Every finding on record at Willowbrooke Court at Cokesbury Village

Based on interview, the facility failed to designate an onsite Infection Control Preventionist at the facility from 6/3/25 to 7/13/25. Findings include:7/28/25 1:30 pm - During an interview, E2 (DON) stated [E7] is working from home. I started on 7/14/25. I have a certification for Infection Prevention training.7/28/25 1:50 pm - During an interview, E7 (ADON, Infection Preventionist) stated, I have been working from home since 6/3/25. I will be back on 7/30/25.7/29/25 11:35 am - During an interview, E2 stated, I don't know that anyone was here between 6/3/25 and 7/13/25 that has an Infection Preventionist certification.7/29/25 2:00 pm - Findings were reviewed during the Exit Conference with E1 (NHA), E2 (DON), E3 (Regional Clinical Director) and E4 (Executive Director) during the Exit Conference.

Based on record review and interview, it was determined that for two (E5 and E6) out of ten employees reviewed for training, the facility failed to have records of abuse, neglect and exploitation training for the contracted employees. Findings include: 7/28/25 11:30 AM- During the review of the staff training worksheet, E1 (NHA) stated that she did not have any documentation of E5 (NP) and E6 (MD)'s abuse, neglect and exploitation training. E1 stated that the facility did not keep a file on the consultant employees and relied on their companies to supply that information. She stated that she had reached out to each consultant's [medical practice] and requested that they send over the documentation of his abuse/neglect/exploitation training. 7/29/25 10:45 AM - During an interview, E1 stated that she had not received any documentation regarding E5 or E6's training for abuse, neglect and exploitation.7/29/25 2:00PM - Findings were reviewed during the Exit Conference with E1 (NHA), E2 (DON), E3 (Regional Clinical Director) and E4 (Executive Director) during the Exit Conference.

Based on record review and interview, one (R5) out of five residents reviewed for infection control, the facility failed to offer and document COVID-19 immunization. Findings include: The facility policy dated 2023 and titled, COVID-19, Influenza, and Pneumococcal Education and Consent for Residents included, . Upon admission, the licensed nurse will obtain consent from the resident, or legal responsible party, using the COVID-19, Influenza, or Pneumococcal Vaccine Consent Form. This form will then be stored in the residents' primary care electronic health record. An immunization history is documented and maintained for each resident in the electronic health record in the immunization section.7/8/25 - R5 was admitted to the facility with diagnoses including traumatic subarachnoid hemorrhage and anemia.7/21/25 - A comprehensive MDS assessment documented R5 had a BIMS score of 14, indicating intact cognition.7/29/25 11:40 am - During an interview, E2 (DON) stated We don't have any vaccine documentation for [R5].7/29/25 2:00 pm - Findings were reviewed during the Exit Conference with E1 (NHA), E2 (DON), E3 (Regional Clinical Director) and E4 (Executive Director) during the Exit Conference.

Based on record review and interview, it was determined that for one (R5) out of five residents reviewed for infection control, the facility failed to offer and document pneumococcal immunization. Findings include: The facility policy dated 2023 and titled, COVID-19, Influenza, and Pneumococcal Education and Consent for Residents included, . Upon admission the licensed nurse will obtain consent from the resident or legal responsible party using the COVID-19, Influenza, or Pneumococcal Vaccine Consent Form. This form will then be stored in the residents' primary care electronic health record. An immunization history is documented and maintained for each resident in the electronic health record in the immunization section.7/8/25 - R5 was admitted to the facility with diagnoses including traumatic subarachnoid hemorrhage and anemia. 7/21/25 - A comprehensive MDS assessment documented R5 had a BIMS score of 14, indicating intact cognition.7/29/25 11:40 am - During an interview, E2 (DON) stated We don't have any vaccine documentation for [R5].7/29/25 2:00 pm - Findings were reviewed during the Exit Conference with E1 (NHA), E2 (DON), E3 (Regional Clinical Director) and E4 (Executive Director) during the Exit Conference.

