Every finding on record at Willowbrooke Court at Indian River Estates

Based on policy review, record review and interview, the facility failed to ensure a discharge summary, to include a recapitulation of the residents stay, for 1 of 2 sampled residents, Resident #3. The findings included: Review of the policy titled Transfer and Discharge Rights, revised 10/2024, documented, in part, Documentation of Transfer or Discharge: . 4. Information provided to the receiving community/provider should include the following: . Discharge Summary. The discharge packet provided by the Administrator included a form titled, Discharge Assessment & Summary. Upon entering the facility on 10/21/24, the Administrator informed the survey team that although they had five active households (resident units), only one household (Biscayne) was certified while the other four were non-certified and licensed only. The Administrator explained they did not accept residents from outside of their community and did not accept Medicaid. The Administrator stated the decertification process happened in two stages, but was completed by 11/20/23. Review of the record revealed Resident #3 was admitted to the Biscayne household on 09/25/24, and then moved to the [NAME] Villa household on 10/17/24, a non-certified and licensed only household. Review of the Minimum Data Set (MDS) assessments revealed a discharge Minimum Data Set (MDS) assessment, with return not anticipated, was completed on 10/17/24. A progress note written by Staff B, Registered Nurse (RN), on 10/17/24 at 10:47 AM documented Resident #3 was safely moved to the [NAME] Villa unit. Further review of the record lacked a discharge assessment and summary, but revealed a Room Change Notification indicating Resident #3 was moving from the skilled services bed on Biscayne to [NAME] Villa. During an interview on 10/24/24 at 11:45 AM, when asked the process when one of the residents in the Biscayne household was discharged out to one of the other households in the facility, Staff B, RN, explained she completes a functional assessment, gives verbal report to the accepting nurse, and it is treated like a room change. When asked if she completes a discharge summary, the RN stated she does not, but stated that would make sense since the resident would be moving out of the certified household into a non-certified household, similar to when they are discharged back to their apartment.

Based on policy review, record review, and interview, the facility failed to encode and transmit a discharge Minimum Data Set (MDS) assessment for 1 of 2 sampled discharged residents. Resident #11. The findings included: Review of the policy titled Transfer From Distinct Part to Non-Certified Household / Neighborhood revised 10/2024 documented in part, Procedure: . 6. The MDS Coordinator shall complete the appropriate Minimum data Set (MDS) assessment. Upon entering the facility on 10/21/24, the Administrator informed the survey team that although they had five active households (resident units), only one household (Biscayne) was certified while the other four were non-certified and licensed only. The Administrator explained they did not accept residents from outside of their community and did not accept Medicaid. The Administrator stated the decertification process happened in two stages, but was completed by 11/20/23. Review of the record revealed Resident #11 was admitted to the facility on [DATE], into the certified Biscayne household. Further review of the census record revealed the resident was moved to a licensed only household, Key West, on 07/13/24. This move indicated Resident #11 no longer lived in a certified facility, which needed to be reflected in the MDS (certification) assessment. Review of the MDS assessments lacked any MDS discharge assessment for the resident's move out of the certified household as of 07/13/24. During an interview on 10/22/24 at 2:52 PM, the MDS Coordinator was asked her MDS process for a resident who moved out of the Biscayne household. The MDS Coordinator explained she would complete (encode) and transmit a discharge MDS assessment with the resident's return not anticipated. During a side-by-side review of the record, the MDS Coordinator confirmed she failed to complete and transmit the discharge MDS assessment for Resident #11.

Based on observations, interviews, record reviews, and review of facility policies and procedures, the facility failed to cook raw unpasteurized eggs in a manner to destroy all viable Salmonella species bacteria, a virulent foodborne pathogen (disease-causing microorganism) that could cause food borne illness for 3 of 3 sampled residents, Residents #11, #334 and #335. Residents #11, #334 and #335 were over [AGE] years of age and were immunocompromised. Residents #11, #334 and #335 preferred undercooked eggs (over easy) for breakfast and were served unpasteurized shell eggs (that have not been specifically treated to destroy all viable Salmonella species bacteria). The practice of serving undercooked unpasteurized shell eggs to a highly susceptible population placed the residents who eat eggs prepared by the facility at a likelihood of serious illness or death from a Salmonella Enteritidis infection. According to the Centers for Disease Control and Prevention (CDC), non-typhoidal Salmonella infection causes severe diarrheal illness. Adults aged [AGE] years and older, and people with a weakened immune system are the most likely to have serious infections. People taking certain medicines (for example, stomach acid reducers) are at increased risk of infection. Symptoms of Salmonella illness include but are not limited to pain in the abdomen or muscles, chills, dehydration, fatigue, fever, loss of appetite, diarrhea, or blood in the stool, usually begin within six hours to six days after infection and last four to seven days. Diarrhea may last for several days and lead to potentially severe dehydration, especially in adults over [AGE] years old. Even after clinical symptoms are no longer obvious, Salmonella bacteria may be found in the stool for several weeks. Chickens can lay eggs that are contaminated with Salmonella Enteritidis. Salmonella Enteritidis is one of the most common serotypes of Salmonella in the U.S. If a person eats an egg contaminated with Salmonella raw, or undercooked, they may be infected with Salmonella Enteritidis. CDC estimates that approximately 1.35 million illnesses and 420 deaths occur due to non-typhoidal Salmonella annually in the U.S. CDC surveillance data for 1993-1997 indicated that serotype Salmonella Enteritidis caused the most deaths in foodborne outbreaks, and that 40% of these deaths occur in nursing home residents ([NAME] SJ, MacKinon LC, [NAME] JS, Bean NH, Slutsker L. Surveillance for foodborne disease outbreaks-United States, 1993-1997, MMWR CDC Surveill Summ, 2000, vol. 49 (pg. 1-62). According to the Food and Drug Administration 2022 Food Code, raw eggs that are broken and prepared in response to a consumer's order and for immediate service shall be cooked to heat all parts of the food to 145 or above for 15 seconds to destroy Salmonella. The facility was not checking the final cooking temperature of the unpasteurized eggs that were cooked to order for residents' preference, such as sunny side up and over easy eggs. On 08/01/23, it was determined facility practice posed Immediate Jeopardy to the health and safety of residents in the facility. The Administrator was informed of the Immediate Jeopardy on 08/01/23 at 5:40 PM. The Immediate Jeopardy was identified on 07/31/23, as beginning on 02/03/23, and removed on 08/01/23. The scope and severity were decreased to an E, no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. The facility census at the time of the survey was 79 residents. All 79 residents consumed the facility food. The findings included: The facility's policy, titled, Egg Preparation, most recently updated 02/2017, documented, in part, the following: Policy: when preparing eggs separately or as part of a recipe, only commercial Grade A or pasteurized egg products may be used. When preparing eggs to order only pasteurized eggs may be used. No raw eggs will be served. Procedure: 1. Examine all fresh eggs discarding any that are cracked or damaged. 