with the Interim Director of Nursing (IDON) on 12/31/21 at 10:11 AM revealed that MDS Coordinator/LPN 1 would be the coordinator for hospice care, and she would arrange an interview. In an interview on 12/31/21 at 10:45 AM, Registered Nurse (RN) 9 was unaware how often hospice services were to be provided for R112, stating, Honestly, I'm not sure. I did see [name] here for [R112]. I guess it's weekly. I'm not used to charting system yet, so I'm not sure where it would be. When asked if she would expect to see the coordinated care between hospice and the facility described in the care plan, RN9 responded, As a nurse, yes, I would expect to see it in the care plan. In a follow-up interview on 12/31/21 at 10:49 AM, the SSC provided paperwork faxed from Hospice that showed Update to Physician Orders. The SSC confirmed this paperwork was just faxed over today and stated, The orders remained the same from over there [the assisted living center where R112 was prior to admission]. Included in the fax was a Hospice Nursing Clinical Note dated 12/27/21 that did not mention any type of frequency of visits or coordination of care with the facility. The SSC again stated she was not in charge of coordinating care, just inviting Hospice to the care plan meeting, which had been done on 12/03/21 for a 12/15/21 meeting. During an additional interview on 12/31/21 at 11:26 AM, the IDON was asked about coordination of care and stated, The Hospice nurse comes to speak with nurse, two CNAs twice a week and nurse weekly and as needed. The hospice nurse will sit with facility nurse and MDS Coordinator will then update the information. When asked to clarify where the information was to be updated, the IDON stated it was normally supposed to be put in the resident's care plan. During a telephone interview on 12/31/21 at 12:47 PM, MDS Coordinator/LPN1 stated the plan of care is created by Hospice and they direct how often they visit or social services comes to see R112. I had them call over to hospice and send it [plan of care] over. I was surprised it wasn't in our files already. When asked if/how the hospice plan of care was incorporated into the facility care plan, MDS Coordinator/LPN1 stated that she did not want to be very specific on the care plan in case Hospice did not show up. When asked about the 08/20/21 assisted living hospice care plan, MDS/Coordinator/LPN1 stated, Hospice should have updated their IDT care plan when she had the change of care [admission to this facility on 12/03/21]. During an additional interview on 12/31/21 at 3:11 PM, the IDON brought in the facility hospice policy and stated, Yes, coordination of care is supposed to be identified on the care plan. Review of the facility policy titled Hospice Care, revised 08/2013, revealed that, Coordination of Care Practices while in Oak Bridge Terrace (OBT) and WBC .3. All services necessary to meet the physical, psychological, medical, and spiritual needs of the beneficiary and family are reflected in the plan of care. The coordinated plan of care will identify the discipline and provider responsible for each intervention. The most recent hospice plan if care is to be retained in the resident's file.

Based on observation, record review and staff interview the facility failed to ensure the kitchen dishware were dry and stored according to standard practice to prevent the risk of bacterial contamination or growth. The facility also failed to maintain the emergency food supply safe for consumption. Findings: During the main kitchen tour on [DATE] at 3:13 PM the facility had, on a tall wire shelving unit, three full-size and six medium-size steam table pans stacked up wet in the clean-ready to use dishware kitchen area. Review of the emergency food supply on the same day at approximately 4:00 PM revealed the following expired items: six number ten cans of beef ravioli, a case of cranberry juice, a case of butterscotch pudding and a box of mandarin oranges. The facility also had multiples number-10-cans food items (pulled chicken, sloppy joe, corn beef hash, beef stew, and tuna) dated (MONTH) and (MONTH) (YEAR) and other things (applesauce, mayo packs) with unidentified use by day. During an interview with the culinary and nutrition services director and the registered dietitian/dietary manager, they both acknowledged the above findings. The dietitian/dietary manager stated that all expired and all the foods with questionable dates were removed and replaced. S/he also said that the facility was in the process of acquiring dehydrated foods for the emergency food supply.

