Every finding on record at Willowbrook Rehabilitation and Care

Based on record review, and staff interviews, the facility failed to ensure 1 of 1 sampled resident (Resident #76) attended his doctor appointment when Resident #76 missed a scheduled orthopedic appointment on 9/12/24 to have stitches removed due to facility failure to transcribe the order resulting in a missed doctor appointment. The findings included:Resident #76 was admitted to the facility on [DATE] with diagnosis including displaced subtrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing and anxiety.Resident # was discharged from the facility on 9/20/24. During an interview with Unit Manager #1 on 9/11/25 at 12:03 p.m. she revealed that Resident #76 missed his appointment to have his stiches removed on 9/12/24. She stated the DON received telephone orders on 9/6/24 but did not document the information. She further stated that as soon as they noticed the error on 9/19/24, they made Resident #76 an appointment. She stated that she did a wound assessment on Resident #76 on 9/19/24 and that the wound did not get infected and Resident #76 did not experience any harm. In an interview with the Director of Nursing (DON) on 9/11/25 at 3:44 p.m. she stated that Resident #76 missed an appointment for his stiches to be removed because she forgot to transcribe the order from Resident #76's doctor on 9/6/24. She stated she received the telephone order 9/6/24 to remove the stitches but did not transcribe it to the Treatment Administration Record (TAR) leading to Resident #76 missing his appointment on 9/12/24. The DON stated that she was responsible for the error of not transcribing the order and communicating to the nursing staff. She stated that when the error was discovered she contacted the doctor's office, and the resident was seen on 9/19/24. In a telephone interview with the prior Administrator on 9/12/25 at 9:17 a.m. She revealed that DON's failure to transcribe a telephone order for Resident #76 on 9/6/24 was responsible for Resident #76's missing his appointment on 9/12/24. The prior Administrator stated that the facility discovered the missed appointment on 9/19/24 when the doctor's office called the facility. She stated that the DON secured an appointment for Resident #76 to be seen on the same date. The prior Administrator further stated that lack of documenting in the TAR caused the error. She stated that a plan of correction was immediately implemented when the error was identified to ensure residents orders and appointments are transcribed correctly. The facility provided the following corrective action plan: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 9/19/24 Resident #76 went to his orthopedic appointment to have staples removed. Unit manager assessed the wound to ensure no signs and symptoms of infection ae present. Director of Nursing (DON) failed to put wound order into Point Click Care (PCC) causing transcript error. The admitting nurse failed to obtain wound care orders when doing initial assessment. -The facility recognizes that all residents who have wounds have the potential to be affected by the noncompliance failure to transcribe orders per the physician and not providing transportation to scheduled appointments for follow-up needs. On 9/19/24 an assessment and review of Resident #76's by the Unit manager found no evidence of trauma or infection. Or deterioration of the surgical wound. On 9/19/24 the Assistant Director of Nursing (ADON) re-educated nurses on contacting the Physician to obtain any wound orders on admission as indicated. On 9/19/24 the Regional Director of Nursing re-educated the DON on ensuring that when taking orders via telephone the orders are placed into PCC, and they are on the residents' Treatment record as indicated to prevent transcription errors.On 9/19/24, Regional Director of Clinical services completed a root cause analysis regarding the noncompliance of transcribing wound orders.Address how the facility will identify other residents having the potential to be affected by the same deficient practice. On 9/19/24 all residents are identified as having the potential to be affected for those who have wounds and follow up appointments. A quality review of 100% of current residents with wounds and scheduled appointments was audited by the Unit managers to ensure all residents who have wounds have orders in pace per physician and any follow-up appointments have transportation scheduled. On 9/19/24 the Unit managers re-educated nurses that when doing the initial skin assessments on all new admissions or readmissions that if there is any wounds to obtain an order for treatment and to place on the treatment record to ensure proper treatment is in place per physician orders and to place all needed follow up appointments in the transportation box to bring to bring to clinical to ensure all appointments are scheduled and transportation is set up accordingly. Address what measures were put in place to ensure the deficient practice will not recur: On 9/19/24 the nursing managers re-educated all nurses when admitting a patient to ensure proper treatment is in place per physician order.-Newly hired nurses will be educated during the orientation on obtaining orders and placing them into PCC for any resident who requires treatment for any wound according to physician orders and to ensure communication to physician and Unit managers related to follow up appointments are scheduled with proper transportation. -A quality review was conducted by unit managers on 9/19/24 to ensure all residents with wounds had treatment in place as indicated and all residents who have appointments scheduled have transportation scheduled. -the Executive Director conveyed an ADHOC Quality Assurance Performance Improvement Committee was to determine the root cause analysis, formulate and approve a plan of correction for the deficient practice to include education, policies and procedures and quality improvement monitoring. The facility will conduct quality improvement audits to ensure compliance with the deficient practice through audits and education. Indicate how the facility plans to monitor its performance to make sure that the solutions are sustained.On 9/19/24, when the deficient practice was identified, the center's Executive Director (ED) conveyed an ADHOC Quality Assurance Improvement meeting to determine the root cause analysis of the deficient practice, formulate and approve a plan of correction to include education, policies and procedures and quality improvement monitoring beginning 9/19/24. The facility will conduct quality improvement audits to ensure compliance with the deficient practice through audits and education.On 9/23/24 the unit managers and DON began using the quality improvement data collection form to monitor all admissions and re-admissions skin assessments to ensure treatment orders are obtained and put into the OCC and any appointments are scheduled 3 times a week x 4 weeks in clinical, then 2 times a week x 4 weeks in clinical, then weekly in clinical x 4 weeks. Beginning 9/19/24 the DON and Nurse Managers conducted Quality improvement monitoring on all admissions and re-admissions to ensure all residents who need treatment for wounds are being treated accordingly and all residents who require appointments are attending all scheduled appointments in clinical meetings 3 days a week x 4 weeks, then 2 times a week x4 weeks, then weekly for 4 weeks to ensure compliance.The Executive Director will report the results of the monitoring to the QAPI committee for review and recommendations for the period of the monitoring period or as is amended by the committee. Compliance/completion date for the corrective action plan: 9/20/24Validation of the corrective action plan was completed on 9/12/25 by the following: A review was completed of the signature pages for the in-service training for nursing staff on correctly transcribing doctor orders. Interview of nursing staff showed they received in-service training regarding transcribing doctor orders correctly. A review of the audit tool used by the facility to monitor performance was found to be completed according to the plan of correction. The monitoring documentation showed the audits were completed on 12/12/24. The facility's corrective action plan completion date of 9/20/24 was validated.

Based on observations, record reviews, and staff interviews, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 31 medication administration opportunities resulting in a medication error rate 6.45% for 2 of 6 residents observed during medication pass (Resident #3 and Resident #41).The findings included:1.Resident #3 was admitted to the facility on [DATE] with diagnoses that included glaucoma.A review of Resident #3's active physician orders dated 7/3/25 included a current order for Dorzolamide HCL-Timolol Maleate Ophthalmic Solution 2-0.5% (a combination medication used to lower intraocular pressure in patients with open-angle glaucoma) one (1) drop to right eye twice a day. This medication was not administered to Resident #3 as ordered on 9/11/25.On 9/11/25 at 9:15 AM, Nurse #1 was observed as he prepared and administered 8 oral medications to Resident #3. Nurse #1 reported Resident #3's Dorzolamide HCL-Timolol Maleate Ophthalmic Solution 2-0.5% was not available on the medication cart for administration. Nurse #1 stated he would reach out to the pharmacy to reorder the medication.During an interview with Nurse #1 on 9/11/25 at 9:20 AM, he indicated he was unable to locate the medication in the medication cart. Nurse #1 was unable to indicate why the medication was not available. He stated he would follow up with the pharmacy to see if the medication could be sent with the next medication delivery. An interview was conducted with the Director of Nursing (DON)on 9/12/25 at 1:00 PM. The DON stated if a medication was not available for administration, the nurse should go to the Omnicell to see if the medication was there. The DON stated she expected that the nurse would notify the provider if a medication was missing and follow further instructions for the missed dose provided by the provider.2. A review of the manufacturer's instructions on the preparation for use of the Budesonide-Formoterol Fumarate Inhalation Aerosol inhaler was conducted. The instructions read, in part: Shake your Budesonide-Formoterol Fumarate Inhalation Aerosol inhaler well for 5 seconds right before each use. Remove the mouthpiece cover. Hold the Budesonide-Formoterol Fumarate Inhalation Aerosol inhaler up to your mouth and close your lips around it. Breathe in (inhale) deeply and slowly through your mouth. Press down firmly and fully on the top of the canister to release the medication. Shake the Budesonide-Formoterol Fumarate Inhalation Aerosol inhaler again for 5 seconds and repeat the above steps.Resident #41 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD).A review of Resident #41's active physician orders dated 6/26/25 included a current order for Budesonide-Formoterol Fumarate Inhalation Aerosol 80-4.5 MCG/AC inhale 2 puffs every 12 hours. Budesonide-Formoterol Fumarate Inhalation Aerosol is an inhaled medication containing a combination of budesonide and formoterol use for the management of COPD.On 9/12/25 at 8:50 AM, Nurse #2 was observed as she administered Budesonide-Formoterol Fumarate Inhalation Aerosol 80-4.5 MCG/AC to Resident #41. Nurse #2 retrieved the inhaler from the box and shook the inhaler for 5 seconds. Nurse #2 removed the mouthpiece and administered 2 puffs of medication without shaking the inhaler between puffs.An interview conducted with Nurse #2 on 9/12/25 at 8:57 AM revealed she had forgotten to wait and shake the inhaler between inhalations. The nurse stated she realized she should have waited and shook the inhaler between doses but just forgot.An interview was conducted with the Director of Nursing (DON) on 9/12/25 at 1:00 PM. The DON stated some of the newer combination inhalers did not require the nurse to wait 3 to 5 minutes between each puff of medication. The DON retrieved the manufacturer's instructions which stated in part the inhaler was to be shaken for 5 seconds, and a repeat inhalation administered. The DON stated she expected that the nurse would follow the manufacturer's instructions when administering inhalers.An interview was conducted with the Administrator on 9/12/25 at 1:49 PM. The Administrator stated she expected medications would be administered as ordered by the provider and manufacturer's instructions would be followed.