2. Grade A raw egg may only be used in recipes where the egg will be cooked (i.e. pudding, cakes, quiche, etc. 3. Grade A raw eggs prepared separately must be cooked to at least 140 degrees for three minutes or 145 degrees for 15 seconds. This will yield a product in which the egg whites are completely set and the yolks are congealed. 4. All poached, over easy and other non-fully cooked egg menu items need to be prepared with pasteurized shell eggs. The facility's policy, titled, Cooked Egg Policy, most recently updated 04/2023, documented, in part, the following: To strive to protect residents from the potential for food-borne illness, all residents will be served eggs that have been cooked to the recommended internal temperature according to the Food and Drug Administration. Procedure: 1. All residents will be served eggs that have been cooked to the recommended internal temperature of 145F, based on federal guidelines. 2. Pasteurized eggs will be used for preparations that will not meet the internal temperature of 145F, such as over-easy or poached eggs. The facility's menus that the residents fill out for their choices for breakfast offered Eggs Made to Order: Scrambled / Over Easy / Fried every day for breakfast. 1. Resident #11, who was over the age of [AGE] years, was admitted to the facility on [DATE] with diagnoses that included: Post Polio syndrome, Personal History of COVID 19 (Coronavirus Disease 2019), Carcinoma (cancer) of skin, scalp and neck, Major depressive disorder, Acute embolism (blockage in a blood vessel due to a blood clot or other foreign matter that gets stuck while traveling through the bloodstream) and thrombosis (the formation or presence of a blood clot within a blood vessel which can block or limit blood flow) of right lower extremity, Atherosclerotic heart disease of the native coronary artery (hardening of the arteries due to gradual plaque buildup) without angina pectoris (chest pain or pressure), Hypertension, Paroxysmal Atrial Fibrillation (an irregular and often very rapid heart rhythm), Hyperlipidemia (high blood cholesterol), Atherosclerosis (a buildup of fats, cholesterol and other substances in and on the artery wall that causes arteries to narrow blocking blood flow), Anemia, Malignant Neoplasm (cancer) of the pancreas, Diaphragmatic Hernia, Disorders of Plasma protein Metabolism (inherited metabolic disorders that involve malfunction of metabolism of proteins in the blood), and Gastroesophageal Reflux Disease (GERD). Review of physician orders revealed Resident #11 had orders that included: Pantoprazole Sodium Tablet Delayed Release 40 MG - for GERD. Review of the Annual Minimum Data Set (MDS) assessment documented Resident #11 had a Brief Interview for Mental Status (BIMS) score of 15 of 15, indicating the resident was cognitively intact. 2. Resident #334, who was over the age of [AGE] years, was admitted to the facility on [DATE] with diagnoses that included: Congestive heart failure (a progressive heart disease that affects pumping action of the heart muscles, which can cause fatigue and shortness of breath upon exertion and fluid retention), Hypertension, Diabetes Mellitus, Alzheimer's disease, Non Alzheimer's dementia, Depression, Deep vein thrombosis of right lower extremity, Multinodular goiter (a condition where the thyroid gland is enlarged due to multiple lumps that can grow on more than one part of the gland), Atrial fibrillation, Rheumatoid Arthritis (a chronic inflammatory disease that affects the joints that results in painful joints, swelling and stiffness in the joint), and Osteoarthritis (degenerative joint disease). Review of the quarterly MDS assessment, dated 06/08/23, documented Resident #334 had a BIMS score of 15 of 15, indicating the resident was cognitively intact. 3. Resident #335, who was over the age of [AGE] years, was admitted to the facility on [DATE] with diagnoses that included: Hypertension, Idiopathic peripheral autonomic Neuropathy (a condition in which the nerves located outside of the brain and spinal cord are damaged causing weakness, numbness, and pain), history of COVID 19 (Coronavirus Disease 2019), Macular degeneration (a vision impairment resulting from deterioration of the central part of retina), Atrial fibrillation, Constipation, Arthritis, Osteoporosis, and Chronic Kidney Disease Stage 3 (moderate kidney damaged and notable loss of function, but they still work well enough without dialysis or a kidney transplant). Review of the quarterly MDS, dated [DATE], documented Resident #335 had a BIMS score of 15 of 15, indicating the resident was cognitively intact. The initial kitchen tour was conducted on 07/31/23 at 8:51 AM, accompanied by the Executive Chef. During an observation in the walk-in cooler, it was noted that there was one full unopened case of unpasteurized shell eggs and a half of a case of unpasteurized shell eggs. It was also noted that there were no pasteurized shell eggs in the walk-in cooler. When the Executive Chef was asked how many staff cook eggs to order (e.g., over easy, sunny side up), the Executive Chef replied that the facility cooked eggs to order for the residents in the individual kitchens on the units without measuring the final cooking temperature of 145 F for 15 seconds for unpasteurized eggs. During a tour of the Biscayne Unit on 07/31/23 at 9:10 AM, it was noted that there were approximately 2.5 dozen unpasteurized shell eggs in the reach-in refrigerator, and no pasteurized shell eggs. During an interview with Staff A, Line Cook, when asked about cooking eggs to order, the Line Cook stated that she cooks eggs to residents' order for breakfast without measuring the final cooking temperature of 145 F for 15 seconds for pasteurized eggs. The line cook stated that none of the residents requested the eggs to be undercooked (e.g., sunny side up, over easy eggs) for breakfast on this day. When asked by the surveyor, Staff A was not aware of the risks of foodborne illness associated with residents consuming undercooked unpasteurized shell eggs. During a tour of the Key [NAME] Unit, on 07/31/23 at 9:55 AM, it was noted that there were no eggs in the reach-in refrigerator. During an interview with Staff B, Cook, when asked about cooking eggs to order for the residents, the Cook stated that he cooks eggs to order for breakfast, including breakfast that morning. The Cook stated that the eggs were removed from the reach-in cooler after it was identified by the surveyor that the eggs were not pasteurized. The Cook stated that he cooked an over easy egg without measuring the final cooking temperature of 145 F for 15 seconds for unpasteurized eggs for one resident on the unit, Resident #11, and that the rest of the residents had scrambled eggs made from pasteurized liquid eggs. When asked by the surveyor, Staff B was not aware of the risks of foodborne illness associated with residents consuming undercooked unpasteurized eggs. During an interview, on 07/31/23 at 12:04 PM, with Staff C, Dietary Aide on the Sweetwater Unit, when asked about residents ordering undercooked eggs, the Dietary Aide replied, none today, they only had three resident that asked for eggs. The Dietary Aide further stated the residents received scrambled eggs made from the pasteurized liquid eggs and that she cooks eggs to order when requested by residents. The staff were cooking the unpasteurized eggs without measuring the final cooking temperature of 145 F for 15 seconds. When asked by the surveyor, Staff