Based on observation, interview, and review of other facility documentation it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Findings include: 8/28/24 9:30 AM thru 9:45 AM - An initial observation of the facility kitchen revealed the following: -Dry food storage area: uncovered graham cracker crumbs. -Walk in refrigerator: unlabeled pies, a large unlabeled casserole, uncovered potatoes and carrots. -Walk in freezer: an unidentified frozen portion of meat was stored in the freezer. Additionally, the gasket to the freezer was not completely sealed, which allowed outside air to flow into the freezer and caused ice to buildup on the floor and shelving at the entrance to the freezer. -Environment: the paint was peeling from the wall in the chemical storage area. 8/28/24 12:30 PM - A cooling fan in use in the dish washing area was noted to have dust and debris. The wall positioned to the right side of the fan also contained dust and debris. 9/3/24 2:00 PM - Findings were reviewed with E1 (ED), E2 (NHA), E3 (DON) and E4 (ADON) at the exit conference.

Based on record review and interview, it was determined that for two (R1and R109) out of three residents reviewed for infection control, the facility failed to establish and maintain an infection control program using enhanced barrier precautions. For R1, the presence of an indwelling feeding tube was criteria for Enhanced Barrier Precautions (EBP). R109 was admitted with PICC (percutaneously inserted central catheter) line and was diagnosed as colonized with enterococcus faecium VRE; both of which are criteria for EBP. Also the facility line listing did not specify the name of the pathogen. Findings include: As per CDC (Centers for Disease Control and Prevention) definition (6/28/24), Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). 1. Review of R1's clinical record revealed: 8/16/24 - R1 was admitted to the facility after being hospitalized for a stroke, which included the insertion of a gastrostomy tube. 8/28/24 12:15 PM and 8/29/24 12:20 PM - During observations, E6 (RN) administered medications to R1 by way of her gastrostomy tube, and E6 did not wear a gown to adhere to Enhanced Barrier Precautions. 8/29/24 12:30 PM - During an interview E6 confirmed that she did not wear a gown for Enhanced Barrier Precautions while administering medications to R1 by way of her gastrostomy tube. 2. Review of R109's clinical record revealed: 5/23/24 - E12 (MD) completed R109's admission history and physical (H&P). 6/5/24 - R109's urine culture was reported to the facility as colonized (75,000 organism count) with enterococcus faecium VRE (vancomycin resistant enterococcus), which was a CDC-targeted MDRO. 6/5/24 - E13 (NP) ordered in R109's EMR, .Enhanced Barrier precautions (EBP) every shift for prevention of transmission of MDRO infections. Use for when infected or colonized with an MDRO or for wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with MDRO . 6/6/24 - E5 (NP) documented her initials on the lab report to acknowledge her awareness of the lab results. 6/20/24 - R109's Enhanced Barrier Precautions were discontinued. 6/27/24 - R109 was readmitted to the facility from the hospital. 6/27/24 - E5 (NP) ordered in R109's EMR, .PICC dressing change weekly .every Tuesday . 6/27/24 - E5 (NP) ordered in R109's EMR, .Enhanced Barrier Precautions every shift for prevention of transmission of MDRO infections. Use for when infected or colonized with an MDRO or for wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with MDRO . 7/1/24 - R109's Enhanced Barrier Precautions were discontinued. Enhanced Barrier Precautions were still necessary for R109 due to his known history of urine colonization with enterococcus faecium VRE, a CDC-targeted MDRO. 7/3/24 - E5 (NP) ordered in R109's EMR, . Foley catheter .Reason/DX (diagnosis): neurogenic bladder. Placement of a indwelling foley catheter was a second indication that R109 required enhanced barrier precautions. 8/9/24 - R109 was transferred to the hospital. At the time of R109's transfer back to the hospital, R109 spent 39 days (from 7/2/24 to 8/9/24) in the facility without the required Enhanced Barrier Precautions. 8/28/24 - A review of the facility Infection Surveillance Monthly report revealed that the facility failed to provide the name of the specific pathogen that the resident was infected or colonized with. 9/3/24 2:00 PM - The findings were reviewed with E1 (ED), E2 (NHA), E3 (DON) and E4 (ADON) at the exit conference.