Based on resident and staff interviews and record review, the facility failed to develop a care plan that addressed discharge goals and plans for 2 of 17 residents (Residents #1 and #55) reviewed for comprehensive care plans. Findings included: 1. Resident #1 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed an active discharge plan was in place for the resident to return to the community. The quarterly MDS assessment dated [DATE] indicated Resident #1 was cognitively intact. The comprehensive care plan, updated 7/14/23, did not include information that addressed discharge plans or goals. In an interview with Resident #1 on 8/1/23 at 2:36 PM, he shared his discharge plan was to remain in the facility for long term care. On 8/1/23 at 1:57 PM an interview was completed with the Social Worker (SW). She typically wrote the care plan that addressed discharge plans and goals for all the residents. She stated when Resident #1 initially came to the facility, his discharge goal was to return to the community. After he completed therapy, it was determined that he needed a higher level of care and so he remained at the facility for long term care. The SW acknowledged there was not a discharge care plan included in Resident #1's comprehensive care plan and said she thought she hadn't completed one since the resident's discharge plans were uncertain when his care plan was developed by the interdisciplinary team. The MDS Coordinator was unavailable for interview. During an interview with the Executive Director on 8/2/23 at 2:57 PM she stated a discharge care plan needed to be developed whether a resident was short term rehabilitation, long term care, or if the discharge plan was unknown. She added the SW had been new to the SW role at the facility and didn't think she knew she could create a care plan that indicated the discharge plan was unknown. 2. Resident #55 was admitted to the facility on [DATE]. The admission MDS assessment dated [DATE] revealed Resident #55 was cognitively intact and an active discharge plan was in place for the resident to return to the community. The comprehensive care plan, updated 7/12/23, did not include information that addressed discharge plans or goals. On 8/1/23 at 1:57 PM an interview was completed with the SW. She typically wrote the care plan that addressed discharge plans and goals for all the residents. The SW acknowledged there was not a discharge care plan included in Resident #55's comprehensive care plan and said she thought she hadn't completed one since the resident's discharge plans were uncertain when his care plan was developed by the interdisciplinary team. The MDS Coordinator was unavailable for interview. During an interview with the Executive Director on 8/2/23 at 2:57 PM she stated a discharge care plan needed to be developed whether a resident was short term rehabilitation, long term care, or if the discharge plan was unknown. She added the SW had been new to the SW role at the facility and didn't think she knew she could create a care plan that indicated the discharge plan was unknown.

Based on observations and staff interviews, the facility failed to secure medicated treatments left in an unattended treatment cart for 1 of 1 treatment cart. The findings included: During wound care observation on 8/1/23 at 10:53 AM, Nurse #1 was observed to push the treatment cart against the wall on the 200 hall and entered a resident room and closed the door to perform wound care. The cart lock was not pushed in indicating a locked position. Observation of Treatment Cart #1 revealed the top drawer to contain topical ointments. The second drawer contained medicated dressings and bandages. The bottom drawer contained resident prescribed medicated creams for both the 100 and 200 halls. On 8/1/23 at 10:58 AM, residents were observed ambulating in the hallway near the unlocked cart. An interview on 8/1/23 at 11:00 AM with Nurse #1 revealed that she was aware the treatment cart should be locked when she walked away from it but she stated that she did not have a key. She stated she had worked at the facility for two months and had made a request for the pharmacy to provide her with a key. She stated that she had to get one from the nurse on the other cart to unlock it and was unable to do that without going back and forth after each wound treatment. Nurse #1 stated that she would turn the cart around so it faced the wall while she was out of sight and in a room with a resident. In an interview with the Administrator on 8/3/23 at 2:30 PM, she stated that she was aware that was a problem when Nurse #1 had begun working at the facility but she had thought it had been taken care of already. She stated that she would contact the pharmacy and have that taken care of immediately.

Based on resident and staff interviews, interview with the Ombudsman and record reviews, the facility failed to provide the resident a written notification for the reason for transfer to the hospital and failed to provide a copy of the transfer/discharge notice to the Ombudsman for 2 of 4 residents (Resident #56 and Resident #58) reviewed for hospitalization . Findings included: 1. Resident #56 was admitted to the facility on [DATE]. He was listed in the electronic health record as his own responsible party. The medical record demonstrated the resident was transferred to the hospital on 6/28/23 due to a change in condition. Resident #56 returned to the facility on [DATE]. No written notice of transfer was documented to have been provided to the resident or Ombudsman. The significant change Minimum Data Set assessment dated [DATE] revealed Resident #56 was cognitively intact. On 8/1/23 at 3:26 PM an interview was completed with Nurse #1. She shared Resident #56 demonstrated a change in condition on 6/28/23 and she assisted with his transfer to the hospital. She explained when a resident was transferred to the hospital, the facility sent the following paperwork with the resident: medication administration record, face sheet, recent lab work, and clinical information about the resident. She said she had not sent a written transfer/discharge notice or provided one to Resident #56 when he was sent to the hospital. During an interview with Resident #56 on 8/2/23 at 10:15 AM, he said the facility had not provided him a written notice of transfer when he was sent to the hospital on 6/28/23. The Social Worker (SW) was interviewed on 8/1/23 at 3:37 PM. She stated typically someone at the facility notified the Ombudsman when a resident was discharged from the facility, but added she was not the staff member responsible for notifying the Ombudsman. A telephone interview was conducted with the Ombudsman on 8/1/23 at 3:57 PM. She reported the facility sent her a notice of transfer/discharge when a 30 day notice was provided to the resident by the facility. She said the facility had not sent her notification when a resident was transferred to the hospital and verified she had not been notified when Resident #56 was sent to the hospital. On 8/2/23 at 9:37 AM an interview was completed with the Executive Director. She stated the facility only sent written notification to a resident if it was a true 30 day notice. She verified the facility had not been sending transfer/discharge notices when a resident went to the hospital. She added the facility had kept a log of transfers to the hospital but had not sent the list to the Ombudsman. The Executive Director added it was the responsibility of the SW to send the list of discharges to the Ombudsman monthly, but there had been some changes in the SW department and it had not been consistently done. 42007 2. Resident #58 was admitted to the facility on [DATE]. The quarterly Minimum Data Set assessment dated [DATE] revealed Resident #58 was not cognitively intact. She was able to ambulate with little assistance. The medical record demonstrated the resident was transferred to the hospital on 5/9/23 and due to a fall. Resident #58 returned to the facility on [DATE]. No written notice of transfer was documented to have been provided to the resident or Ombudsman. The Social Worker (SW) was interviewed on 8/1/23 at 3:37 PM. She stated typically someone at the facility notified the Ombudsman when a resident was discharged from the facility, but added she was not the staff member responsible for notifying the Ombudsman. On 8/3/23 at 10:30 AM the Administrator stated she was not familiar with the transfer/discharge form that included a portion stating that the ombudsman should be notified of all discharges, including hospital transfers, from the facility. She stated the facility only sent written notification to a resident if it was a 30-day notice of discharge. She stated the facility had not been sending transfer/discharge notices when a resident went to the hospital.