C was not aware of the risks of foodborne illness associated with residents consuming undercooked unpasteurized eggs. During an interview with Resident #11, on 07/31/23 at 1:51 PM, when asked about the breakfast served this morning, Resident #11 replied, I had one over easy egg, with hash browns and a slice of bacon. Resident #11 further stated that he has one over easy egg several times a week. During an interview, on 07/31/23 at 5:22 PM, with a Sales Representative from [NAME] Wholesale Fruit and Produce, the food vendor that the facility purchases their eggs from, the Sales Representative confirmed that the vendor did not have pasteurized shell eggs to sell and had never had them. During an interview, on 08/01/23 at 7:11 AM, with Staff D, Dietary Aide, when asked about residents that ask for and receive undercooked eggs, Staff D replied, 3 or 4 (residents). Staff D further stated that she prepared eggs to order based on residents' preferences. When asked, Staff D was not aware of the risks of foodborne illness associated with residents consuming undercooked unpasteurized eggs. During the interview, on 08/01/23 at 7:37 AM, with the Registered Dietitian (RD), the RD stated that she was not aware that the facility was using undercooked, unpasteurized eggs, I assumed they were all pasteurized. During an interview, on 08/01/23 at 7:37 AM, with the Executive Chef and the Culinary Services Director, when asked about ordering and receiving shell eggs, the Executive Chef stated he had been ordering the unpasteurized shell eggs from [NAME] Wholesale Fruit and Produce vendor for the previous 5.5 months and that he had not ordered or received eggs from any other vendor. The Executive Chef stated that he ordered the eggs as he felt that the eggs that he was ordering were more natural and healthier. The Executive Chef stated that he was not aware that the eggs were unpasteurized. During a review of the website from [NAME] Wholesale Fruit and Produce (where the facility buys eggs from) revealed that there were no pasteurized shell eggs that could be ordered from the supplier. During an interview, on 08/01/23 at 9:24 AM, with Staff E, Certified Nursing Assistant (CNA), when asked about residents being served undercooked eggs, Staff E stated that Resident #335 requests and receives over easy eggs once or twice a week. When asked Staff E stated that she was not aware of the risks of foodborne illness associated with residents' consuming undercooked unpasteurized shell eggs. During an interview, on 08/01/23 at 9:37 AM, with Resident #335, she confirmed that she ordered and received undercooked and unpasteurized shell eggs regularly. During an interview, on 08/01/23 at 1:12 PM, with Resident #334, when asked of her preferences for eggs, Resident #334 stated that she requested over easy eggs regularly for the 5.5 months that she had been in the facility. Resident #334 further stated that she has over easy eggs Monday, Wednesday and Friday, but I don't eat the yolks. Review of the invoices for the [NAME] Wholesale Fruit and Produce vendor revealed the unpasteurized eggs were ordered on 02/03/23 and to be delivered on 02/03/23 to the facility. During an interview, on 08/01/23 at approximately 4:30 PM, the Administrator was told that the Agency had a concern related to the facility serving undercooked unpasteurized eggs. The Administrator stated she was not aware the facility was serving undercooked unpasteurized shell eggs prior to the concern being brought to her attention. During an interview, on 08/02/23 at 12:30 PM, with the Infection Preventionist, the Infection Preventionist stated that there had been no reports of residents with signs or symptoms of Salmonella illness. She confirmed she was not aware of the residents being served undercooked unpasteurized eggs. During an interview, on 08/03/23 at approximately 9:00 AM, with the Medical Director by telephone, the Medical Director stated that he had been made aware of the concern by the Administrator. The facility submitted an acceptable Immediate Jeopardy removal plan on August 2, 2023. The survey team verified the following immediate actions were in the Immediate Jeopardy removal plan: On 07/31/23 at approximately 9:30 AM, the facility removed unpasteurized shell eggs from the unit kitchens. Pasteurized shell eggs were brought to the units from the IL (Independent Living) community that shared the campus with the facility. The facility ordered and received pasteurized shell eggs from US Foods on 08/01/23. The surveyor visually confirmed facility received pasteurized shell eggs from the food vendor. The surveyor confirmed via record review, residents were monitored for signs and symptoms of Salmonella (infection). All food contact and non-food contact surfaces appeared to be clean and sanitized. An Ad-hoc QAPI meeting was conducted on 08/01/23 with all components of the IJ addressed, including: Educating staff. Reviewing and updating policies and procedures. Purchasing and receiving pasteurized shell eggs. Monitoring residents for signs and symptoms of Salmonella [infection]. Messaging staff via electronic health system (Point Click Care). As of 08/01/23 at 5:45 PM: 15 out of 15 Licensed Practical Nurses had been educated. 54 out of 56 Certified Nursing Assistants had been educated. 26 out of 29 Registered Nurses had been educated. 21 of 21 Dietary staff had been educated. The surveyor confirmed via interviews with staff on all units, including the Registered Dietitian (RD), the Executive Chef, Dietary staff and nursing staff, that the staff were educated by the Administrator and the Director of Nursing about the signs and symptoms of Salmonella and to report immediately to the appropriate Supervision. Staff were provided with information on a paper card with the education. During interviews, staff were able to: Explain the risks associated with consuming undercooked unpasteurized shell eggs. Distinguish a raw shell egg from a pasteurized shell egg. Demonstrate knowledge of the symptoms of Salmonella. Demonstrate knowledge of the facility's policies and procedures regarding egg preparation. The surveyor confirmed via interviews with staff that information and instruction was posted to the electronic health system. The facility provided example of the information posted to Point Click Care. The surveyor confirmed full house audits to identify residents at risk of foodbourne illness due to consuming undercooked unpasteurized shell eggs with none of the residents being adversely affected by consuming undercooked unpasteurized eggs. The surveyor confirmed via record review that care plans were updated to reflect the risk of foodbourne illness associated with residents consuming undercooked unpasteurized eggs. The surveyor confirmed via record reviews residents being monitored for signs and symptoms (s/s) of Salmonella [infection] with no findings / concerns. The surveyor confirmed via interviews with Resident #11, #334 and #335 that they were provided and understood education regarding the use of undercooked unpasteurized eggs and the risk of foodbourne illness associated with consuming undercooked unpasteurized eggs. During observations of the Main kitchen and the kitchens on the units on 08/01/23, 08/02/23 and 08/03/23, the facility only had pasteurized shell eggs. During interview with the RD, she stated that she is providing more oversight to the kitchen and will be conducting weekly audits in the kitchens on the units and the main kitchen for safety and quality. She further stated that she will be providing more oversight to the kitchen over the budget and purchase of foods and supplies based on communications with the Executive Chef and the Dietary Staff. The Culinary Services Director demonstrated oversight of the budget and purchasing by use of an electronic budgeting system that is shared with the Executive Chef and Corporate.