Based on record review and interview, it was determined that for one (R1) out of two residents reviewed for medications, the facility failed to ensure that the admission pharmacy review of medications identified the correct route of medication administration. Findings include: Review of R1's clinical record revealed: A review of a facility policy titled Resident Health Services Manual, Policies and Procedures, Subject: Drug Regimen Review, revised 2/19 revealed: Policy: . Drug Regimen Review Includes: .A review of the drug regimen to identify, and if possible, to prevent potentially clinically significant medication adverse consequences. Clinically significant medication issues may include, but are not limited to: . Medication dose, frequency, route, or duration not consistent with resident's condition . 8/16/24 - R1 was admitted to the facility directly from a hospitalization after an acute stroke. R1's hospital discharge records revealed that R1 now had swallowing difficulties resulting from the stroke and that R1 was not to have anything by mouth because R1 could not swallow safely. R1 had a gastrostomy tube (tube for liquid nutrition, fluids and medications) inserted into her stomach during her hospitalization and the tube was in place at R1's facility admission. R1's facility admission diet was ordered as nothing by mouth diet and with an Enteral (stomach) Feed Order for nutrition. R1's admission medications were ordered to be administered via her feeding tube. The following medication was ordered on 8/16/24: Aspirin Tablet Chewable 81 mg, Give 1 tablet by mouth once a day for CVA. 8/19/24 - A pharmacy medication review was completed by P1 (Consulting Pharmacist). The report revealed Based upon the information .the resident's medication regimen contained no new irregularities . 8/29/24 3:15 PM - During an interview, E6 (RN) confirmed the aspirin 81mg was ordered to be given to R1 by mouth. 9/3/24 12:15 PM - During an interview, P2 (Consulting Pharmacy Clinical Manager) confirmed that the route of medication administration is a component of a pharmacy medication regimen review and that R1's 8/19/24 review of medications did not identify the incorrect oral route for the aspirin order. The pharmacy review did not identify the incorrect medication route of admistration for the aspirin. 9/3/24 2:00 PM - Findings were reviewed with E1 (ED), E2 (NHA), E3 (DON) and E4 (ADON) at the exit conference.

Based on observation and interview, it was determined that the facility failed to ensure that food was stored and prepared in a sanitary manner. Findings include: The initial kitchen tour on 9/28/23 from 9:00 AM - 9:45 AM revealed that two moldy boxes of strawberries were found in the walk-in refrigerator. 10/3/23 2:44 PM - Findings were reviewed during the Exit Conference with E1 (NHA), E2 (DON), E3 (ADON), E4 (ED) and E5 (DAL).

Based on record review and interview, it was determined that for one (R307) out of three (3) residents sampled for the use of Unnecessary Medications, the facility failed to ensure that R307 received adequate monitoring for the use of a psychoactive medication. Findings include: 9/23/23 - R307 was admitted to the facility with diagnoses including but not limited to atrial fibrillation (irregular heart rhythm that increases risk for blood clots), vascular dementia without behavioral, psychotic or mood disturbance, and walking difficulty. 9/24/23 - E7 (NP) ordered Trazadone 150 mg (antidepressant) and melatonin 3 mg (sleep aid) daily at bedtime for the diagnosis of insomnia. 9/24/23 - R307's care plan documented, I use the psychotropic medication Trazadone (antidepressant) related to my insomnia. The goals included but not limited to, .remain free of psychotropic drug related complications, including movement disorder, discomfort, low blood pressure . The interventions included administer the psychotropic medications as ordered and monitor for side effects and effectiveness every shift. Review of the record lacked evidence of monitoring sleep for insomnia that required the use of medication. Additionally the facility failed to have evidence that the potential side effects of the Trazadone were being monitored. 10/3/23 2:44 PM - Findings were reviewed during the Exit Conference with E1 (NHA), E2 (DON), E3 (ADON), E4 (ED) and E5 (DAL).

Based on record review, observation, and interviews, it was determined that for one (R4) out of one resident reviewed for dialysis, the facility failed to ensure that R4's admission physician's orders dated 8/8/23 included hemodialysis treatments for Tuesday, Thursday and Saturday. Findings include: 8/8/23 - R4 was admitted to the facility with diagnoses including but limited to: atrial fibrillation (irregular heart rhythm that increases risk for blood clots) and chronic kidney disease (stage 5) with R4 being dependent on renal dialysis. 8/9/23 - R4 was care planned for hemodialysis with interventions including; encourage me to go to my scheduled dialysis appointments and monitor for dressing site on my right chest wall. Dressing is changed at dialysis. 9/28/23 11:15 AM - This surveyor observed R4's bed was empty and was unable to find R4. During an interview, E6 (LPN) stated that R4 was at his hemodialysis appointment and usually arrives back at the facility around 4:30 PM. 9/29/23 9:14 AM - During an interview, R4 confirmed that he leaves the facility to go to an off-site hemodialysis unit every Tuesday, Thursday and Saturday. R4 stated that his wife drives him to the dialysis center and that his chair time is 11 AM. 10/2/23 1:25 PM - During an interview, E2 (DON) confirmed that there was not an order for hemodialysis treatments on Tuesday, Thursday and Saturday on R4's EMR. 10/3/23 2:44 PM - Findings were reviewed during the Exit conference with E1 (NHA), E2, E3 (ADON), E4 (ED) and E5 (DAL).