Based on resident and staff interviews and record reviews, the facility failed to provide the resident a written notification of the bed hold policy upon a resident's transfer to the hospital for 2 of 4 residents (Resident #56 and Resident #58) reviewed for hospitalization . Findings included: 1. Resident #56 was admitted to the facility on [DATE]. He was listed in the electronic health record as his own responsible party. The medical record demonstrated the resident was transferred to the hospital on 6/28/23 due to a change in condition. Resident #56 returned to the facility on [DATE]. No written notice of the facility's bed hold policy was documented to have been provided to the resident. The significant change Minimum Data Set assessment dated [DATE] revealed Resident #56 was cognitively intact. On 8/1/23 at 3:26 PM an interview was completed with Nurse #1. She shared Resident #56 demonstrated a change in condition on 6/28/23 and she assisted with his transfer to the hospital. She explained when a resident was transferred to the hospital, the facility sent the following paperwork with the resident: medication administration record, face sheet, recent lab work, and clinical information about the resident. She said she had not sent the bed hold policy or provided one to Resident #56 when he was sent to the hospital. During an interview with Resident #56 on 8/2/23 at 10:15 AM, he said the facility had not provided him a copy of the bed hold policy when he was sent to the hospital on 6/28/23. The Business Office Manager was interviewed on 8/1/23 at 3:33 PM. She explained the bed hold policy was provided to a resident at the time of admission. Additionally, the charge nurse provided the bed hold policy to the resident when they were transferred to the hospital. On 8/2/23 at 9:37 AM an interview was completed with the Executive Director. She stated staff were supposed to send the bed hold policy when a resident was transferred to the hospital. She explained the nurses used to send a packet of information with the resident that included the bed hold policy. Recently, the facility transitioned from a packet of information that was kept at the nurse's desk to computer generated forms and nurses hadn't included the bed hold policy when they sent a resident to the hospital. 42007 2. Resident #58 was admitted to the facility on [DATE]. The quarterly Minimum Data Set assessment dated [DATE] revealed Resident #58 was not cognitively intact. She was able to ambulate with little assistance. The medical record demonstrated the resident was transferred to the hospital on 5/9/23 and due to a fall. Resident #58 returned to the facility on [DATE]. No written notice of the facility's bed hold policy was documented to have been provided to the resident's responsible party. The Business Office Manager was interviewed on 8/2/23 at 2:35 PM. She stated the bed hold policy was provided to a resident at the time of admission and then the nurse in charge during the time of transfer would provide anything else that was needed. On 8/3/23 at 3:30 PM, the Executive Director stated that the bed hold policy was provided to the resident and/or resident representative during admission and it was part of the admission documents. She stated she was not aware they needed to send the bed hold policy each time a resident was transferred to the hospital. She also stated that the facility recently moved to computer generated transfer packets and the bed hold may have been a part of the packet in the past but was inadvertently omitted currently.

Based on observations and resident and staff interviews, the facility failed to post the availability of the facility's survey results. This practice had the potential to affect all residents in the facility. Findings included: During a tour of the facility including the secured unit on 03/17/22 at 9:06 AM an observation was made that survey results were not posted. There was no notice posted in the facility regarding the availability and location of recent survey results. On 03/17/22 at 9:10 AM Resident #19, the Resident Council President revealed she had no knowledge of the location of the survey results notebook. She stated she was not aware where they were located and had not seen any signage that directed residents to their location. On 03/17/22 at 9:17 AM an interview with a Nurse #1 working on the secured unit revealed there was no survey results notebook on the secured unit. She stated the results were up front. She further stated if family asked about the results, she would take them up front and find them On 03/17/22 at 9:20 AM in an interview with a Nurse Aide #1 regarding the location of the survey results, she stated I would assume they would be up front. She indicated if family asked for the results, she would locate them and inform the family of their location. On 03/17/22 at 9:22 AM in an interview with the Activity Director she indicated the results were posted at the front. On 03/17/22 at 9:22 AM during an interview with the Administrator she pointed at the file holder outside her door where the survey results book was observed. She stated there used to be a sign on the file holder that indicated it contained the survey results notebook. She further stated the results were not posted anywhere else in the facility. She indicated to her knowledge there were no signs posted anywhere else in the facility indicating the location of the survey results. On 03/17/22 at 11:40 AM in a follow-up interview with the Administrator she stated she expected signage to be posted at all nurse stations and in the lobby indicating the location of the survey results. She further stated she expected survey results and the location of survey results to be discussed in Resident Council and that all newly admitted residents were to be made aware of their location.

Based on observation, record review and staff interviews, the facility failed to implement Centers for Disease Control and Prevention (CDC) guidelines by not posting precautionary signage at the entrance of the facility's COVID-19 quarantine unit that instructed Health Care Providers (HCP) they must wear Personal Protective Equipment (PPE) while working on the unit and while caring for residents, who were on enhanced droplet isolation precautions, for five of five residents who resided on the quarantine unit (Residents #9, #10, #11, #12 and #13). This failure occurred during the COVID-19 pandemic. Findings included:OVID The CDC guideline titled Responding to Coronavirus (COVID-19) in Nursing Homes dated 04/30/20 read in part: Place signage at the entrance to the COVID-19 care unit that instructs HCP they must wear eye protection and an N95 or higher-level respirator (or facemask if a respirator is not available) at all times while on the unit. Gowns and gloves should be added when entering resident rooms. On 12/20/2020 at 11:45 AM Nurse #1 stated the COVID-19 quarantine unit was located on the 100-hall behind the closed fire doors. On 12/20/2020 at 12:50 PM an observation of the 100-hall revealed closed fire doors. Resident rooms 105 through 114 were located behind the closed doors. No signs indicating COVID-19 quarantine or enhanced droplet precautions was observed posted outside of the facility's COVID-19 quarantine unit. On 12/20/2020 at 1:30 PM Nurse #1 clarified the COVID-19 quarantine rooms were resident rooms 109 through 114. She explained the residents, who resided in these rooms, were either newly admitted or being readmitted into the facility. She further explained the residents on COVID-19 quarantine required staff to wear masks, eye protection, gowns and gloves while providing care. Nurse #1 also explained that the Director of Nursing (DON) held frequent staff meetings to keep all staff updated on the facility's COVID-19 status. The nurse stated all staff knew which rooms were the facility's quarantine beds. On 12/20/2020 at 2:00 PM an observation was made of rooms 109 to 114. No COVID-19 quarantine or enhanced droplet precaution signage were observed posted in the hallway or on the doors of the identified quarantine rooms which included rooms #109, #110, #111, #112 and #113. Review of the facility's census indicated the following: Resident #9 resided in room [ROOM NUMBER]B and was admitted to the facility on [DATE]. Resident #10 resided in room [ROOM NUMBER]A and was admitted to the facility on [DATE]. Resident #11 resided in room [ROOM NUMBER]A and was admitted to the facility on [DATE]. Resident #12 resided in room [ROOM NUMBER] and was admitted to the facility on [DATE]. Resident #13 resided in room [ROOM NUMBER] and was admitted to the facility on [DATE]. On 12/20/2020 at 2:05 PM an interview was conducted with Nurse Aide (NA) #1. She stated she regularly worked on the 100-hall. She stated rooms 109 to 114 were designated for COVID-19 quarantine residents. She explained that masks, goggles, gloves and gowns were necessary to enter the quarantine rooms. She stated the DON and unit managers had frequent updates for the staff regarding the facility's COVID-19 status. An observation of the 100-hall was made on 12/20/2020 at 4:00 PM. No COVID-19 quarantine or enhanced droplet precaution signage was observed posted in the hallway or on the doors of the identified quarantine rooms. An observation of the 100-hall was made on 12/21/2020 at 8:58 AM. The fire doors were propped open. No COVID-19 quarantine or enhanced droplet precaution signs were observed posted in the hallway or on the doors of the identified quarantine rooms. An interview was conducted on 12/21/2020 at 9:36 AM with NA #2. She stated the COVID-19 quarantine hall was for residents who had been admitted or had returned from the hospital. She stated room [ROOM NUMBER] was not a quarantine room, but the other rooms on the 100-hall were designated for COVID-19 quarantine use. She explained that a mask, goggles, gloves and a gown were necessary when entering those residents' rooms. She stated the DON and unit managers frequently updated the staff with COVID-19 information. An interview with Nurse #2 was conducted on 12/21/2020 at 9:56 AM. She stated everyone knew the end of 100-hall was the COVID-19 quarantine unit. She explained the residents on quarantine had been admitted or readmitted from the hospital and had tested COVID-19 negative. She explained that rooms 105-106 were not quarantine rooms, rooms 107-108 had been but were not currently used as quarantine rooms, and rooms 109-113 were currently being used as quarantine rooms. She explained that masks, goggles, gloves and gowns were necessary to enter the quarantine rooms. Staff were aware of what was necessary through staff meetings with updates and education provided by the DON and managers. An interview was conducted on 12/21/2020 at 11:08 AM with the Administrator and the DON. The Administrator explained the COVID-19 quarantine unit was the end of the 100 hall, rooms 109 through 113 with room [ROOM NUMBER] to be used as the nurses' station should there be an event of active COVID-19. The Administrator explained Personal Protective Equipment (PPE) carts were available on the quarantine unit and staff were aware of what PPE was necessary through training sessions. She stated all staff knew which rooms were designated as COVID quarantine rooms, but precaution signs should be posted.