Based on record review and interview the facility failed to provide showers, per request and schedule, for 1 of 1 sampled resident reviewed for choices, Resident #41. The findings included: During an interview on 03/28/2022 at 9:32 AM, with Resident #41, she stated had not had a shower in two weeks. A review of Resident #41's records revealed Resident #41 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] & Mobility, Lack of Coordination, and [CONDITION(S)]. Review of the Significant change MDS (Minimum Data Set) for wound healing, dated 03/16/22, revealed the resident had a Brief Interview Mental Status (BIMS) of 12, which indicated her cognition is mildly impaired. Her functional status for bathing documented total dependence with one person assist. Review of Resident #41's care plan documented the resident has an ADL (Activity of Daily Living) self-care performance deficit related to Dementia, weakness, confusion, impaired vision and hearing. The documented interventions included the resident required total dependence by 1 staff with bathing and showering, as necessary, and to give a sponge bath when a full bath or shower cannot be tolerated. Resident #41's CNA (Certified Nursing Assistant) Task sheet for showers documented Resident #41's bathing preference days are Wednesdays and Saturdays on the 3:00 PM-11:00 PM shift. The CNAs were documenting bathing in two areas, the task sheet in the computer and a paper document in a binder for bathing. Further review of both documents revealed the following: January 2022: Received showers 0 of 5 on scheduled days and 3 on nonscheduled days. 01/17/22, 7 AM-3PM shift (Monday): Shower documented in computer. 01/24/22, 7AM-3PM shift (Monday): Shower documented in computer. 01/31/22, 7AM-3PM shift (Monday): Shower documented in computer and in a binder. February 2022: Received 1 of 8 showers on scheduled days and 1 bed bath on nonscheduled day 02/07/22, 7AM-3PM shift (Monday): Bed Bath 02/09/22 7AM-3PM shift (Wednesday): Shower March 2022: Received 2 of 9 showers on scheduled days and 1 shower on nonscheduled days. 03/05/22, 7AM-3PM shift (Saturday): shower 03/06/22, 7AM-3PM shift (Sunday): Shower 03/30/22, 2:03PM (Wednesday): Shower During an interview on 03/30/22 at 1:53 PM with Staff M, CNA (Certified Nursing Assistant), she stated, I have worked in this facility [AGE] years, [AGE] years as a CNA. Staff M was asked how the shower schedule works for the residents. She responded, They have shower days listed and can have a shower any days they want. The aides will log the showers in the computer. The tab under bathing has boxes for a shower, sponge bath, etc. We will then click the box, and it documents for that day what that resident had. If they dirty themselves after a bowel movement, I will sponge bathe them. I would document that under bathing. I gave Resident #41 a shower this morning, because she asked for one. During an interview with Resident #41 on 03/30/22 at 2:50 PM, the resident was asked if she had a shower today. She stated, Oh yes, it felt so good! My hair was itching so bad. She stated she had not been getting showers prior to this morning. She stated she has never refused a shower, but she believes maybe one time she asked to have it the next day, but she never got it. She stated she would prefer to have her showers on the 7AM-3PM shift because the aides in the afternoon don't seem to want to give her one. Review of a Progress Note from the Director of Nursing (DON), dated 03/30//22 at 2:58 PM, documented, I went to speak with resident. I asked her when she would prefer her shower. She stated that she would prefer to keep her showers on Wednesday and Saturday, but she would like to change the time from afternoon shifts to day shifts. I asked her if there were any other days that she would like to have a shower or bath and she replied, 'No, two days is plenty, I am inactive.' I let her know that if she should change her mind that we could change her bathing schedule at any time.