Based on record review and interview, it was determined that for one (R4) out of three residents reviewed for Unnecessary Medications, the facility failed to ensure that R4's medical record met with accepted professional standards and practices with regards to the anticoagulation order. Findings include: 8/8/23 - R4 was admitted to the facility with diagnoses including but limited to: atrial fibrillation (irregular heart rhythm that increases the risk for blood clots) and chronic kidney disease (stage 5) with R4 being dependent on renal dialysis. 8/8/23 - R4's electronic medical record (EMR) documented a verbal order from E7 (Nurse Practitioner) for Eliquis oral tablet 5 mg (milligrams) (Apixiban)- give one tablet by mouth two times a day for anticoagulation (the process of preventing the clotting of blood). Anticoagulation is not a medical diagnosis; it is a physiologic state. The medical diagnosis, which required that R4 be in a state of anticoagulation, was R4's diagnosis of atrial fibrillation. Therefore, atrial fibrillation should have been the medical diagnosis for the use of the drug, Eliquis. 10/2/23 1:25 PM - During an interview, E2 (DON) confirmed that the documented medical reason for the Eliquis order stated anticoagulation. E2 also confirmed that anticoagulation was not a medical diagnosis. 10/3/23 2:44 PM - Findings were reviewed during the Exit conference with E1 (NHA), E2, E3 (ADON), E4 (ED) and E5 (DAL).

Based on observations, interviews, and review of facility documentation, the facility failed to establish a grievance policy that included components of the Federal requirement under §483.10(j)(4). Findings include: During a resident meeting with surveyors on 5/28/19 at approximately 11:00 AM, only one (1) out of seven (7) residents, who wished to remain anonymous, was aware of how to file a grievance. The copy of the facility's grievance policy and procedure was requested. The undated document provided was titled, Grievance Report. It stated, A grievance is any issue that is not resolved by an individual or department to the satisfaction of the resident or family/legal representative. According to the Centers of Medicare and Medicaid Services such grievances may include those with respect for care and treatment and the behavior of staff and other residents. The facility's admission Information Book, page 21 stated, Grievance Policy/Complaint Resolution .Residents, family members and visitors may voice grievances/concerns and suggestions with respect to treatment, care and/or services. These grievances/suggestions may be made without any fear of recrimination or reprisal. The administrator or designee will make prompt efforts to resolve the grievances and evaluate the suggestions .Grievance forms are available at the nurses' station for the individual to document her/his grievance/suggestion. (If so instructed by the individual, a staff member may complete the form.) We request all grievances be brought to either the licensed nurse, director of nursing, social worker or administrator .An investigation and follow-up is completed on each grievance and is reviewed with the individual who filed the grievance . The facility failed to establish a grievance policy and procedure that included Federal requirements under §483.10(j)(4) as follows: .Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include: (i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance . (ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations; An observation of the first floor Healthcare Center on 5/28/19 at approximately 2:08 PM, lacked evidence of any postings in prominent locations throughout the facility containing information regarding the facility's grievance process, identifying who the Grievance Officer was, how to contact them, and how to file grievances anonymously. Findings were reviewed with E2 (DON) during an interview on 6/3/19 at approximately 9:50 AM. Findings were reviewed with E1 (NHA), E2 (DON and E5 (ED) during the exit conference on 6/3/19 at approximately 4:45 PM.