Based observations, record review and staff interviews, the facility failed to ensure a resident ' s dignity by not providing privacy during incontinent care and talking on a cellular phone while providing care for 1 of 1 resident (Resident #45) reviewed for dignity. The findings included: Resident # 45 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of a quarterly Minimum Data Set assessment dated [DATE] revealed Resident #45 had severely impaired cognition, was always incontinent of bowel and bladder and required extensive assistance of two people for her activities of daily living. On 1/28/20 at 10:28 AM, the surveyor toured the locked unit. Upon arriving to Resident #45 ' s room, the surveyor observed Resident #45 ' s room door open, the privacy curtain partly pulled closed and Resident #45 ' s legs uncovered. NA #1 was observed leaning over the resident ' s body and using a wiping motion with her hand. The surveyor knocked and entered the room to pull the privacy curtain to allow Resident #45 privacy and at that time observed NA #2 assisting with the care of Resident #45 and NA #1 talking on her cellular phone which was cradled between her chin and shoulder while providing incontinent care to Resident #45. NA #1 stated I ' m sorry, my child was throwing up. On 1/28/20 at 10:30 AM, the surveyor notified the Director of Nursing who stated she would address the concern right away. On 1/29/20 at 10:11 AM NA #2 was interviewed. She stated she pulled the curtain because the door didn ' t stay closed, but the curtain got stuck and could not be closed further. She stated the staff were not allowed to have their cellular phones in use while they are providing care. On 1/30/20 at 9:08 AM, NA #1 was interviewed. She stated on 1/28/20, her and NA #2 were providing incontinent care to Resident #45 and getting her out of bed for lunch. She stated that she did close the door to Resident #45 ' s room but it did not latch so it swung open. She stated that was when NA #2 pulled the curtain and she thought it was closed. NA #1 stated she had her cellular phone in her pocket and her child ' s school called due to illness. She stated she took the call because she wanted to be available to her child and also wanted to complete Resident #45 ' s care. NA #1 stated staff were not be on their cellular phones during care. On 1/30/20 at 3:34 PM, the Director of Nursing was interviewed. She stated they did have a problem with Resident #45 ' s door not closing all the way and she had maintenance fix it that day. She stated the curtain was able to be pulled all the way around the beds to provide privacy. She stated she discouraged cellular phone usage and NA #1 should not have answered the call while she was providing care.

Based on record review and staff interviews, the facility failed to develop a baseline care plan that included individualized information to provide effective, person-centered care for a resident requiring [MEDICAL TREATMENT] and an indwelling catheter and receiving insulin for 1 of 3 (Resident #71) resident with closed records. The findings included: Resident #71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was sent to the hospital on [DATE]. A nursing admission assessment dated [DATE] indicated Resident #71 received [MEDICAL TREATMENT] 3 times/week and had a shunt in his right upper arm. The assessment also indicate Resident #71 was an insulin dependent diabetic and had an indwelling catheter. An Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 had intact cognition and required limited assistance with most of his activities of daily living. Resident #71 used an indwelling catheter, received insulin and received [MEDICAL TREATMENT] while a resident of the facility. A record review revealed no baseline care plan for Resident #71. A record review revealed Daily Skilled Notes indicating Resident #71 had an indwelling catheter in place and a shunt to his right upper arm. A review of the (MONTH) 2019 Medication Administration Record [REDACTED]. An interview was conducted on 1/29/20 at 11:15 AM with the MDS nurse revealed baseline care plans were kept on the resident ' s charts. An interview was conducted on 1/30/20 at 1:44 PM with Unit Manager #1. She revealed the baseline care plans are completed by the nurse that completes the admission. She stated sometimes the Unit Managers help with getting them completed. An interview was conducted on 1/30/20 at 3:37 PM with the Director of Nursing. She stated Resident #71 should have had a baseline care plan because there was a packet that the admitting nurse completed when a resident was admitted , and it included the baseline care plan. She did not know why it wasn ' t in the chart.

Based on record review and staff interviews, the facility failed to maintain an accurate medical record regarding resident medications for 1 of 5 residents reviewed for unnecessary medications (Resident #18). The findings included: Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the (MONTH) 2019 physician orders [REDACTED]. A review of a physician ' s progress note dated 10/13/19 revealed Resident #18 ' s medications had been reviewed. The medications did not accurately reflect the medications Resident #18 was prescribed and were listed as follows: [MEDICATION NAME] 5 milligrams daily, [MEDICATION NAME] 20 milligrams daily, klonopin 1 milligram three times a day, [MEDICATION NAME] sodium 100 milligrams daily, donepezil 10 milligrams daily, [MEDICATION NAME] 20 milligrams, [MEDICATION NAME]-[MEDICATION NAME] 0.5 milligrams-3 milligrams (2.5 milligram base) 3 milliliters nebulizer solution, latanoprost 0.005% eye drops, [MEDICATION NAME] 30 milligrams daily, [MEDICATION NAME] 0.01% eye drop one drop each eye daily, [MEDICATION NAME] 20 milligrams, [MEDICATION NAME] 5 milligrams every 6 hours as needed, quetiapine 50 milligrams three times a day and [MEDICATION NAME] 0.25% eye drops instill one drop into affected eyes twice a day. A review of the (MONTH) and (MONTH) 2019 physician orders [REDACTED].#18 was receiving were unchanged from (MONTH) 2019. A review of a physician ' s progress noted dated 12/6/19 revealed Resident #18 ' s medications had been reviewed, however did not accurately reflect the medications Resident #18 was prescribed. The medications listed were unchanged from the physician ' s progress note dated 10/13/19. A review of the (MONTH) 2020 physician orders [REDACTED]. An interview was conducted on 1/30/10 at 2:01 PM with Unit Manager #2. She stated Resident #18 ' s physician saw residents in the evening and did his progress notes on the computer and medical records put them onto the chart. She stated she did not review the progress notes. She stated she did take the charts into the interdisciplinary meetings to discuss [MEDICAL CONDITION] medications, but she did not review the progress notes. A message was left with the physician ' s office on 1/30/20 at 1:49 PM. The physician did not return the surveyors call; therefore, an interview could not be conducted. An interview was conducted on 1/30/20 at 2:01 PM with the Medical Records Director. She stated the physician saw residents in the evening, completes the progress notes in this office then calls here and she prints them and files them into the resident ' s charts. An interview was conducted on 1/30/20 at 3:37 with the Director of Nursing. She stated the physician had a private practice as well and several residents in the facility to see. She stated once the progress noted were placed on the charts, sometimes they reviewed the progress notes in the interdisciplinary team meetings, but there was no process to audit the chart to ensure the medications listed in the progress notes were accurate.

Based on observations, record review and staff interviews, the facilities Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor their interventions that the committee put into place following the recertification and complaint survey conducted on 1/25/2019. This was for one deficiency that was originally cited in the area of Baseline Care Plan (F655) and was recited on the current recertification survey of 1/30/2020. The continued failure of the facility during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA Program. Findings included: This tag is cross referenced to: 1. F655- Baseline Care Planning-Based on observations, record review and staff interviews, the facility failed to develop a baseline care plan that included minimum healthcare information to provide effective, person-centered care for a resident with an indwelling catheter for 1 of 2 residents (Resident #73) reviewed for catheters. During the facility's recertification survey on 1/25/19, the facility failed to develop a baseline care plan that included minimum healthcare information to provide effective, person-centered care for a resident with an indwelling catheter for 1 of 2 residents (Resident #73) reviewed for catheters. An interview was conducted with the Director of Nursing on 1/30/2020 at 10:32 AM who stated she was unaware of the missed baseline care plan. She futher revealed that there would be an increased attention to that in the future. An interview conducted with the Administrator on 1/30/2020 at 3:08 PM revealed the facility did have an active Quality Assessment and Assurance Committee and they met quarterly. The administrator further stated that the committee most likely would be meeting monthly to address this and other potential issues.