Based on observation, interview, and record review, the facility failed to treat 1 of 17 sampled resident who reside in the [NAME] Villa neighborhood in a dignified manner, Resident #57, who was served all meals on Styrofoam or paper disposable dinnerware with plastic utensil, while all other residents were served on traditional dinnerware with regular utensils. The findings included: On 03/28/22 at 8:36 AM, Resident #57 ambulated into the dining room with his rolling walker and sat down at a table. Resident #57 was served his breakfast meal on disposable dinnerware with plastic utensils. The [NAME] Villa neighborhood housed 17 residents as of 03/28/22, and residents came and went from the dining room as desired. There would be five to seven residents in the dining room for the breakfast meal, and later determined there were up to nine or ten residents in the dining room for the lunch and dinner meals. Other residents were served in their rooms. The kitchen area was maintained, and food served by dietary staff, although all nursing staff was also trained to assist. On 03/28/22 at 8:51 AM, Staff D, a private home health aide was standing in the [NAME] Villa dining room watching the residents. When asked why Resident #57 was eating on disposable dinnerware, Staff D, the private aide stated, because he likes to [NAME] into his plate . you'll see what I mean. On 03/28/22 at 12:12 PM, Resident #57 was observed eating lunch in the [NAME] Villa dining room. His meal was served on the disposable dinnerware. On 03/30/22 at 8:49 AM, Resident #57 had just finished eating breakfast, which was again served on disposable dinnerware with plastic utensils, except for the cereal, which was in a regular bowl (photographic evidence obtained). Resident #57 ambulated back to his room. When asked why he was eating on paper plates, Resident #57 stated he did not know. Resident #57 was very hard of hearing, had some trouble expressing his thoughts, and conversation was difficult. He was able to explain his food was soft because of a swallowing problem. When asked if he wanted regular plates and silverware, Resident #57 stated, Guess I'll leave it up to them and shrugged his shoulders. Resident #57 was again observed on 03/30/22 at 12:30 PM with the disposable dinnerware and when done, stated he wanted to go back to his apartment. Resident #57 was observed during this meal and all previous meals with the disposable dinnerware on paper napkins. At no time was Resident #57 observed hacking up [MEDICATION(S)] or spitting. During an interview on 03/30/22 at 12:31 PM, when asked why Resident #57 was eating on disposable dinnerware, Staff F, a Certified Nursing Assistant (CNA) stated, because he spits in his plate. When asked if they appropriately clean and disinfect the plates, the CNA stated, I guess the kitchen staff don't like it (referring to the resident's behavior) or something. On 03/30/22 at 12:50 PM, when asked why Resident #57 was served his meal on disposable dinnerware, Staff G, a Dietary Aide, explained it was a doctor's order because he spits in his plate and hacks up [MEDICATION(S)]. When asked if the dishes are cleaned and sanitized after use, the Dietary Aide stated they were. When asked if a regular plate could be cleaned and disinfected for Resident #57, the Dietary Aide stated it could be. The Dietary Aide then stated, To be honest with you, I have small kids and we can't wear gloves in the dining room, and I can't pick up his plate when he spits in it. When asked if she could pick up his plate, put it in the dish washer, and then wash her hands, she said yes, she could, but still would not want to pick up his plate. The Dietary Aide again stated it was a doctor's order. When asked how the doctor's order was initiated or why it was brought to the doctor's attention for an order, the Dietary Aide stated, I think he saw it himself. Review of the record revealed Resident #57 was admitted to the facility on [DATE], to the [NAME] Villa neighborhood. Review of the current Minimum Data Set (MDS) assessment dated [DATE] lacked any score for mental status. This same MDS documented Resident #57 could eat independently after being set up. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This same order was written on 12/26/21 with the resident's most current re-admission to the facility. Review of the care plan initiated on 11/25/21 documented the continued need for a mechanically altered diet. One of the interventions documented by the Registered Dietician was Please provide me with disposable products for all meals. Review of the behavior monitoring completed by the CNAs in the tasks section of the electronic medical record lacked any documented spitting behavior in the past 30 days. During an interview on 03/30/22 at 2:55 PM, Staff I, a Licensed Practical Nurse (LPN), was asked about the order for the paper products for Resident #57. Staff I, the LPN, stated she thought it was brought up by dietary during the COVID-19 pandemic, because he has a lot of [MEDICATION(S)] all the time. When asked if there was a functional need for the use of paper products for Resident #57, the LPN again stated, I think it is a dietary thing. During an interview on 03/30/22 at 3:04 PM, the Director of Culinary services was asked why Resident #57 was served on disposable dinnerware, while everyone else was being served on traditional dinnerware. The Director of Culinary services stated it happened when he first got here, as he was hacking up [MEDICATION(S)] and spitting it on his plates and into his cups. The Director of Culinary services stated some of the CNAs and dietary aides mentioned it. The Director of Culinary stated, We use universal precautions, and then we had COVID, and our medical director said it was ok to use paper products for Resident #57. The Director of Culinary services agreed they do disinfect the plates and glasses, and further stated, Staff were saying they would not touch it. It wasn't a decision I made alone. It was a team decision. When asked about glove use, the Director of Culinary services explained that gloves are not to be worn while serving food as it's a dignity issue. The Director of Culinary services stated, but after meals while cleaning up it's fine to wear gloves. The Director of Culinary services stated staff could wear glove during a meal if there was a need to clean something up. The Director of Culinary services stated she had educated staff on universal precautions. When asked if she specifically educated them related to Resident #57 and his behaviors, the Director of Culinary services did not believe she had. During an interview on 03/30/22 at 3:33 PM, the Registered Dietician was asked about the care plan related to paper plate use for Resident #57. The Registered Dietician stated there was a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Registered Dietician stated at the time he was spitting up and vomiting. When asked if she was part of the decision to use paper products, she stated she does not recall being part of the conversation, and she just knows he has the issue with spitting up. When asked if there was a functional reason for the paper products, the Registered Dietician stated there was not, but she just had an order, so she care planned it. The Registered Dietician stated she understood the concern with the use of paper products and dignity. On 03/30/22 at 4:30 PM, Resident #57 ambulated to the [NAME] Villa dining room for dinner. Resident #57 was provided a regular spoon, but disposable dinnerware set on paper napkins. At this meal, residents in the dining room were served a hand scooped frozen dessert in a scalloped glass bowl, while Resident #57 was noted with a frozen dessert in a cardboard container. Resident #57 was observed during this entire meal, and at no time was Resident #57 observed hacking up [MEDICATION(S)] or spitting. On 03/30/22 at 4:35 PM, Staff N, the MDS Coordinator provided the November 2021 care plan meeting for Resident #57. Review of this meeting lacked any documentation related to the use of paper products. When asked for documented evidence of the team decision to provide paper products to Resident #57, the MDS coordinator stated, There is an order. When told the Director of Culinary services stated it was a team decision, the MDS Coordinator referred to the Director of Nursing. On 03/30/22 at 4:57 PM, the MDS Coordinator returned to the surveyor and stated, What I'm finding out is the decision was made between the previous Nutritional Care Coordinator and Staff I, the LPN, and an order was obtained, but I can't find any notes to show that. During an interview on 03/31/22 at approximately 3:30 PM, the Social Worker agreed holding a conversation with Resident #57 was extremely difficult related to his hearing problem, even with the provided headset (amplifier devise). The Social Worker stated she attempted to re-assess his mental status, and his Brief Interview for Mental Status (BIMS) score was 1, on a 0 to 15 score, indicating cognitive impairment. The Social Worker explained that after the first question, Resident #57 stated, why bother referring to asking the questions. The Social Worker stated Resident #57 was cognitively impaired, and that his only activity was walking in the hallway, walking to and from the dining room, and eating.