Based on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (R13) out of one (1) resident reviewed for the care area of vision and hearing. The facility failed to offer and/or apply R13's hearing aides on multiple occasions for approximately nine (9) months. Findings include: Review of R13's clinical record revealed the following: 7/5/18 - R13 was admitted to the facility. 7/12/18 - The admission MDS assessment stated R13 had minimal difficulty hearing - difficulty in some environments (such as- when person speaks softly or setting is noisy). 7/12/18 - A care plan for a communication problem related to hearing loss was created. Interventions included: Collect my hearing aids at bedtime, and place in charger. Replace them each morning as I may misplace or lose them; Ensure that my hearing aids are in place. 7/22/18 12:10 PM - A nurse's progress note stated, .Staff located bilateral hearing aides .'he/she doesn't wear very often' and declined to wear them at this time . 8/2/18 - R13's Personal Property Inventory notes B/L hearing aides + charger 8/18/19. 8/8/19 - A physician's orders [REDACTED].*Document when declines HA's. 10/11/18 and 1/3/19 -Quarterly MDS assessments stated R13 had minimal difficulty hearing. 3/28/19 - A quarterly MDS assessment stated R13 had minimal difficulty hearing and was moderately impaired for daily decisions making (decisions poor; cues/supervision required). 5/28/19 2:48 PM - During an interview R13 stated the he/she had hearing aides, but is unsure if they were lost here in the facility or before he/she came. 8/1/19 through 5/30/19 - Review of CNA documentation reports, medication and treatment administration records, and nursing progress notes lacked any documented evidence that R13 was offered his/her hearing aides. Additionally, there was no documented evidence that R13 was refusing placement of the hearing aides. 5/30/19 1:21 PM - During an interview, E6 (Charge Nurse) stated that R13 used to not like wearing the hearing aides. E6 stated that he/she would look for them. 5/30/19 3:00 PM - E6 (Charge Nurse) stated that R13's hearing aides were found in the back of the resident's drawer and were currently being charged. The facility failed to ensure that physician's orders [REDACTED]. There was no evidence that the facility was offering the hearing aides daily or that the resident was refusing their placement from 8/1/18 through 5/30/19. 6/3/19 10:31 AM - Findings were reviewed with E1 (NHA), E2 (DON) and E5 ED). Findings were reviewed with E1 (NHA), E2 (DON and E5 (ED) during the exit conference on 6/3/19 at approximately 4:45 PM.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the MDS assessment accurately reflected the resident's status for one (R14) out of 18 residents sampled. Findings include: Review of R14's clinical record revealed the following: 2/7/19 10:29 PM - A nurse's progress note stated the POA agreed to having R14's anticoagulant (blood thinning medication) discontinued. The anticoagulant was discontinued by the Nurse Practitioner. 3/28/19 - The significant change MDS assessment erroneously coded that R14 received an anticoagulant for the seven (7) days of the assessment review time period. 5/31/19 11:15 AM - In an interview with E4 (RNAC), the erroneous coding of anticoagulant use was confirmed. Shortly after the interview, E4 informed the surveyor that a modified MDS was submitted. 6/3/19 10:31 AM - Findings were reviewed with E1 (NHA), E2 (DON) and E5 (ED). Findings were reviewed with E1 (NHA), E2 (DON and E5 (ED) during the exit conference on 6/3/19 at approximately 4:45 PM.

Based on observations and interview, it was determined that the facility failed to ensure that food was stored and prepared in a sanitary manner. Findings include: The initial kitchen tour on 5/28/19 from 8:00 AM - 9:00 AM revealed the following: - A broom was resting on top of the hand washing sink basin near the dish washing area; - A bag of tater tots was opened and uncovered in the walk-in freezer; - The kitchen fume hood was greasy. Findings were confirmed with E3 (food service director) on 5/28/19 at approximately 9:00 AM. Findings were reviewed with E1 (NHA), E2 (DON and E5 (ED) during the exit conference on 6/3/19 at approximately 4:45 PM.