Based on observation, interview, and review of facility policies titled Holding Hot and Cold Potentially Hazard Food, Food Temperature, and Hand Washing and Hand Hygiene, the facility failed to follow proper sanitary and food handling practice procedure in three out of three steam tables observed during lunch and dinner line temping. The dietary staff failed to maintain cold foods at appropriate temperature during the food service. Dietary staff also failed to sanitize the thermometer probe appropriately during food temping and to change glove and sanitize hands while contacting/touching foods and other items during food placement. The findings included: In an interview with the Dietary Manager on 11/13/2017 during stage I of the survey, at approximately 1:35 PM s/he stated that meals; breakfast, lunch, and dinner, are brought from the main kitchen of the facility Oakbridge Terrace, which is located in the same campus at Park Point Village. The food is then placed on the steam table of the kitchen, the steam table of the Humming Bird dining room and in the steam table of the Butterfly dining room. The kitchen steam table serves the residents who wish to stay in their room and the other two steam tables serve residents who wishes to come to the dining rooms. On 11/14/2017 at 11:50 AM the Dietary manager stated the kitchen steam table is ready for temping although some residents have been served their meals already. This observation revealed that Server # 1 did not sanitize hands before, during or after temping foods and used the same temperature probe between food items, sanitizing the probe with the same alcohol pad the entire temping process. Food temping revealed the following; crab cake patty at 150 F degrees, white bean vegetables soup at 170 F degrees, steam carrots at 156 F degrees, mashed potatoes at 167 F degrees, Grilled vegetable wrap at 46 F degrees, Caesar pasta salad at 46 F degrees, sweet tea at 31 F degrees, and brown gravy at 158 F degrees. At 11:58 AM the dietary manager the stated that the temperature of the grilled vegetable wrap and the Caesar pasta salad were within standard temperature of 41 F degrees when s/he temped the foods upon arrival to the facility. S/he proceeds to put the grilled vegetable wrap back into the refrigerator and states that s/he was going to place the pasta salad in smaller containers for it to reach proper temperature faster. At approximately 12:05 PM the grilled vegetable wrap is temped again, and the internal temperature reads 41 F degrees, but the Caesar pasta salad is still above 41 F degrees. At this point, the dietary manager decides to serve the grilled vegetable wrap but not the Caesar pasta salad. Continuing food temping observation in the Hummingbird and Butterfly dining rooms respectively the same practice is (no hands washing or sanitizing and using the same alcohol pad to wipe thermometer probe after temping each food) observed being performed by Server #2 and server #3. Server # 3 is also observed placing the used alcohol pad on the countertop of the steam table and grabbing it again to wipe the thermometer probe many times over. S/he is also observed dropping the used alcohol pad into the brown gravy and quickly pulling it out with his/her bare fingers, however s/he was not observed serving the gravy to residents after that. On 11/14/2017 at 4:25 PM a second food line temping observation is done. Server # 1 is observed temping the food without sanitizing his/her hands and use the same alcohol pad to sanitize the thermometer probe being use between foods. All food temperatures are within standards at this time. After Server #1 finished temping food s/he washed hands and put on disposable gloves and proceeds to serve food, however s/he failed to change disposable gloves after touching foods. Server #1 touch each of these foods; fish, broccoli, zucchini, potatoes on several occasion as s/he place the food on the plate with the same disposable glove on. Server #2 is observed washing his/her hand once in the kitchen at approximately 4:50 PM, however, s/he went into the walking freezer and did not sanitize or wash hands after touching the door handle. As s/he exits the walking freezer s/he is also observed putting his/her thump finger in the mouth as if s/he was biting fingernail and did not sanitize or wash hands. At approximately 4:35 PM same practice is observed in the Hummingbird and Butterfly dining rooms performed by Server #2 and server #3 On 11/15/2017 at approximately1:20 PM the above findings are shared and confirmed by the dietary manager. S/he stated that s/he is not aware that the thermometer needed to be sanitized after temping each food. S/he also noted that the servers do wash and sanitize their hands that they were probably nervous.