Based on observation, interviews, and record reviews, the facility failed to ensure accurate assessments and implementation of wanderguard for 2 of 4 sampled residents, Residents #41 and #61; and failed to document evidence showing that a thorough fall investigation was completed for 1 of 3 sampled residents with falls, Resident #45. The findings included: Review of the policy, titled, Elopement/Wandering Risk Assessment, revised 03/2021, documented, Purpose: to strive to identify residents who are at risk for wandering and potential elopement and provide a safe environment while maintaining their highest practicable level of physical, mental, and psychosocial well-being. Procedure: 1. Residents are assessed upon admission to determine their risk for wandering or elopement and a wander guard bracelet is applied for the initial 72-hour assessment period. The resident will be reassessed as follows: Upon admission; after 72 hours of admission; Within one month of admission; Quarterly; With any new behaviors related to exit seeking activities. 3. Wander guard bracelets are to be worn by residents exhibiting signs of any of the above behaviors or on being assessed at risk to wander or elope. 12. Bracelets are not to be removed except for replacement, upon transfer from the monitored unit, or when the resident's medical condition renders them no longer to be an elopement risk (i.e., bed/chair bound). 1. Record Review of Resident #41 documented an admission to the facility on [DATE] with diagnoses to include [CONDITION(S)], Dementia Without Behavioral Disturbances, Hypertension, History of Falling, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] [CONDITION(S)], Chronic Pain Syndrome, Neuritis, [CONDITION(S)], Muscle Weakness, Abnormalities of Gait & Mobility, Lack of Coordination, and [CONDITION(S)]. Review of her Significant change MDS (Minimum Data Set) for wound healing, dated 03/16/22, revealed the resident had a BIMS (Brief Interview Mental Status) of 12, which means her cognition is mildly impaired. The MDS also documented that Resident #41 has a wander elopement alarm used daily. Review of the Physician Orders, dated 01/15/22, documented an order for a 'Wander Guard ID#42, expires 08/27/22', and to check for placement and function Q shift (every shift). A review of the resident's care plan documented a risk to wander with interventions in place that included a room that is located away from entrances / exits, a wander alert device during the first 72 hours after admission or readmission, and a wander alert device to be checked for function, placement and expiration regularly. She also had a care plan documenting having impaired cognitive function or impaired thought processes related to dementia with behaviors and on [CONDITION(S)] medication. Review of the most recent Wander Assessment/Risk scale, dated 02/06/22, documented a score of 6, indicating the resident is at risk for wandering. Observations and an interview on 03/30/22 at 2:38 PM with Resident #41 revealed the resident sitting in her recliner in her room. She was asked if she wears a bracelet / wander guard that is on her. She stated, I am supposed to wear it but it's too big, it's hanging on my wheelchair. She was asked if she uses her wheelchair to get around the facility, and she advised the surveyor that she used to use it more, but she now uses her walker to get around. The wander guard was observed hanging from the handle of her wheelchair. On 03/31/2022 at 8:45 AM, Resident #41 was observed in the hallway using her walker going back to her room after breakfast. The surveyor did not see the wander guard on her but observed it again hanging on wheelchair. Photographic evidence obtained. During an interview on 03/31/22 at 9:20 AM with Staff N, MDS Coordinator, she was asked if Resident #41 is at risk for wandering / elopement. She reviewed the resident's care plan and said, She has a Care Plan for risk to wander and her MDS documents she has a wander guard. During an interview on 03/31/22 at 9:44 AM with DON (Director of Nursing), the DON stated, This resident doesn't usually go outside the household. The wander guard should be on her ankle or wrist. If she doesn't ambulate, it might be put on her wheelchair. The Wander risk assessments are completed quarterly. When residents are first admitted , all residents will be placed with a wander guard for three days. During an interview on 03/31/22 at 9:54 AM with Staff M, CNA (Certified Nursing Assistant), she acknowledged Resident #41 has a Wander guard that is on her wheelchair or walker. During an interview on 03/31/22 at 10:20 AM with Staff C, RN (Registered Nurse), she acknowledged that Resident #41 has a Wander guard, and it is sometimes on her wrist, ankle or sometimes on the device the resident uses. She uses both [walker and wheelchair]. We test the wander guard every shift when we go in. She stated that if the resident changes mobility devices, she does not move it over. We check to see if it is on the resident or mobile device. 2. Review of the record revealed Resident #45 was admitted to the facility on [DATE], with a re-admission on 01/19/22 after a two-day hospital stay. Review of the current Minimum Data Set (MDS) assessment dated [DATE], documented Resident #45 had a Brief Interview for Mental Status (BIMS) score of 04, on a 0 to 15 scale, indicating the resident was cognitively impaired. This MDS indicated Resident #45 had had a fall with a fracture. During an interview on 03/29/22 at 3:41 PM, when asked how she fell and hurt her leg, Resident #45 could not recall. Resident #45 uncovered her right leg and showed the surveyor her now healed incision, extending from her outer right hip to her knee. Review of a progress notes dated 01/17/22 at 2:41 PM by Staff I, a Licensed Practical Nurse (LPN), documented, Resident called on team room phone (a room used by staff for charting and meetings) from room number and this writer answered. Resident stated, I was trying to call my cousin and I am sitting on the ground in my room and my leg hurts. This writer immediately went to resident's room and she is sitting on the floor on bottom in front of window. Lights in room were turned off by resident she stated because they were too bright. Call light was not initiated. C/O [complained of] 8/10 RLE [right lower extremity] pain. Vitals all WNL [within normal limits]. Foley [urinary drainage device] intact. RLE [right lower extremity] visibly swollen with no noted redness. 2 person assist with transfer to w/c [wheelchair] with difficulty. Resident grimacing and holding right thigh. This note further documented the physician, Director of Nursing (DON), and family were notified, and Resident #45 was sent to the emergency room (ER). A subsequent progress note, dated 01/17/22 at 11:27 PM, revealed Resident #45 was admitted to the hospital with a right femur (leg) spiral fracture and needed surgery. Review of the current care plan, initiated on 12/25/19, documented that Resident #45 was at risk for falls. Interventions in place prior to the fall included having personal items including her phone within reach. During an interview on 03/31/22 at 8:42 AM, when asked about Resident #45's fall with subsequent fractured hip, Staff F, the resident's usual Certified Nursing Assistant (CNA), stated she was not at the facility that day, but she heard her phone was out of reach and the resident got up to get her phone and fell and broke her hip. During an interview on 03/31/22 at 11:09 AM, Staff I-LPN who took the phone call from Resident #45 on the day of the fall, was asked what happened. Staff I recalled receiving the phone call from Resident #45. The LPN stated she was shocked and ran into her room. Staff I stated she found Resident #45 on the floor and her phone was next to her. Staff I stated she tends to get up and furniture-walk