Based on medication pass observations, record review, and interviews, it was determined that the facility failed to ensure that its medication error rates were not 5 percent (%) or greater. The medication error rate for the medication pass observation was 4 out of 25 opportunities which was 16%. Findings include: The [MEDICATION NAME] Balance (lubricating eye drops) Product Information sheet (https;//www.[MEDICATION NAME].com/product-ingredients/[MEDICATION NAME]-balance-lubricating-eye-drops/) stated, .Directions Shake well before using . The [MEDICATION NAME] Sodium ([MEDICAL CONDITION] hormone replacement medication) manufacturer's prescribing information stated, .2.1 General Administration Information Administer .as a single daily dose, on an empty stomach, one-half to one hour before breakfast .at least 4 hours before or after drugs known to interfere with .absorption .7.1 Drugs Known to Affect [MEDICAL CONDITION] Hormone .and may alter the therapeutic response .Calcium [MEDICATION NAME] .administer .at least 4 hours apart from these agents . 1. R47 had a current physician's orders [REDACTED]. On 4/20/17 at approximately 8:15 AM, during the medication pass observation, E5 (LPN) prepared to administer R47's [MEDICATION NAME] Balance eye drops. Observation of both the box storing the container of eye drops and the container itself revealed instructions to shake well before using. E5 failed to shake the container of eye drops before administering them to R47. During an interview on 4/20/17 at 10:30 AM, E5 acknowledged that the eye drop instructions stated to shake well before using and E5 confirmed that she failed to do so. Findings were reviewed with E2 (NHA) and E3 (DON) during an interview on 4/20/17 at approximately 10:55 AM. 2. R45 had a current physician's orders [REDACTED]. On 4/20/17 at approximately 8:30 AM, during the medication pass observation, E6 (LPN) prepared to administer R45's [MEDICATION NAME] Balance eye drops. Observation of both the box storing the container of eye drops and the container itself revealed instructions to shake well before using. E6 failed to shake the container of eye drops before administering them to R45. During an interview on 4/20/17 at 10:45 AM, E6 acknowledged that the eye drop instructions stated to shake well before using and E6 confirmed that she failed to do so. Findings were reviewed with E2 (NHA) and E3 (DON) during an interview on 4/20/17 at approximately 10:55 AM. 3a. R66 had a current physician's orders [REDACTED]. On 4/20/17 at approximately 8:50 AM, during the medication pass observation, E6 prepared to administer R66's morning medications. Observation of the blisterpack revealed that the Calcium [MEDICATION NAME] 600 mg tablet that was administered to R66 did not contain any Vitamin D as ordered. During an interview on 4/20/17 at 10:45 AM, E6 acknowledged that the blisterpack containing R66's Calcium [MEDICATION NAME] did not contain Vitamin D as ordered. Findings were reviewed with E2 (NHA) and E3 (DON) during an interview on 4/20/17 at approximately 10:55 AM. During this interview the NHA stated the [MEDICATION NAME] 600+D tablet 600-400mg-unit had been sent by the pharmacy and was on the cart. 3b. R66 had a current physician's orders [REDACTED]. During the medication pass observation on 4/20/17 at 9:00 AM, E6 administered R66's morning medications, two (2) of which were Calcium [MEDICATION NAME] and [MEDICATION NAME]. R66 was then taken to the dining room for breakfast. At 9:14 AM, R66 was observed in the dining room. When asked if eating, E7 (CNA) stated that R66 had already eaten toast and was just waiting for the entree. R66 had taken [MEDICATION NAME] less than 15 minutes earlier. The facility failed to ensure that R66's [MEDICATION NAME] was administered one-half to one hour before breakfast and with at least 4 hours before or after drugs known to interfere with absorption, such as Calcium [MEDICATION NAME]. Findings were reviewed with E2 (NHA) and E3 (DON) during an interview on 4/20/17 at approximately 10:55 AM.

Based on observation and interview it was determined that the facility failed to ensure housekeeping and maintenance services maintained a sanitary and comfortable interior for 9 (2001, 2003, 2014, 2016, 2024, 2026, 2028, 2029, 2037) out of 39 rooms reviewed. Findings include: Observations during Stage 1 (4/19/16 and 4/20/16 9:30 AM to 3:00 PM) and on an environmental tour on 4/26/16 at 11:50 AM, revealed the following; 1. Rooms 2001, 2003, 2014, 2024, 2029, 2037-are missing transition strips between bathroom and hallway leaving a black sticky residue. 2. Room 2014- long black scuff marks on wardrobe/closet. 3. Room 2016- toilet bolts missing covers leaving exposed hardware. 4. Room 2026 - dark horizontal marking along the entrance wall and below the sink in the bathroom, worn caulk around the toilet base, orange wall with marking left of mirror, and a loose towel hook. 5. Room 2028 A - dresser in disrepair. During an interview on 4/25/16 at 1:39 PM with E10 (Maintenance Director) it was confirmed that the facility was aware of the missing transition strips and findings of disrepair were reviewed and confirmed as not listed on the facility log of scheduled maintenance. These findings were reviewed with E1 (NHA), E2 (NHA trainee) and E3 (DON)on 4/25/16 at 3:30 PM.