Based on record review and staff interviews, the facility failed to maintain an environment free from physical restraints for 1 of 2 (Resident # 275) residents reviewed for restraints by placing pajama bottoms to prevent rising. Findings included: Resident #275 was admitted to the facility on [DATE] and resided in the memory care unit. [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #275 had severely impaired cognition and required extensive assistance with two people for transfers. Restraint was not coded on the assessment. A record review revealed no physicians order for a restraint, no assessment for a restraint and restraints were not care planned. A care plan updated 7/20/18 was reviewed for safety that revealed resident had poor safety awareness and had confusion. Interventions included gripper socks, fall mat at bedside and maintain a clear pathway. An interview on 1/24/19 at 2:40 PM with the Administrator revealed she did not recall an incident involving a resident being restrained by a nursing assistant. An interview on 1/24/19 at 3:45 PM with NA #1 revealed she was working in the memory care unit on the night of 5/31/18 during second shift when the fire alarm went off. She stated the staff were supposed to put all of the residents in their rooms. She stated she was putting Resident #275 in her room and didn't want her to fall, so she loosely placed her pajama bottoms around her waist. She stated another staff member came in and saw the pants applied to Resident #275's waist and went to get Unit Manager #2 who came back and instructed her to clock out after she wrote a statement. She stated she was educated by Unit Manager #2 that the facility was restraint free, residents could not be restrained for any reason. An interview on 1/24/19 at 4:17 PM with the Activity Director for the memory care unit revealed she was in the facility the evening of 5/31/18 but was not working. She stated when the fire alarm went off, she went to the memory care unit to assist the staff and residents. She and other staff were putting the residents into their rooms. After the alarm stopped sounding, she observed Resident #275 sitting at one of the tables and noted a color variation to her clothing and looked further to see their was fabric tied to her. She stated she immediately went to report to Unit Manager #2 who went to the unit. The Activity Director stated NA #1 was instructed to leave and Unit Manager #2 educated the other staff about restraints. She stated she was asked to provide a written statement, which she did do. An interview on 1/25/19 at 8:31 AM with Unit Manager #2 revealed she no longer worked at the facility. She stated on the evening of 5/31/18, she was in the front of the building working on the schedule when the fire alarm went off. She stated that prior to that incident, the fire alarm had been going off frequently and the facility was having problems with it. She stated the Administrator was in the facility at the time. She stated the Activity Director came and told her that she had seen a resident restrained. Unit Manager #2 stated she immediately went to the memory care unit and removed the pants. She stated she instructed NA #1 to clock out then notified Unit Manager #3 who notified the Administrator. She stated she also provided a written statement. An interview on 1/25/18 at 10:12 AM with Unit Manager #3 revealed she also no longer worked at the facility. She stated she was working the evening of 5/31/18 when the fire went off at approximately 4:45 PM. She stated Unit Manager #2 notified her that Resident #275 had been restrained. Unit Manager #3 went to the conference room to notify the Administrator. Unit Manager #3 stated she also provided a written statement that was turned into the Administrator. A follow up interview with the Administrator on 1/25/18 at 2:47 PM revealed she could not recall the incident and was unable to locate any of the documentation about it. She stated the facility is restraint free.

Based on observations, record review and staff interviews, the facility failed to develop a baseline care plan that included minimum healthcare information to provide effective, person-centered care for a resident with an indwelling catheter for 1 of 2 (Resident #73) residents reviewed for catheters. Findings included: Resident #73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of an admission Minimum Data Set assessment dated [DATE] revealed Resident #73 had severely impaired cognition and had an indwelling catheter. A review of the baseline care plan dated 12/23/18 revealed, under a problem of Altered Elimination, a goal of: will be odor free without skin breakdown. Interventions included: incontinent care as needed and monitor skin. Indwelling catheter was not included on Resident #73's baseline care plan. An observation on 1/22/19 at 4:55 PM revealed Resident #73 in his wheelchair with a catheter tube and drainage bag under the wheelchair. An interview on 1/24/19 at 3:30 PM with NA #2 revealed Resident #73 had an indwelling catheter. She revealed he was admitted with it. NA #2 was responsible for catheter care. An interview on 1/25/19 at 5:09 PM with the Director of Nursing revealed she expected indwelling catheters to be included on the baseline care plan. An interview on 1/25/19 at 5:14 PM with Nurse #1 revealed the nurse was responsible for implementing the baseline care plan. She stated she was on duty when Resident #73 was admitted and she completed the baseline care plan. She revealed Resident #73 was admitted with an indwelling catheter and she overlooked putting it on the baseline care plan.

Based on observations, record reviews, resident and staff interviews, the facility failed to follow-up on the Registered Dietician's diet change recommendation for 1 of 1 resident receiving [MEDICAL TREATMENT] treatment (Resident #70). Findings included: Resident #70 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The Care Plan dated 12/18/18 revealed Resident #70 had the potential for imbalanced nutrition and received a therapeutic diet. Interventions included: observe and report to the Physician signs and symptoms of malnutrition; and, RD (Registered Dietician) to evaluate and make diet change recommendations whenever necessary. The Initial Nutrition assessment dated [DATE] documented Resident #70 received [MEDICAL TREATMENT] treatment three times each week and received a cardiac diet. The RD recommended the resident receive a change in diet to a renal diet. There was no documentation available indicating the RD's diet change recommendation was communicated to the Physician. Review of the significant change minimum (MDS) data set [DATE] indicated Resident #70 was cognitively intact, received a therapeutic diet and received [MEDICAL TREATMENT] treatment. During an interview on 1/23/19 at 4:10 p.m., Resident #70 revealed she was not on a renal diet, but did not think she should continue to receive potatoes with her meals because of her renal condition. The resident stated that when the facility served potatoes, she left them uneaten on her plate. Review of the resident's meal card indicated she received a regular diet. The review of the [MEDICAL TREATMENT] Communication Record dated 1/25/19 included the recommendation from the [MEDICAL TREATMENT] center to encourage protein intake, follow renal diet, and a 32 ounce per day fluid restriction. During an interview on 1/25/19 at 2:59 p.m., Unit Manager#1 stated that the RD was to document any recommended orders on a facility Communication Form, and give the recommendation to the Unit Manager or the Director of Nursing who would then write the telephone order. Unit Manager#1 indicated she did not recall receiving any such recommendation from the RD.

Based on observations, record review and staff interviews, the facility failed to obtain a physician's order [REDACTED].#73) residents reviewed for catheters. Findings included: Resident #73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of an admission Minimum Data Set assessment dated [DATE] revealed Resident #73 had severely impaired cognition and had an indwelling catheter. A review of the physician's order [REDACTED]. A review of a physician ' s progress note dated 12/22/18 revealed a trial of catheter discontinuation would seem to be reasonable. A review of a physician ' s progress note dated 1/16/19 again revealed a trial of catheter discontinuation would seem to be reasonable. An observation on 1/22/19 at 4:55 PM revealed Resident #73 in wheelchair in hallway with catheter tubing and a drainage bag under his wheelchair. An interview on 1/24/18 at 3:30 PM with NA #2 revealed Resident #73 had an indwelling catheter. An interview on 1/25/19 at 11:16 AM with the physician revealed he meant to put Resident #73 on [MEDICATION NAME] for couple of days than attempt catheter removal but did not. He stated a trial of removal should be attempted. An interview on 1/25/19 at 4:30 PM with Unit Manager #1 revealed when a resident is admitted , the nursing staff makes sure there is a [DIAGNOSES REDACTED]. She stated if the physician to address the catheter removal, the nurse would be responsible for reminding him. An interview on 1/25/19 at 5:09 PM with the Director of Nursing revealed the physician progress notes [REDACTED]. She stated orders are either called in or written by the physician and there was not a process for reviewing the progress notes. She revealed she expected residents with indwelling catheters to have physician's order [REDACTED].