Based on observation, interview, and review of facility policy titled Hand Washing and Hand Hygiene, the facility failed to follow proper hand washing and hand hygiene practice during meal serving at lunch and dinner. The findings included: The food line temping observation on 11/14/2017 at 11:50 AM reveals that Server # 1 did not sanitize hands before, during or after temping foods and used the same temperature probe between food items, sanitizing the probe with the same alcohol pad the entire temping process. Continuing food temping observation in the Hummingbird and Butterfly dining rooms respectively the same practice is (no hands washing or sanitizing and using the same alcohol pad to wipe thermometer probe after temping each food) observed being performed by Server #2 and server #3 at approximately 12: 05 PM. Server # 3 is also observed placing the used alcohol pad on the countertop of the steam table and grabbing it again to wipe the thermometer probe many times over. S/he is also observed dropping the used alcohol pad into the brown gravy and quickly pulling it out with his/her bare fingers, however s/he was not observed serving the gravy to residents after that. On 11/14/2017 at 4:25 PM a second food line temping observation is done. Server # 1 is observed temping the food without sanitizing his/her hands and using the same alcohol pad to sanitize the thermometer probe being used between foods. After Server #1 finished temping food s/he washed hands and put on disposable gloves and proceeds to serve food, however s/he failed to change disposable gloves after touching foods. Server #1 touched each of these foods; fish, broccoli, zucchini, potatoes on several occasions as s/he placed the food on the plate with the same disposable glove on. Server #2 is observed washing his/her hand once in the kitchen at approximately 4:50 PM, however, s/he went into the walking freezer and did not sanitize or wash hands after touching the door handle. As s/he exits the walkin freezer s/he is also observed putting his/her thumb finger in the mouth as if s/he was biting fingernail and did not sanitize or wash hands. At approximately 4:35 PM in the Hummingbird and the Butterfly dining rooms Server #2 and server #3 were observed temping and serving foods without hands washing, sanitizing and using the same alcohol pad to wipe the thermometer probe after temping each food. On 11/15/2017 at approximately 1:20 PM the above findings are shared and confirmed by the dietary manager. S/he stated that s/he is not aware that the thermometer needed to be sanitized after temping each food. S/he also noted that the servers do wash and sanitize their hands, that they were probably nervous.

Based on full and limited record reviews, interviews, and review of the facility policy titled Care Conference, Interdisciplinary, Planning and Implementing, the facility failed to prepare, review and revise a comprehensive plan of care which addresses Advanced Directives 11 of 11 residents reviewed for Advanced Directives. The facility failed to include the Certified Nursing Assistant in the care planning process for 10 out of 11 residents reviewed for interdisciplinary care plan participation. Resident # 4, Resident #21, Resident #34, Resident #2, Resident #23, Resident #65, Resident #6, Resident #45, Resident # 48, Resident #61, and Resident #47 not have advanced directives addressed on their comprehensive care plans. There was no evidence that a C.N.A. was involved in the care planning process for Resident # 4, Resident #21, Resident #34, Resident #2, Resident #23, Resident #65, Resident #6, Resident #45, Resident # 48, and Resident #47. The findings included: The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Review of the Comprehensive care plan initiated 6/23/17 with current target date of 12/21/17 revealed that Advanced Directives are not addressed in focus statements, goals, or interventions. Review of the facility's Care Conference, Interdisciplinary, Planning and Implementing policy on 11/15/17 at 9:00 AM revealed that item #4 on page 2 of 3 identifies individuals who are to be included in the care planning process including, but not limited to, representatives from nursing (nurses and nursing assistance with responsibility for the resident), culinary, social services, rehabilitation, and activities. Further review revealed that item #5 on page 2 of 3 outlines that the interdisciplinary comprehensive care plan addresses areas including but not limited to standards of current professional practice and Resident's personal and cultural preferences. Review of the Care Plan Meeting Review meeting form on 11/14/17 at 4:15 PM revealed that interdisciplinary team meetings were held for Resident #4 on 7/6/17, 7/11/17, and 10/4/17 with no evidence of C.N.A. participation during the care planning process. During an interview on 11/15/17 at 10:00 am, Minimum Data Set (MDS) Nurses #1& #2 reviewed the record and verified that Advanced Directives