in her room, and refuses to wear a leg bag for the Foley. When asked if she asked Resident #45 what happened, Staff I stated Resident #45 said she got up out of her wheelchair and was walking. Staff I could not recall what the resident said she was doing. During an interview on 03/31/22 at 12:37 PM, Staff H, the CNA who was assigned to the resident on the day of the fall, stated she doesn't recall exactly what happened when Resident #45 sustained the fall with subsequent fracture, but remembers Resident #45 was on the floor. Staff H stated, We didn't move her at first, because she was hurting real bad . sharp pain and fidgeting. When asked if she recalls anyone asking the resident what she was doing, Staff H stated, We asked her . I think she said she was trying to get around to the phone to the other side of the bed. We found her at the foot of the bed. I never knew (name of Resident #45) to walk. She always wheeled herself with her feet and would take herself to the bathroom. That day was the only time I knew of her to try to walk. When asked if management spoke with her after the event as part of the investigation, or if she wrote any type of statement. During an interview on 03/31/22 at 12:51 PM, Staff B, a Registered Nurse (RN), explained that Staff I-LPN, asked her to assess Resident #45 after the fall, as another set of eyes. When asked if Resident #45 said what she was trying to do, Staff B, the RN stated Resident #45 said she was trying to do something . something about a phone but did not recall exactly. When asked if management spoke with her after the incident about what happened, Staff B, the RN stated, No. During a subsequent interview on 03/31/22 at 1:00 PM, when asked what was Resident #45's usual mobility routine prior to the fall, Staff F-CNA, stated Resident #45 would never get up and try and walk. Staff F explained she would leave the Foley bag hanging on the side of the bed next to the bathroom because the resident would self-transfer from the bed to her wheelchair and go to the bathroom by herself. Staff F stated Resident #45 did get occasional calls from her family. When asked if she asked the resident upon her return to the facility what she was trying to do, Staff F stated Resident #45 could not remember but later said the resident said something about the phone. The DON was asked to locate and provide documented evidence of a review of the 01/17/22 fall sustained by Resident #45. The DON provided a summary of the fall. During an interview on 03/31/22 at approximately 12:00 PM, the DON was asked if there was any other documented evidence that she spoke with staff about the fall to determine the cause of the fall. The DON stated she does not write down every interview she completes. When asked if spoke with staff to try to determine what the resident was doing at the time of the fall, the DON again stated she did, but did not have any documented evidence of this. 3. During observations throughout the survey, Resident #61 was noted to independently self-propel in her wheelchair throughout the [NAME] Villa neighborhood. On 03/28/22 at 10:52 AM, Resident #61 was observed at the end of the hallway, trying to get into the room of Resident #39, who was not happy and closed the door on Resident #61. Review of the record revealed Resident #61 was admitted to the facility on [DATE]. Review of the Wandering Risk Scale assessments revealed the last completed assessment was on 01/13/21. The electronic medical records (EMR) had two additional incomplete Wandering Risk Scale assessments dated 11/18/21 and 02/06/22. The record lacked any further wandering risk assessments. Review of the Behavior Symptoms documented in the tasks portion of the EMR revealed Resident #61 exhibited wandering behaviors on 5 of the 30 days, all within the past 10 days, and mainly documented by Staff F, the resident's usual CNA. During an interview on 03/30/22 at 11:25 AM, Staff I, a Licensed Practical Nurse (LPN) stated Resident #61 has not been exit seeking nor has she eloped, but she will wander into other resident rooms. When asked about the Wandering Risk Assessments, Staff I explained they are done quarterly and with any event. When asked how she knows when it is due to be done, the LPN stated it will show up red on the EMR. During a side-by-side review of the record at this time, Staff I agreed the last two wandering risk assessments were incomplete and the last completed assessment was dated 01/13/21. When told Resident #61 was observed on Monday 03/28/22 trying to get into the room of Resident #39, the LPN stated, Oh boy, I hope (name of Resident #39) wasn't there as she would not be happy. Staff I was told Resident #39 was at the door, was not happy, and closed it on Resident #61. During an interview on 03/30/22 at 11:56 AM, Staff F-CNA, stated she documented wandering for Resident #61 in the EMR because the resident goes in and out of other resident rooms and has been known to take items from other residents.

Based on observation, interview, record review and policy review, the facility failed to ensure proper care and services for 1 of 1 sampled resident, Resident #25, who was being fed by enteral means, as evidenced by nursing staff provided more fluids than were assessed by the Registered Dietician and ordered by the physician, which had the potential for fluid overload; failed to follow orders for recording intake and output; and failed to ensure an ordered laboratory draw was completed for Resident #25, who was primarily fed via enteral means (via tube) but could also take fluids orally. The findings included: Review of the policy, titled, Tube Feedings & Medication Administration, revised 06/2018, documented, Procedure: 1. Check the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . d. Amount of water to flush per shift. Bolus Feeding: . 5. Flush the tube with 30 - 60 ml of water, or amount otherwise ordered by physician, after nourishment is introduced. Documentation: . 3. Record intake and output in the intake and output section of the electronic record or if the electronic record is not available in the Intake and Output Record. Review of the record revealed Resident #25 was admitted to the facility on [DATE], with a re-admitted [DATE]. Review of the current Minimum Data Set (MDS) assessment documented Resident #25 received 51% or more of her daily nutrition via a tube feeding. The MDS documented Resident #25 had a BIMS score of 12, indicating the resident had some cognitive impairment. Review of the current orders related to Resident #25's nutritional and fluid needs revealed the following: 04/06/21, Regular diet, Regular texture, Thin/Regular consistency Dietary liberties for special occasions. Serve only per resident's request. 04/01/21, Ensure Plus four times a day for enteral feeding. Administer 1 can via bolus and record % consumed. 04/01/21, Flush G-tube (specific type of feeding tube) with 50 ml of warm water before meals and with 50 ml of warm water after meals. Also, flush G-tube with 50 ml of warm water at bedtime for maintenance. (Note this would total 450 ml of water via the tube in a 24-hour period.) 04/01/21, Document total intake via G-tube on log sheet in Treatment Administration Record (TAR) binder. Includes flushes & Ensure. 04/30/21, Give 120 ml fluid of choice twice daily by mouth for hydration and record % consumed. 