Based on record review, interview and review of other facility documentation it was determined that the facility failed to provide the necessary care and services according to the plan of care for three (R62, R48 and R20) out of 25 sampled residents. For R62, the facility failed to monitor and assess for constipation after the resident went 9 shifts / 3 days with no BM. For R48 and R20 the same pain scale was not utilized post pain medication. Findings include: 1. The facility's Constipation / Bowel Protocol issued 2/2011 included in the procedure that staff would record usual bowel habit and laxative used on admission, encourage fruit, fruit juices and high fiber cereal, record bowel movements on the electronic application, encourage physical activity, observe for signs and symptoms of constipation and if constipation is suspected the licensed nurse would notify the physician who will establish a regimen per the resident's history and needs. The following was reviewed in R62's clinical record: R62 was admitted on [DATE] with orders for a routine laxative for constipation and orders for as needed laxatives for constipation. 3/5/16 - A care plan was developed for the concern I have constipation at times. The approaches were prune juice in AM and MOM as needed. The care plan failed to address specific assessment and monitoring. 4/17 - 4/ 24/16 - Review of the electronic documentation for bowel movements revealed that the R62 went 20 shifts with no BM. Review of the MAR and the nurses notes for the same period of time lacked evidence of intervention or assessment for constipation. During an interview on 4/25/16 at 1:40 PM with E3 (DON) it was revealed that R62 had been interviewed by staff and verbalized that she has regular bowel movements and did not go 20 shifts with no BM. E3 went on to explain that staff get an alert on the EMR after 9 shifts with no BM. The nurse should then address the alert by checking with the resident or staff to see if the resident needed interventions. E3 stated that staff probably asked the resident and forgot to document their assessment and the missed BM documentation in the EMR. There was no evidence that staff assessed and monitored R62's constipation. These findings were reviewed with E1 (NHA), E2 (NHA trainee) and E3 on 4/25/16 at 3:30 PM. 2. Pain management standards were approved by the American Geriatrics Society in April 2002 which included: appropriate assessment and management of pain; assessment in a way that facilitates regular reassessment and follow-up; same quantitative pain assessment scales should be used for initial and follow up assessment; set standards for monitoring and intervention; and collect data to monitor the effectiveness and appropriateness of pain management. Facility policy entitled Pain Management (last revised 9/2015) included the pain management tool (located on the MAR) is used to assess pain and document findings. Review of R48's clinical record revealed the following: 10/19/15- R48 had a prescription for PRN pain medication to be given every four hours as needed for moderate to severe pain. 3/18/16- Care plan problem for pain included the following approaches: assess me for verbal and non-verbal signs and symptoms of distress or pain. February 2016 through April 2016- Review of PRN eMAR's found R48 received: - 8 doses of PRN pain medication in February (2/1, 2/11, 2/21, 2/22, 2/24, 2/26, 2/28, 2/29) ; -17 doses of PRN pain medication in March ( 3/2, 3/3, 3/4, 3/5, 3/8, 3/11, 3/15, 3/21, 3/25, 3/26, 3/30 and two doses on 3/6 3/7, 3/31); -6 PRN doses in April ( 4/10, 4/14, 4/19, 4/22/ 4/23/ 4/24). There was no documented evidence that the facility used a post pain assessment using the same pain scale that was used prior to administration. There was no evidence in the nurses notes that a numeric pain assessment scale was used following the administration of these medications. During an interview on 4/25/16 at 10:27 AM with E12 (LPN) it was explained that the ones who can verbalize you ask, otherwise you go by the facial expressions (the faces scale), we use 0-10 with ten being outrageous pain. Specifically for R48, E12 reported that with her we couldn't use a number we would use the picture. E12 confirmed that for administration of PRN pain medications we use the 0-10 scale before and after, because the pain may not be completely gone it may start at an 8 and go down to a three. E12 then explained that for documenting post assessment it (the eMAR) doesn't really allow it gives a range and you can document in your notes too, just pre (pain assessment) , afterwards you can document if it was most effective or not effective. The facility failed to assess resident pain levels using the same pain assessment scale before and after PRN pain medication administration. These findings were reviewed with E1 (NHA), E2 (NHA trainee) and E3 (DON) on 4/25/16 at 3:30 PM. 3. Review of R20's clinical records revealed: 8/28/15 - Care plan problem for pain (generalized in joints) included the following approaches: take medications (extra strength tylenol twice daily); inform nurse of pain level and effectiveness of pain medication; follow PT/OT recommendations if receiving therapy; reposition, in pain when first wake up, pain worse in right hand and arm; use aspercreme to areas of pain; [MEDICATION NAME] twice daily and PRN. February 2016 through April 2016 - Review of PRN eMARs found R20 received: - 5 doses of [MEDICATION NAME] (March 15 and 21, April 2, 8 and 16) and two doses of tylenol (February 2 and 17). All seven doses did not include a post pain assessment using the same pain scale that was used prior to the medication. There was no evidence in the nursing notes between February 2016 and April 2016 that a numeric post pain assessment scale was used for these 7 PRN pain medications. - 27 doses of PRN gastrointestinal medications for gas, indigestion, or rectal pain which were documented as being effective for the intended indication: * February 5, 20 and 22. * March 1 (two doses), 2, 10, 13, 15, 16, 20, 23, 24, 28, 29 and 31. * April 1, 2 (three doses), 4, 8, 11 (two doses), 13, 15 and 20. During an interview with E8 (LPN) on 4/22/16 at 11:35 AM to inquire about post-pain assessment process, E8 showed the options listed in computer were effective; somewhat effective and not effective. When asked if a pain score was used after pain medication, the nurse stated no since just the words in the computer program. During an interview with E9 (RN) on 4/22/16 at 1:50 PM to review the times of medication pouring and post assessments E9 stated I see what you mean that they are at the same time. When discussing the use of the same pain scale assessment before and after PRN pain medication E9 said the computer does not give the option of using pain scores. E9 added the facility may be able to have something built in the computer to record pain scores. The facility failed to assess resident pain levels using the same pain assessment scale before and after PRN pain medication administration. These findings were reviewed with E1 (NHA), E2 (NHA trainee) and E3 on 4/25/16 at 3:30 PM.