were not addressed on the comprehensive care plan initiated 6/23/17 with current goal date of 12/21/17, stating that they were not aware that this was a requirement. They further reported that there was no evidence of C.N.A. participation in care planning for the meetings held on 7/6/17, 7/11/17, and 10/4/17. MDS Nurse #1 stated that they have been trying to involve C.N.A.'s in the care plan process and have them attend the meetings with intermittent success. She stated that with the variable level of acuity of the resident population, in addition to the high turnover of short term rehabilitation residents who do not remain in facility an entire quarter, with the number of C.N.A's available to cover each other's assignments, it has been very difficult for C.N.A's to leave the floor to actively participate in the actual Interdisciplinary Care plan / Team meetings. MDS Nurse #1 further verified that the facility was not following the Care Conference, Interdisciplinary, Planning and Implementing policy. Resident # 21 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the Comprehensive care plan initiated 5/23/2017 with current target date of 11/21/17 revealed that Advanced Directives are not addressed in focus statements, goals, or interventions. Review of the Care Plan Meeting Review meeting form on 11/15/17 at 1:15 PM revealed that interdisciplinary team meetings were held for Resident #21 on 6/7/17, 9/6/17, and 11/2/17 with no evidence of C.N.A. participation during the care planning process. Resident # 34 was admitted to facility with [DIAGNOSES REDACTED]. Review of the Comprehensive care plan initiated 9/1/15 with current target date of 2/5/18 revealed that Advanced Directives are not addressed in focus statements, goals, or interventions. Review of the Care Plan Meeting Review meeting form on 11/16/17 at 8:20 AM revealed that interdisciplinary team meetings were held for Resident #34 on 5/24/17, 8/9/17, and 11/18/17 with no evidence of C.N.A. participation during the care planning process. MDS #1 verified during interview on 11/15/17 at 10:45 AM that there were no advanced directives on the care plan for Resident #34 and that there was no evidence of C.N.A. care participation during the care planning process for meetings 5/24/17, 8/9/17, and 11/18/17. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Comprehensive Care plan review on 11/15/2017 at 1:47 PM revealed that advance directives are not included or discussed in the resident #2's care plan dated 10/13/2017. Further investigation of the interdisciplinary care plan signature form revealed no participation of the CNA in the care planning meeting dated 10/25/2017. During an interview on 11/15/2017 at approximately 3:30 PM the Minimum Date Set Coordinators, nurses #1 and #2, confirmed that Advance Directives was not include in the resident's care plan and that the CNA did not participate in the care plan meeting held on 10/25/2017. The facility admitted Resident #23 with [DIAGNOSES REDACTED]. Based on the Comprehensive Care plan reviewed on 11/15/2017 at approximately 1:55 PM advance directives are not included in the care plan dated 05/05/2017 and 10/24/2017 for resident # 23 reviewed for advance directives inclusion in the care plan. Further investigation revealed not the participation of the Nursing Assistant (C.N.A) in the care plan meeting dated 09/13/2017, 10/18/2017, and 11/01/2017 reviewed for CNA participation in the care plan meeting. During an interview on 11/15/2017 at approximately 3:30 PM the Minimum Date Set Coordinators, nurses #1 and #2, confirmed that Advance Directives was not included in the resident's care plan and that the CNA did not participate in the care plan meeting held on 09/13/2017, 10/18/2017, and 11/01/2017. The facility admitted Resident # 65 with [DIAGNOSES REDACTED]. Care Plan review on 11/14/17 revealed no care plan related to Advance Directive choice and no documentation that A CNA (Certified Nursing Assistant) attended the care plan meeting held for this resident on 10/4/17. Interview on 11/15/17 at 10:40 AM with MDS (Minimum Data Set) / Care Plan Coordinator # 1 and #2 confirmed that they were unaware that the Advanced Directives should be covered on the care plan. They also confirmed that CNA's do not always attend the care plan meetings. Review of the Interdisciplinary Care Plan Signature Form for Care Plan Meeting on 10/4/17 was confirmed that CNA did not attend. The facility admitted Resident # 6 with [DIAGNOSES REDACTED]. Care Plan Review on 11/14/17 and 11/15/17 revealed no care plan to address the Advanced Directive choice for this resident. Also review of the Interdisciplinary Care Plan Signature Form showed no documentation of a CNA attended the care plan meeting for 10/25/17, 4/26/17,or 2/3/16. Interview with MDS/Care Plan #1and #2 on 11/15/17 at 10:40 AM confirmed that Advanced Directive information not included in care plans and CNA's do not always attend care plan meetings due to work load.