Based on staff interviews and medical record review, the facility failed to complete a Significant Change in Status Minimum Data Set (MDS) assessment for 3 of 17 residents (Residents #37, 49 and 68) reviewed for MDS assessments. Findings included: 1. Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment dated [DATE] revealed Resident #37 needed extensive assistance with eating and was totally dependent for toilet use. She was also coded as a 10% or more weight loss in a six month look back period. A review of the quarterly MDS assessment dated [DATE] revealed Resident #37 needed limited assistance with eating and required extensive assistance with toilet use. She was coded as neither having a weight loss of 5% or more in a one month look back period nor a 10% or more in a six month look back period. A review of Resident #37's MDS assessments revealed a Significant Change in Status Assessment was not completed after the significant weight loss and areas of activities of daily living (ADL) decline were identified. An interview was completed on 1/4/18 at 8:10 AM with Nurse Aide (NA) #1. She stated Resident #37 was totally dependent for toilet use and said the resident had been unable to stand up for about a month. She further stated Resident #37 needed to be assisted with her meals and that staff held her cup for her when she drank fluids. An interview was completed on 1/4/18 at 10:07 AM with MDS Nurse #1. She said she noticed Resident #37 declined in eating and toilet use and referred her for therapy to work with her. She reported the resident had been either limited assistance or extensive assistance for eating each quarter. She acknowledged the resident had declined in toilet use from extensive assistance to dependent. She reported Resident #37 had a gradual weight loss over six months and stated, We normally do a significant change with a significant weight loss. She stated the Registered Dietician (RD) completed the weight loss portion of the MDS assessment and notified the MDS nurse when a significant weight loss occurred. MDS Nurse #1 said she was not notified of Resident #37's significant weight loss and that a significant change assessment should have been completed when the weight loss was identified on the quarterly assessment. An interview was completed with the Registered Dietician (RD) on 1/4/18 at 10:21 AM. She stated she did not complete MDS assessments but that the Clinical Nutritionist completed the nutrition portion of the MDS assessment. An interview was completed with the Clinical Nutritionist on 1/4/18 at 11:20 AM. She stated she completed the nutrition portion of the MDS assessment along with a nutritional review note and gave her report to the RD and Assistant Director of Nursing. The report included residents with weight loss and the Clinical Nutritionist said the MDS Nurse obtained information on weight loss from those reports. A review of a nutritional review note dated 11/27/17 revealed Resident #37 had a gradual weight loss of 10.09% over six months. An interview was completed with MDS Nurse #2 on 1/5/18 at 10:32 AM. She stated a significant change assessment should have been completed due to the significant weight loss and two or more areas of ADL decline. She indicated the coding was correct on the quarterly MDS dated [DATE]. MDS Nurse #2 said MDS Nurse #1 was still in training and thought that the criteria for a significant change assessment was inadvertently missed. An interview was completed with the Administrator on 1/5/18 at 11:25 AM. She stated that when an MDS assessment was completed and there were areas of decline identified that met the criteria for a significant change, she expected a significant change assessment be completed for the resident. 2. Resident # 68 was readmitted to the facility on [DATE] following a hospitalization for a [MEDICAL CONDITION] sustained from a fall at the facility. [DIAGNOSES REDACTED]. On 1/2/18 at 12:45 PM, an observation was made of Resident #68 being wheeled to the dining room for lunch and being assisted with her meal by a nursing assistant. On 1/4/18 at 1:45 PM, an observation was made of the resident being transferred with 2 nursing assistants. On 1/4/18 at 2:46 PM, an observation of wound care to the sacral pressure ulcer. On 1/2/18 at 11:17 AM a review of the record revealed an admission nursing assessment dated [DATE] reflecting 2 Stage 2 pressure ulcers and a surgical wound to her left hip. On 1/2/18 at 11:25 AM a review of the medical record revealed a physicians' order to clean the sacral and left buttock wounds with normal saline, apply silver alginate and cover with a foam dressing every other day and as needed. On 1/2/18 at 11:25 AM a review of the medical record revealed a 14 day Minimum Data Set (MDS) assessment dated [DATE] reflecting the resident required 2 person extensive assistance with bed mobility and transfers and 1 person extensive assistance with eating and locomotion on unit. A review of the Quarterly MDS dated [DATE] revealed the resident required 1 person extensive assistance with bed mobility and transfers and supervision with assistance of one person for eating. On 1/4/18 at 11:09 AM, an interview was conducted with the MDS nurse about significant changes in assessment. The MDS nurse revealed she didn't complete a Significant Change in assessment for Resident #68 because even though the Resident did have a decline, she considered it her new normal. She further revealed she spoke to team members as well as her consultant and they have decided that when residents return from the hospital, they will complete an admission assessment. On 1/5/18 at 10:34 AM, an interview conducted with the previous and now as needed (prn) MDS nurse revealed that a significant change in assessment should have been completed. On 1/5/18 at 11:00 AM, an interview with the Administrator revealed that her expectation was that if a resident had a change in status, a significant change in assessment MDS should be completed. 3. Resident #49 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #49 revealed a weight on 11/2/17 of 202 pounds and a readmission weight on 11/25/17 of 190 pounds. This represented a significant weight loss of 5.9 percent in one month The quarterly Minimum Data Set MDS, dated [DATE] indicated Resident #49 had a stage 2 pressure ulcer that was not present on the previous MDS. This MDS did not include a significant weight. Interview with MDS Nurse #1 on 1/3/18 at 4:15 PM revealed she did not do a significant change MDS. Her explanation included, when the resident came back from the hospital, that was her new baseline. During the interview, she explained she would ask her corporate MDS consultant for clarification. Follow up interview on 1/4/18 at 1:50 PM with MDS Nurse #1 revealed an admission or a significant change MDS should have been completed for Resident #49. Interview with the Director of Nursing on 1/5/18 at 10:00 AM revealed she would defer to the former MDS nurse who was training MDS Nurse #1. Interview with MDS Nurse #2, who was training MDS Nurse #1 was conducted on 1/5/18 at 10:19 AM. MDS Nurse #2 explained a significant change MDS should have been completed when the quarterly MDS was done on 12/2/17.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment to reflect that the resident was receiving [MEDICAL TREATMENT] for 1 of 1 (Resident # 9) residents reviewed for [MEDICAL TREATMENT]. Findings included: Resident # 9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/3/18 at 4:00 PM, a record review revealed a care plan for [MEDICAL TREATMENT] and a physician's orders [REDACTED]. On 1/3/18 at 4:00 PM, a record review of the Quarterly MDS dated [DATE] revealed the facility had not coded that the resident was receiving [MEDICAL TREATMENT] in section O of the assessment. On 1/4/18 at 10:09 AM, an interview with Nurse # 1 revealed the resident received [MEDICAL TREATMENT] on Monday, Wednesday and Friday and had an arteriovenous fistula in her right upper arm. On 1/4/18 at 11:09 AM, an interview with the MDS nurse revealed the resident was receiving [MEDICAL TREATMENT] and she missed coding it accurately on the MDS. On 1/5/18 at 11:00 AM, an interview with the Administrator revealed her expectation was that MDS's are coded accurately.

Based on staff interviews and medical record review, the facility failed to provide a CMS- (Centers for Medicare and Medicaid Services) Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) prior to discharge from Medicare part A services to two of three residents (Residents #46 and 50) reviewed for SNF Beneficiary Protection Notification Review. Findings included: 1. Resident #46 was admitted to the facility under part A Medicare services on 9/12/17. A review of the medical record revealed a CMS- Notice of Medicare Non-Coverage letter (NOMNC) was signed by Resident #46's responsible party on 12/4/17. The notice indicated that Medicare coverage for skilled services were to end 12/7/17 and the resident would transition to long term care placement. A review of the medical record revealed a CMS- SNF ABN was not provided to the resident or responsible party. An interview was completed with the Administrator on 1/5/18 at 8:53 AM. She stated since Resident #46 remained in the facility she thought the SNF ABN was not required and the facility only issued the NOMNC. An interview was completed with the Director of Social Services (DSS) and the Business Office Manager (BOM) on 1/5/18 at 9:26 AM. The DSS stated she issued the non-coverage notices after the therapy department notified her when a resident was discharged from Medicare part A services. The DSS said she gave at least a 48 hour notice to residents and families when part A Medicare services ended. The BOM added that the facility had never used the ABN form when residents' Medicare part A services ended and remained in the facility. 2. Resident #50 was admitted to the facility under part A Medicare services on 9/14/17. A review of the medical record revealed a CMS- Notice of Medicare Non-Coverage letter (NOMNC) was signed by Resident #50's responsible party on 12/5/17. The notice indicated that Medicare coverage for skilled services were to end 12/9/17 and the resident would transition to long term care placement. A review of the medical record revealed a CMS- SNF ABN was not provided to the resident or responsible party. An interview was completed with the Administrator on 1/5/18 at 8:53 AM. She stated since Resident #50 remained in the facility she thought the SNF ABN was not required and the facility only issued the NOMNC. An interview was completed with the Director of Social Services (DSS) and the Business Office Manager (BOM) on 1/5/18 at 9:26 AM. The DSS stated she issued the non-coverage notices after the therapy department notified her when a resident was discharged from Medicare part A services. The DSS said she gave at least a 48 hour notice to residents and families when part A Medicare services ended. The BOM added that the facility had never used the ABN form when residents' Medicare part A services ended and remained in the facility.