Based on record review and interview it was determined that for one (R62) out 25 sampled residents the facility failed to develop a care plan for the identified problem of constipation. Findings include: The following was reviewed in R62's clinical record: R62 was admitted on [DATE] with orders for a routine laxative for constipation and orders for as needed laxatives for constipation. 3/5/16 - A care plan was developed for the concern I have constipation at times. The approaches were prune juice in AM and MOM as needed. During an interview on 4/25/16 at 12:00 PM E9 (RN) provided the above brief care plan for constipation. R62's care plan lacked evidence of monitoring for constipation, the use of routine medication and under what circumstances a PRN laxative should be offered. These findings were reviewed with E1 (NHA), E2 (NHA trainee) and E3 (DON) on 4/25/16 at 3:30 PM.

Based on record review and interview it was determined that for one (R35) out of 25 sampled residents the facility failed to ensure the accuracy of the comprehensive assessment in the area of bladder continence. Findings include: Cross refer F514, example #1. The following was reviewed in R35's clinical record: 12/16/15 - Health History on admission documented the resident was incontinent of bladder and used adult briefs. 12/16/15 - Assessment for Bowel and Bladder Rehabilitation/Retraining/Restorative Program documented R35 was incontinent of both bowel and bladder and was incontinent prior to admission per resident. 12/17 - 12/23/15 - During the review period for the MDS, staff incorrectly documented in the EMR that R35 was continent of urine 4 times. 12/23/16 - MDS 5 day / admission documented based on the CNA documentation that R35 was frequently incontinent of urine. 12/30/15 - MDS 14 day documented based on the CNA documentation that R35 was frequently incontinent of urine. During an interview on 4/22/16 at 10:06 AM E11 (CNA) stated R35 does not use the bathroom, he is incontinent of urine and he uses briefs. E11 went on to add that when the CNAs document C for continent they are really indicating the resident was dry and are using the wrong code for documentation. An interview on 4/22/16 at 2:19 PM with R35 confirmed that he was admitted to the facility incontinent of urine and remains incontinent because he can no longer feel when he has to go. The facility incorrectly coded frequently incontinent of urine instead of totally incontinent. These findings were reviewed with E1 (NHA), E2 (NHA trainee) and E3 (DON) on 4/25/16 at 3:30 PM.