Based on record review, interview and facility policy the facility failed to monitor functioning of wanderguard weekly or placement of wanderguard daily for Resident # 69. ( 1 of 2 residents reviewed for wandering) The findings included: Resident # 69 was admitted to the facility with [DIAGNOSES REDACTED]. The MDS ( Minimum Data Set) dated 10/9/16 revealed at E1000A noted Wandering, risk of getting into dangerous place. Further investigation showed the resident had 1-3 episodes of wandering in the facility. The resident was assessed and found to be at risk for elopement. A Physician;s order was obtained on 10/4/16 for wanderguard to be placed on right ankle. There were no physician orders for monitoring: however, the DON ( Director of Nursing) presented their facility policy for Elopement Monitoring. The facility post a list of all current residents with elopement deterrent bracelets in the facility at the nurses station. Residents are photographed ( with permission) for proper identification in case of elopement. This information will be placed on the Resident's care plans with appropriate goals, interventions, and approaches. The bracelets must be checked weekly by nursing to ensure proper functioning The Maintenance Department checks the doors weekly to make sure functioning properly. The maintenance log book was checked for compliance. The DON stated she also expected the staff to check daily for placement of bracelets and document checks on the TAR (Treatment Administration Record). The DON and ADON both confirmed the staff had not documented the checking of the wanderguard bracelet on Resident # 69 since it had been placed on 10/4/16. The resident had not left the unit nor gone outside since admission. Maintenance had been checking weekly all exit doors to assure the system was working correctly. The CNAs ( certified Nursing Assistant) have individual resident care plans posted on inside of closet door in each residents room. The wanderguard bracelet was listed here Resident's name was listed on list posted at the nurses station as wanderer.

Based on record review, interview and facility Policy the facility failed to initiate a care plan for Resident # 69 related to placement of a wanderguard for potential risk of elopement. ( 1 of 2 residents reviewed for wandering.) The findings included: The facility admitted Resident #69 with diagnoses, including, but not limited to Dementia with Behaviors and Mild Cognitive Impairment. Documentation noted resident had episode of wandering on admission. Record review on 11/9/16 revealed a physician's orders [REDACTED].# 69. Observation revealed the resident to have bracelet applied to right wrist. No documentation could be found in the resident record for a care plan related to the placement of a wandergaurd. Per policy #6 all residents assessed as being at risk for elopement must have this information placed on their care plans with appropriate goals, interventions, and approaches. An interview with LPN #1 ( Licensed Practical Nurse) confirmed he/she did not see a care plan or any documentation related to the wanderguard. The nurse conferred with the ADON ( Assistant Director of Nursing) who also searched the record for documentation. She found mention of wanderguard on interim care plan on day of admission ( 10/4/16) that wanderguard placed. No care plan could be found for the potential risk of elopement and/or wanderguard placement.

Based on observations and interviews the facility failed to ensure staff in the kitchen preparing and serving meals had appropriate hair restraints in place. Staff observed in the main kitchen and kitchenettes in dining rooms without hair restraints in place or front and side of hair not covered while preparing meals. The findings included: During the initial observation of the main kitchen on 9/15/15 at approximately 9:57 AM, the Dietary Manager (DM) and the Culinary Director were observed with no hair restraints in place. After bring the concerns to the staff's attention, the DM was noted putting on a hair restraint but the restraint did not cover the front or side of the hair. During observation on 9/15/15 at approximately 4:32 PM of the food temperature in the main kitchen, the Culinary Director was observed in the kitchen without a hair restraint. The DM and a staff member doing the food temps did not have their hair completely covered in the front or side of their head. During an observation on 9/15/15 at approximately 5:17 PM of the food temps in the kitchenette area in the dining area on the unit revealed the DM and dietary staff were at the steam table with their hair not completely restrained. The DM and dietary staff confirmed the findings. During observation on 9/16/15 at approximately 9:40 AM of the dish washing process. Three stained water/tea pitches were noted in the clean dishes area. The stained dark brown water/tea pitchers were confirmed by the Dietary Manager who reported the pitchers are cleaned with a stain remover weekly. The DM further stated that if the stains do no come out the facility disposes the pitchers.