Based on observations and staff interviews, the facility failed to secure 1 of 3 medication carts (200 Hall) for two observations and failed to store medications safely on 2 of 2 residents (Resident #4 and Resident #75.) Findings included: 1) An observation on 11/16/16 at 1:00 pm revealed Nurse #1 was assisting a resident with feeding in the dining area of the 200 Hall which is a secured unit. The medication cart was located behind the nurse ' s station. The county ' s Environmental Specialist, who was in the facility conducting the annual inspection asked the facility ' s Maintenance Director who had the key to the medication storage rooms so he could inspect the medication storage areas. As Nurse #1 approached the nurse ' s station with the keys, the Environmental Specialist opened the drawers without the use of keys. Nurse #1 stated she did not understand how the cart could be unlocked because she locked it earlier. An interview with Nurse #1 on 11/16/16 at 2:21 pm revealed the nurse thought she had locked the medication cart after she finished passing her medications. Nurse #1 stated the time from when she completed passing the medications to the time it was noted that the medication cart was unlocked was 20 minutes. Nurse #1 also reported it was the facility ' s policy to lock the medication cart whenever a nurse walked away from the cart. 2) An observation on 11/16/16 at 4:20 pm revealed the medication cart on the 200 hall was unlocked and unsupervised. The medication cart was located behind the nurse ' s station. There was no staff members behind the nurse ' s station. There were noted to be bilateral swinging half doors that were locked with a slide lock on each side of the nurse ' s station. An observation of Nurse #4 revealed she reached over the door and unlocked it and entered the nurse ' s station. An interview with Nurse #4 on 11/16/16 at 4:22 pm revealed that the medication cart was unlocked and it should be locked at all times. Nurse #4 reported she forgot to lock it and even though it was behind the nurse ' s station it should be locked at all times when it was not in use or unattended. Nurse #4 reported that the swinging half doors were always locked, but the residents could reach over them. Nurse #4 stated the residents have come up to the door and put their hands on the door and would reach over the door. Nurse #4 stated that when the medication cart was out in the hall, the residents were all up in it! The nurse reported we have to stay with the medication cart at all times when we are out in the hall. An interview with the Director of Nursing (DON) on 11/17/16 at 3:37 pm revealed her expectations were that the nurses ensured the medication carts were locked at all times when they were unattended. 3) During a medication pass on 11/16/16 at 8:40 am with Nurse #2 on the 100 hall, the nurse noticed that a medication called Omeprazole (a medication to help with gastro reflux disease) was due at 7:30 am. She took the medication out of the medication card and put it into a medication cup and reported she would need to call the doctor to see if the medication could be administered late. The nurse proceeded to draw up the remaining medications for Resident #75 and put them in a medication cup. She brought the medications into the resident, but left the Omeprazole in the medication cup unattended on the medication cart. The medication cart was facing the hallway and parked next to Resident #75 ' s room. An observation on 11/16/16 at 8:48 am revealed there were no residents in the hallway as the nurse entered the resident ' s room. An observation on 11/16/16 at 8:50 am revealed there were no residents in the hallway as the nurse exited the resident ' s room. An interview with Nurse #5 on 11/16/16 at 10:30 am revealed she realized she left the medication on the medication cart and stated she should have thrown it out because she knew she was going to obtain a new order. Nurse #5 reported she should have disposed of it in the needle box. Nurse #5 reported that anytime she had to dispose of a medication, she would always put it in the needle box because the residents would come up to the medication cart and go through the trash bin which was attached to the medication cart. An interview with the Director of Nursing (DON) on 11/17/16 at 3:37 pm revealed her expectations were that the nurses secured medications appropriately. 4) An observation on 11/16/16 at 2:45 pm revealed Nurse #5 was at the medication cart on the 100 hall. She was shaking a vial with a medication in it. There was noted to be a syringe out of the package with the cap on it, placed on the medication cart. A visitor called out we need a nurse! The nurse placed the vial on the medication cart near the syringe and told the surveyor to watch that! She left immediately to enter a resident ' s room on the 100 hall. There were no residents in the hall at this time. An interview with Nurse #5 on 11/16/16 at 2:49 pm when she returned to the medication cart revealed that she should not have left the medication or the syringe on the medication cart and should have stored it properly and safely when she was called away. She reported she realized it was unsafe to leave the medication and syringe exposed while the cart was unattended. An interview with the Director of Nursing (DON) on 11/17/16 at 3:37 pm revealed her expectations were that the nurses secured medications appropriately.

Based on resident and staff interviews and record review the facility failed to secure a lift pad to the total lift during a transfer, resulting in injury for one of three sampled residents. Resident #1 The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A readmission on 8/27/13 revealed a [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 required extensive assistance of two staff with transfers, extensive assistance with bed mobility and was non ambulatory. Resident #1 was alert and oriented with no impairment in short or long term memory. The care plan dated 7/12/13 addressed a problem of potential falls. Approaches for staff to use for fall prevention included provide therapy as ordered, encourage resident to call for assistance as needed, assist resident with turning and reposition, assist resident with transfers and Hoyer lift for transfers. Review of the care information in the care plan note book for direct care staff " Kardex " (with no date) revealed instructions to transfers Resident #1 " with assist of 2, full body lift. " An assessment " Transfer Quarterly Summary ... " dated 8/22/13 indicated Resident #1 required a two person assist for transfers and use of a total lift. Review of the nurses ' notes dated 8/28/13 at 4:30 AM revealed an aide went into the resident ' s room to get her up. In the process of transferring Resident #1 with the lift, the sling slipped off the hook of the lift. The aide and a family member were able to grab Resident #1 and lower her to the floor. Resident #1 sustained a skin tear to the right arm, and a skin tear to the lower left leg. The lower leg skin tear was approximately 6 to 8 inches. Resident #1 was alert and oriented to person, place and time. Per family request, Resident #1 was sent to the emergency room for evaluation and treatment. Review of the emergency room physician ' s report dated 8/28/13 revealed the left lower leg laceration was treated with 11 stitches and measured 8 centimeters. The fall investigation dated 8/29/13 revealed two to three staff members did not assist in the transfer. The fall committee review and recommendations included educating staff on the use of the total lift, all lifts were checked and the aide was removed from duty during the investigation. Interview with Resident #1 on 9/12/13 at 8:15 AM revealed she had a fall from the total lift and cut her left leg. The aide was using the lift, and the pad came loose when she was raised up in the lift. Interview on 9/12/13 at 9:42 AM with aide #2 revealed care information about Resident #1 was provided in a care plan note book kept at the nurse ' s desk. Aide #2 reported Resident #1 required assistance by two staff for all of her activities of daily living except eating. A total lift and two staff were required for transfers for Resident #1. Interview with the therapy manager on 9/12/13 at 10:12 AM revealed Resident #1 had several admissions to the hospital with readmissions to the facility. On the first admission, training was done with nursing staff on how to transfer Resident #1 and protect the right leg amputation. The resident was to be transferred using a total lift with two staff members. Interview with the Administrator on 9/12/13 at 12:50 PM revealed an investigation was conducted with the aide involved in the lift incident. A statement was provided by the aide describing the incident. The aide was aware she was to have 2 staff for use of lift. She did not explain why she did not find another staff member for assistance. During the application of the lift pad, the aide was in a hurry to apply the pad. She acknowledged she had training during orientation on the use of the lift. The aide also documented she was aware another staff member was to be present when a total lift was used for transfer. Interview with the Director of Nursing (DON) on 9/12/13 at 2:52 PM revealed aides were aware of the facility requirement for total lifts to have two staff members. A return demonstration had been done on orientation with use of the lift. During the investigation of the lift incident with Resident #1, the aide demonstrated how the lift pad/sling was applied to the lift. The DON revealed one loop on the corner of the pad/sling was not secured in the lift hook. The corner at the shoulder of Resident #1 was not secured which caused the resident to slide out of the pad/sling. The aide said Resident #1 slid head first not leg first and was caught before hitting the floor by the aide and a family member. Further interview revealed it was her expectation nursing staff was to have 2 staff present during the use of the total lift. If there was not another aide available, the aide was to obtain help from their nurse.