Based on observations, record review and interview, the facility failed to review and revise a care plan to include interventions to prevent further falls for 1 of 2 sampled residents reviewed. Resident #14 had a fall with injuries and the care plan was not updated to include interventions for the fall. The findings included: The facility admitted Resident #14 with a [DIAGNOSES REDACTED]. An observation on 9/16/15 at 11:49 AM revealed Resident #14 seated in a wheelchair in the day area. The resident was noted with a reddened area/small bump to forehead. There were no chair alarms or other devices in place. A record review on 9/16/15 at approximately 12:14 PM revealed a nurse's note dated 7/04/15 that resident was observed on floor mat near his/her bed by Certified Nurse Aide (CNA) who heard the bed alarm sounding off. The nurse note indicated the resident received a skin tear to left elbow and abrasion to right toe. Review of an incident/accident log dated 6/01/15 to 9/16/15 indicated the resident had a fall on 7/03/15 and 7/04/14. There was no documentation in the nurse's note regarding the 7/03/15 fall. A nurse's note dated 9/12/15 indicated the resident was observed leaning forward in a wheelchair a fell forward out of the wheelchair. The resident received two (2) 1 x 1 cm (centimeter) abrasions to the forehead. The incident/accident log did not include the 9/12/15 fall. A review of an INCIDENT INVESTIGATION FORM dated 9/12/15 indicated the resident had a fall and the corrective action put in place would include monitoring and for a chair alarm to be put in place. Further record review revealed the care plan was not updated to address the 9/12/15 fall with an injury. A care plan with start date of 8/05/15 in the concerns section indicated the resident was a falls risk related to poor safety and that the resident had made multiple attempts to get out of bed and chair without assistance. An interview on 9/16/15 at approximately 12:30 PM with Licensed Practical Nurse (LPN) #1 confirmed Resident #14's care plan was not updated to address the 9/12/15 fall. The LPN further stated the facility was still in the process of making a determination of which interventions to put in place.

Based on observations, record review and interviews, the facility failed to put interventions in place to prevent further falls for 1 of 2 sampled residents reviewed. Resident #14 had a fall with injuries with no interventions in place to address the cause of the fall. The findings included: The facility admitted Resident #14 with a [DIAGNOSES REDACTED]. An observation on 9/16/15 at 11:49 AM revealed Resident #14 seated in a wheelchair in the day area. The resident was noted with a reddened area/small bump to forehead. There were no chair alarms or other devices in place. A record review on 9/16/15 at approximately 12:14 PM revealed a nurse's note dated 7/04/15 that resident was observed on floor mat near his/her bed by Certified Nurse Aide (CNA) who heard the bed alarm sounding off. The nurse note indicated the resident received a skin tear to left elbow and abrasion to right toe. Review of an incident/accident log dated 6/01/15 to 9/16/15 indicated the resident had a fall on 7/03/15 and 7/04/14. There was no documentation in the nurse's note regarding the 7/03/15 fall. A nurse's note dated 9/12/15 indicated the resident was observed leaning forward in a wheelchair a fell forward out of the wheelchair. The resident received two (2) 1 x 1 cm (centimeter) abrasions to the forehead. The incident/accident log did not include the 9/12/15 fall. A review of an INCIDENT INVESTIGATION FORM dated 9/12/15 indicated the resident had a fall and the corrective action put in place would include monitoring and for a chair alarm to be put in place. An observation on 9/16/16 at approximately 12:22 PM, revealed the resident was seated in the dining area with no alarms or other devices in place. An interview and observation with Licensed Practical Nurse (LPN) #2 confirmed the findings. An interview on 9/16/15 at approximately 12:30 PM with LPN #1 revealed no device was in place because the facility was still in process of making a determination of which interventions to put in place. The LPN further confirmed the intervention that was identified on the 9/12/15 INCIDENT INVESTIGATION FORM and the chair alarm was not implemented. An interview on 9/16/15 at approximately 4:15 PM with the Director of Nursing (DON) stated that the facility put in fall interventions within 24 hours of a fall. The DON further stated the facility does not want to use chair alarms but could not address why a chair alarm intervention was included on the INCIDENT INVESTIGATION FORM as an intervention. An interview on 9/17/15 at approximately 10:40 AM with the Director of Nursing revealed a decision was made to include a personal alarm while therapy worked out the details of a pommel cushion. .