Based on observations, record review and staff interviews, the facility failed to disinfect glucometers (a device to obtain blood sugar level) between resident uses in accordance with the manufacturer's recommendations to for 4 of 16 residents (# ' s 24, 13, 104 & 118) who required blood glucose finger sticks. The facility further failed to follow policy and procedure of standard precautions and CDC (Center for Disease Control) guidelines for use of glucometers to reduce the risk of transmission of blood borne pathogens for 16 of 16 residents (#s 9, 13, 24, 26, 40, 54, 58, 60, 64, 77, 104, 108, 109, 116, 117 & 118) receiving blood glucose fingersticks. Immediate jeopardy began on 8/29/12 and was removed on 8/31/12. The facility Administrator, Director of Nursing and Corporate Consultant were informed of the immediate jeopardy on 8/29/12 at 12:30 PM. The facility provided a credible allegation of compliance on 8/31/12 at 2:11 PM. Immediate Jeopardy was abated on 8/31/2012 at 5:48 PM. The facility will remain out of compliance at a scope and severity level E (a pattern of no actual harm with the potential for more than minimal harm that is not immediate jeopardy) for the facility to complete employees training and to monitor its corrective action. The findings included: Review of a facility policy dated 8/04 revised 12/09 revealed instructions to " Disinfect the blood glucose monitor after each use with 1:10 dilution of sodium hypochlorite (bleach) unless the recommendations say otherwise. Note: Do not use alcohol to disinfect the monitor. " A policy dated 3/12 and entitled " Blood Glucose Monitoring " directed staff to: " Cleanse glucometer after each resident use with a dilute bleach solution of 1:10 (one part bleach to 9 parts water) or utilize approved disinfectant wipes per manufacturer ' s instructions. " The Standard Precautions policy dated 3/12 noted, under Resident Care Equipment, " Reusable equipment is not to be used for the care of another resident until it has been cleaned and reprocessed appropriately " and that resident care equipment that is soiled with blood will be handled in a manner that prevents transfer of microorganisms to other residents and environments. The manufacturer ' s recommendations were reviewed. Cleaning and Disinfecting Guidelines on page 47 included cleaning and disinfecting can be completed by using a commercially available EPA (Environmental Protection Agency) registered disinfectant detergent or germicide wipe. Observations of four nurses performing blood glucose monitoring on 8/29/12 revealed the multi use glucometers were not disinfected in accordance with manufacturer's recommendations before and after use. 1. On 08/29/12 at 11:40 AM nurse #1 was observed performing a finger stick on resident # 13 to obtain blood for glucose testing (FSBS). The nurse was not observed to disinfect the glucometer prior to performing the finger stick. She placed the blood on a test strip and inserted the strip into a glucometer. Following completion of the procedure, nurse #1 cleaned the glucometer with an alcohol swab. Nurse #1 was questioned as to what the cleaning solution was on the swab and the nurse responded "alcohol" and held up the empty package. After further questioning, the nurse explained that she cleaned the glucometer with alcohol before and after performing a FSBS. She also stated that there was one glucometer that was used for all the residents on the unit who required finger sticks for blood glucose testing. There were no disinfectant wipes observed in the medication cart. When asked if she had ever been trained on cleaning of glucometers she stated she did not remember what cleaning product to use. 2. At 4:42 PM on 8/29/12 nurse #2 demonstrated the procedure for performing a FSBS. He demonstrated how he inserted a test strip into the glucometer and used a one time use lancet to stick the resident ' s finger, stating he had just completed a FSBS. Nurse #2 was then observed to place the glucometer in the top drawer of the medication cart. He did not demonstrate or explain that he cleaned and disinfected the glucometer before or after use. An interview with nurse #2 at that time revealed he did not disinfect the glucometer because it was disinfected on the night shift. He continued that he did not know what the manufacturer's recommendations were for cleaning and disinfecting the glucometer or where he could find those recommendations. He also did not know what the night shift used to clean the glucometer. Further questioning revealed the nurse was not aware whether the glucometer was cleaned and disinfected prior to use to test the resident ' s FSBS. No disinfectant wipes were observed in the medication cart. The nurse did not know where the information came from regarding night shift cleaning. After leaving the room, the nurse placed the glucometer on the medication cart on top of the basket of the single use lancets. The nurse did not clean or disinfect the glucometer after the FSBS and before returning it to the medication cart. The glucometer screen was visibly soiled with dark colored residue. 3. On 8/29/12 at 4:50PM Nurse #3 was doing a FSBS on resident #24. After leaving the room the nurse placed the glucometer on the medication cart and then on the basket of unused lancets. The nurse did not clean the glucometer after returning it to the medication cart. Then at 5:00 PM nurse # 3 stated that she was preparing to do another FSBS. The nurse did not clean or disinfect the glucometer and was stopped from performing the FSBS before entering the resident ' s room. Interview with the nurse revealed she usually cleaned the glucometer at the beginning of the shift and she had not cleaned and disinfected it before using it on residents. Nurse # 3 further stated that it was not cleaned or disinfected between residents as the 11-7 shift cleaned the glucometers with a bleach wipe each night. The nurse did not know where this information came from. The nurse confirmed the glucometer needed to be cleaned containing 1:10 bleach solution. The nurse stated she could not remember if she had any in-service training for cleaning and disinfecting glucometers 4. On 8/29/12 at 4:50 PM an interview with nurse #4 revealed she had just completed a finger stick (did not identify the resident), and had already cleaned the glucometer with alcohol. She further stated that the glucometers were cleaned on the 3rd shift and did not know with what they were cleaned. She gathered the one time use lancet, gloves, alcohol pad, and test strips and entered resident #104 ' s room. She completed the finger stick and went back to the cart to clean the glucometers with alcohol and gather supplies for the next finger stick. Nurse #4 entered resident #118 ' s room and completed the finger stick using the same glucometer that she used for Resident # 104. She stated she had always used alcohol to clean the glucometers. On 8/30/12 at 10:50 AM an interview was conducted with the Administrator, Director of Nursing (DON) and the Regional Director of Clinical Services (DCS). The DON was also the Infection Control Nurse. The Administrator stated she had been in the facility for four days and was not aware of this practice. On 8/30/2012 at 12:05 PM the administrator provided a list of sixteen residents in the facility that received blood glucose monitoring with the glucometers. The DCS stated that an inservice was done in February, 2011 by Nurse #5, who was no longer employed at the facility. She continued the in-service included directives for glucometers to be cleaned between every resident. She added that the staff were in-serviced according to the March, 2012 " Standard Precautions Policy " . She further stated that the night shift was never assigned to clean the glucometers. The DCS stated that they did have one box of 1:10 bleach solution wipes (number of wipes not indicated), EPA approved in the storage room. She further stated the wipes had not been distributed to the nursing units. She did know why they were not distributed. The facility Administrator, Director of Nursing and Corporate Consultant were informed of the immediate jeopardy on 8/29/12 at 12:30 PM. The facility provided a credible allegation of compliance on 8:31/12 at 2:11 PM. Willowbrook Credible Allegation of Compliance glucometer cleaning to provide proper infection control during blood glucose testing. 1. On August 29, 2012 at 4:45pm the Administrator and the Director of Nursing were notified by the Surveyor that the cleaning and disinfecting of the glucometers was not being performed according to CDC guidelines, the Administrator and the Director of Nursing identified a source for obtaining appropriate cleaning and disinfecting wipes. The Medical Records coordinator went to the local hospital to obtain a supply. She returned at 5:45pm with CaviWipes. The label for the CaviWipes states that they are EPA registered # -8 to be effective against: Hepatitis B, Hepatitis C, and Human Immunodeficiency Virus, BCG, Staph aureaus, pseudomonas aeruginosa, salmonella [MEDICATION NAME] mentagrophytes, MRSA, VRE, Staph aureaus with reduced susceptibility to [MEDICATION NAME], herpes Simplex Virus types 1 and 2, influenza A2 Virus. At 5:45 pm, she took those to each nurses ' stations and all glucometers were cleaned and disinfected by the staff nurses who were working at that time. Re-education per facility policy, manufacturer ' s recommendations which state " To use a wipe, remove from container and follow product label instructions to disinfect the meter. Take extreme care not to get liquid in the test strip and key code ports of the meter. Many wipes act as both a cleaner and disinfectant, though if blood is visibly present on the meter, two wipes must be used: use one wipe to clean and a second wipe to disinfect " , and the CDC guidelines. The CaviWipes were placed on the carts at 6:00pm after re-education for use during future blood glucose monitoring. 2. Sixteen residents that received blood glucose monitoring were at risk with this deficient practice. The two RN ' s and one LPN who were working on second shift (3p - 11p) on August 29, 2012 as well the MDS nurse were re-educated about cleaning and disinfecting the glucose monitors prior to and following use at 5:45pm by the Director of Nursing. The two staff RNs who were working second shift on 8/29/2012 re-educated the two staff LPNs who came in to work third shift (11p-7a) at 11 pm. The Director of Nursing verified the understanding of the two third shift LPNs 6:30am on 8/30/12 by having them state the procedure for cleaning and disinfecting the glucometers prior to and following use. At 6:30am 8/30/2012 the Director of Nursing re-educated the 2 RNs and 1 LPN who had arrived to work first shift (7am-3pm) as to the policy of cleaning and disinfecting the glucose monitors prior to and following use. At 2:15pm one staff LPN and then 2:40pm another staff LPN was re-educated. They were observed performing this task at the next scheduled blood glucose testing on their assignments at 4:00pm for the first LPN and 4:15pm for the second LPN by the Director of Nursing. This was all the licensed staff that had worked up to that point. All licensed nursing employees will be re-educated as they arrive for their shifts or in a mandatory staff meeting that is scheduled for Friday, August 31, 2012 at 3:30pm, which ever opportunity presents itself first. 3. The Director of Nursing or staff RN will monitor as to the policy of cleaning and disinfecting the glucose monitors prior to and following use daily for 7 days, choosing a different licensed nurse to observe in that 7 day period. Any new hired licensed nursing staff will be educated as to the cleaning and disinfecting procedure for blood glucose monitoring with a retune demonstration prior to performing this procedure. The Director of Nursing or staff RN will monitor staff nurses performing blood glucose monitoring three times weekly for four weeks, one time weekly for four weeks, and monthly thereafter for ten months. If any of the Licensed Nurses demonstrate a deficiency in the practice they will be taken off that assignment and re-educated with a successful return demonstration before they can continue on their assignment. The PI (Process Improvement) committee has met to approve this plan on 8/30/2012 at 5:45pm. The results of the monitoring will be reported to the future PI committee meetings that occur monthly on the third Thursday of each month for review and assessment of effectiveness of the intervention in preventing the deficient practice from reoccurrence. The facility alleges compliance on 8/30/2012 at 6pm. On 8/31/12 at 1:10 PM an observation of Nurse # 5 utilizing proper technique of cleaning the glucometer was completed. There were no problems or concerns with the cleaning. During the observation nurse #3 came to nurse #5 and asked to borrow the wipes from the cart. She stated she did not have wipes on her cart. At 1:10 PM an observation of nurse # 6 demonstrated the proper technique for disinfecting the glucometers. The nurse stated he disinfects the glucometers before and after each resident ' s finger stick. At 1:15 PM an observation of nurse #7 demonstrated the proper technique for cleaning the glucometers. The nurse left the cart to obtain a container of wipes from another nurse, as she did not have wipes on her cart. The nurse explained the steps per the manufacturer ' s recommendations. On 8/31/12 at 2:11 PM observations of the medication carts were done and containers of wipes were on every cart. The facility ' s credible allegation was accepted and the immediate jeopardy was abated on 8/31/2012 at 5:48 PM after validation was completed.