Based on record review, interview and review of the facility's POLICES AND PROCEDURES PSYCHOPHARMACOLOGIC MEDICATIONS policy, the facility failed to ensure that 1 of 5 sampled resident reviewed for unnecessary medications was adequately monitored for its use. Resident #15 was receiving [MEDICATION NAME] at 50 milligrams everyday with no documentation of behaviors for its use, then the dose was increased to 100 mg every with no documentation of behaviors. The findings included: The facility admitted Resident #15 with [DIAGNOSES REDACTED]. A record review on 9/16/15 at approximately 11:56 AM revealed a care plan that indicated Resident takes medications for Anxiety, Depression, [MEDICAL CONDITION] and Paranoia. Interventions included watch for behavioral changes, anxiety, agitation and crying. Further review of the medical record revealed there was no documentation of behaviors in the chart to indicate the use for [MEDICATION NAME]. A pharmacy consultation form for July 2014 indicated the resident was on Seroqeul 50 mg (milligrams) since 11/12 and recommended a gradual reduction which was declined with a note benefits and risk. A pharmacy consultation form for July 2015 indicated the resident was on [MEDICATION NAME] on 100 mg since 12/30/14 and requested gradual reduction due to no episodes of paranoid/arguing documented on behavior sheets. Review of the nurse's notes, social notes and behavioral sheets for the past three (3) months revealed there was no documentation of behaviors or the use of [MEDICATION NAME]. An interview on 9/17/15 at approximately 9:30 AM with Licensed Practical Nurse (LPN) #1 confirmed the finding that there was no documentation related to the use of [MEDICATION NAME]. LPN #1 stated that the [MEDICATION NAME] was increased from 50 milligrams (mg) to 100 mg in December 2014 due to the family's request for the dose increase. Reportedly the family informed the physician that the resident was hostile to his/her spouse and the dose was increased. The nurse confirmed the facility did not have any documentation to indicate the resident was hostile to his/her spouse. A nurse's note dated 1/09/15 indicated the pharmacy faxed a consult sheet related to increasing medications with no noted behaviors by nursing staff. Review of the facility's POLICES AND PROCEDURES PSYCHOPHARMACOLOGIC MEDICATIONS policy, on page 3 of 4, #8 that Presence or absence of adverse behavior and side effects from medication use, if present, will be documented on the pharmacy provided behavior monitoring form.

Based on observation and interviews, the facility failed to prominently display written information regarding how to receive refunds for previous payments on 1 of 1 units. The findings included: On 10/7/14 at 10:10 AM, the facility's postings were observed in a wooden case with glass doors. No information was posted regarding the process for applying for refunds. In addition, the case was located with the top approximately 8-10 inches from the ceiling. During an interview at that time, the Nursing Home Administrator confirmed there was no information posted regarding how to apply for refunds. The Administrator further confirmed that residents in wheelchairs might have difficulty seeing the postings at the top of the cabinet.

Based on observation and interviews, the facility failed to ensure the survey results were readily accessible to residents and failed to post a notice of their availability on 1 of 1 units. The findings included: On 10/7/14 at 10:10 AM, the facility's survey results were observed in a wooden case with glass doors. The case was located with the top approximately 8-10 inches from the ceiling with a lock located approximately in the middle of the cabinet and the key was in the lock. During an interview at that time, the Nursing Home Administrator confirmed the residents would have to open the case to read the survey result. The Administrator stated that the residents could ask anyone to get the information for them but also confirmed that the residents in wheelchairs would not be able to access the information independently. At approximately 4:00 PM on 10/8/14, the Administrator also confirmed there was no signage posted that survey results were available and could be read by any individual.

On the days of the survey based on observations, interviews, and review of facility policies titled 'Personal Appearance Standards', 'Food Storage Chart', and 'Thermometer Calibration', the facility failed to distribute and serve food under sanitary conditions. During the observation of the lunch meal , the transfer of food was observed uncovered and the transfer of soiled dishes was observed uncovered. During the observation of the main kitchen, dietary staff was observed without beard restraints. Prior to serving the evening meal, dietary staff did not know how to calibrate the thermometer. The findings included: During the observation of the lunch meal on 5/28/13 At 12:14 PM, a dietary staff member was observed to transfer buns and a container of sauce to another dining room without covering the food items. Soiled dishes were observed transported to the kitchen uncovered,. Observation of the main kitchen on 5/28/13 at 11:00 AM revealed two male dietary staff without beard restraints. On 5/30/13 at approximately 2:10 PM, a second observation was made of the main kitchen which revealed three male dietary staff without beard restraints. This was confirmed by the Director of Dietary on 5/30/13. Observation of the small kitchen in the Skilled area on 5/28/13 at 11:45 AM revealed one partial bag of parmesan cheese with a use by date of 5/27/13 and one partial bag of cheddar cheese with a use by date of 5/26/13. This was verified by the Dietary Manager/Registered Dietician(DM/RD) at that time. Observation of the trayline in the small kitchen located in the Skilled building on 5/29/13 at 4:12 PM revealed that Dietary Staff Member #1 did not know what the desired temperature should be when calibrating the thermometer prior to taking food temperatures. This was confirmed by the DM/RD at that time. Observation of the tray line on 5/29/13 in the Butterfly Dining Room revealed that Dietary Staff Member #2 did not know how to calibrate the thermometer prior to taking food temperatures. Review of the facility policy titled 'Personal Appearance Standards' listed under #4 the following: Men with facial hair, moustache and/or beard, must wear a beard guard while in the production kitchen. Review of the facility 'Food Storage Chart' lists the following: Cheese- all cheeses except hard cheese(14 days) has an expiration of 7 days once opened Review of the facility policy titled 'Thermometer Calibration' lists the following for Ice-Point Method for Calibrating a Thermometer: 1. Fill a deep container with crushed ice. Add clean tap water until the container is full. 2. Put the thermometer stem or probe into the ice water so that the sensing area is completely submerged. Wait 30 seconds or until the indicator stops moving. 3. Holding the calibration nut securely with the tool provided on the case, or with a wrench rotate the head of the thermometer until it reads 32 degrees Fahrenheit."

On the days of the survey based on observations, record reviews, interviews and the Drug Facts and Comparison book (updated monthly) the facility failed to ensure that it was free of medication error rates of five percent or greater. The medication error rate was 7.1 %. There were 3 errors out of 42 opportunities for error. The findings included: Error #1: On 3/6/12 at 9:15 AM, during observation of medication pass, Licensed Practical Nurse (LPN) #1 was observed to administer [MEDICATION NAME] Eye gtts (drops), "one gtt each eye daily" to Resident A. LPN #1 was observed to instill one drop of [MEDICATION NAME] into each eye of Resident A without shaking the bottle before instillation. The Drug Facts and Comparisons book, page 1725, states, (under "General Considerations in Topical Opthalmic Drug Therapy"): "Resuspend suspensions (notably, many ocular steroids) by shaking to provide an accurate dosage of drug." During an interview on 3/6/12 at approximately 9:30 AM, LPN #1 confirmed that it was a suspension and was aware it should have been shaken before instillation into the resident's eyes. Error #2: On 3/6/12 at 9:35 AM, during observation of medication pass, LPN # 2 was observed to administer "[MEDICATION NAME] Allergy 24 hour, Non-Drowsy 180 mg tablet." Prior to giving Resident B the [MEDICATION NAME], LPN #2 crushed the medication. The Drug Facts and Comparisons book, page 700, states (under Patient Information): "Instruct patients not to crush or chew sustained released preparations." During an interview on 3/6/12 at 4:15 PM, LPN #2 confirmed [MEDICATION NAME] 24 hour was a sustained release, and was not aware that the medication shouldn't been crushed. Error #3: On 3/6/12 at 3:20 PM, during observation of medication pass LPN #2 was observed to administer NAME] ([MEDICATION NAME]) F/C 40 mg tablet DR (Delayed Release) and 8 other medications to Resident #8. Prior to administering the medication LPN #2 crushed every medication besides [MEDICATION NAME]. The Drug Facts and Comparisons book, page 1138d, states (under Administration and Dosage): "Instruct the patient to swallow the tablet whole and not split, chew or crush the tablet." During an interview on 3/6/12 at 3:48 PM, LPN #2 verified [MEDICATION NAME] DR is a delayed released medication and stated that it shouldn't have been crushed.