02/07/22, Basic Metabolic Panel (BMP) (Routine) laboratory draw. Review of the most current progress note by the RD, dated 03/08/22, documented Resident #25 had orders for enteral nutrition: Ensure Plus . which provides 948 ml fluid daily. Flush with 50 ml water before meals, after meals, in the evening for maintenance (400 ml). Provides a total of 1298 ml/water daily. She has orders for 120 cc. H2O BID (twice daily), consumes 100% most days. (Note the calculation of 400 ml for the water flush should be 450 ml, with the provision of fluids via tube at 1398 ml of water daily.) The documented resident fluid need was calculated at 1360 ml/day, as per this progress note. During an observation on 03/29/22 at 10:39 AM, Staff J, a Registered Nurse (RN) provided the ordered Ensure Plus via bolus (administering the nutrition via gravity) to Resident #25. Before the RN gave the Ensure Plus, she flushed the feeding tube with 120 ml (milliliters) of water. After the Ensure Plus, the RN provided another 120 ml of water. The amount of water was verbally confirmed by Staff J. During an observation on 03/29/22 at 12:01 PM, Staff J-RN provided medications crushed in applesauce for Resident #25. During this medication administration, Staff J explained Resident #25 received her nutrition via the tube, but she can and does take her pills by mouth. Resident #25 was offered and accepted a drink of water after the administration of the pills. A large water jug was noted at her bedside. On 03/29/22 at 2:12 PM, Staff J-RN was observed in the room of Resident #25. She was just capping off the resident's tube and stated she had just finished. Two empty water cups were noted at the bedside, just as had been used with the earlier administration. Staff J confirmed she had just provided the Ensure Plus bolus, with 120 ml of water both before and after administration. During an interview on 03/29/22 at 2:18 PM, Staff J-RN confirmed she was giving 120 ml water before and after each meal instead of the ordered 50 ml. The RN confirmed the order for the 120 ml of fluid twice daily is to be offered and given by mouth. Staff J explained she was giving the extra fluid with the Ensure Plus bolus feed because she had the 120 ml twice daily order for fluids by mouth, and the resident refuses it. When asked why this wasn't communicated to the RD (Registered Dietician) or physician to have the order changed, the RN did not have any answer. Staff J agreed that by giving the 120 ml of water before and after each feeding, Resident #25 would be receiving 960 ml of water each day, instead of the ordered 450 ml of fluid. When asked why she gives more fluids than ordered, Staff J stated, just for the hydration . she gets the dry lips. When asked about an intake and output record in the TAR (Treatment Administration Record) binder as ordered, Staff J found the record, which contained some documentation daily, but not consistently on each shift. Staff J stated she does not document on that record. During an interview on 03/29/22 at 2:34 PM, the RD explained Resident #25 refuses to eat anything by mouth as it grosses her out and even the thought of food makes her upset. The RD stated prior to her admission to the facility, her husband was feeding her via a tube at home. When asked about her fluid and hydration status, the RD stated Resident #25 is getting her fluid needs met through the tube with the formula and water flushes. The RD stated Resident #25 is also encouraged to drink water with medications, which she believes the nurses document on the MAR. The RD stated Resident #25 will accept water to drink by mouth. When asked about the purpose of the intake and output record in the TAR order, the RD was unsure, stating she reviews the intake on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The RD suggested we look at the current laboratory values to determine the resident's fluid status. The RD was shown the order for the BMP on 02/07/22 and was asked to locate and provide the results. The RD was unable to locate the results. During an interview on 03/29/22 at 3:02 PM, Staff K, the day shift CNA (Certified Nursing Assistant), stated she does not encourage Resident #25 to drink fluids by mouth, but explained Resident #25 will sometimes ask for water to drink and the CNA will provide it. At this same time, Staff L, the evening CNA, was noted passing out fresh water to all of the residents. Staff L stated she provides water for Resident #25 and encourages her to drink it. Staff L stated Resident #25 is supposed to drink 120 ml during the shift. Staff L stated she records the resident's intake in the computer. Review of the CNA documentation in the computer for the past 30 days (02/28/22 through 03/29/22) revealed the following: Resident #25 drank fluids 6 times during the breakfast meal, ranging from 60 ml to 360 ml time. Resident #25 drank fluids 5 times during the midday meal, ranging from 40 ml to 350 ml at a time. Resident #25 drank fluids 12 times during the evening meal, ranging from 60 ml to 120 ml at a time. The medical record for Resident #25 had documented fluid intake in three different locations to include on the MAR (Medication Administration Record), the intake and output paper record in the TAR binder, and the CNAs documentation. During a subsequent interview on 03/29/22 at 3:19 PM, Staff J-RN, explained any order for laboratory draws get put into the computer, the night shift prints out the requisition for the labs to be drawn, and then a laboratory staff will come the next morning to draw the sample. When asked to locate and provide the ordered BMP (Basic Metabolic Panel) labs for Resident #25 on 02/07/22, Staff J was unable to find it. The RN also looked for a subsequent progress note as to why the order was not completed and could not find any documentation.

Based on observation, interview and record review, the facility failed to ensure proper labeling and storage of medications, as evidenced by failure to secure medication cabinets for 3 of 19 sampled residents, Residents #66, #16, and #57; failure to store medications properly for 1 of 3 inspected medication carts (loose medications); and failure to accurately label medications for 1 of 6 sampled residents, Resident #44. The findings included: 1a. Clinical record review revealed Resident #66 was initially admitted to the facility on [DATE] with a re-admission on 01/27/20. The annual (modification) minimum data set (MDS) assessment reference date 01/27/22, revealed, Resident #66 had a brief interview for mental status score of 03 indicating Resident #66 was cognitively impaired. This MDS documented Resident #66 exhibited behaviors that included: pacing, and rummaging. The care plan, with revision date 02/03/22, recorded Resident #66 had impaired cognitive function or impaired thought processes related to dementia. A progress note dated 03/24/22 at 11:28 PM, documented Resident #66 had increased confusion, agitation, grunting, and pacing. On 03/28/22 at 8:41 AM, an observation was made in Resident #66's room, in the Bueno Vista unit, of the medication cabinet located towards the left side of the room. The medication cabinet was observed to be left unlocked and unattended with 3 bottles of medications (meds) sitting inside of it that included Losartan, [MEDICATION(S)], and [MEDICATION(S)]. There was another resident's name written on these bottles of the medications, but this resident no longer lives in the facility. Resident #66, who was currently residing in this room, was observed with confusion, pacing, and wandering between her room and the Bueno Vista unit. She was self-ambulatory using a rolling walker. On 03/28/22 at 1:42 PM, the medication cabinet located in Resident #66's room remained unlocked with the 3 bottles of meds inside the cabinet. During that time the attending nurse, Staff B, a registered nurse (RN), was made aware of the finding. Staff B and the surveyor went into the resident's room. Staff B noted the medication cabinet was unlocked. Staff B stated, Those medications shouldn't be in the cabinet, as [the resident's name written on the bottle of the medications] had passed away. During this time Resident #66 was observed out of bed, wandering around in the room using a rolling walker, and was noted with confusion. 1b. Clinical record review revealed Resident #16 was admitted to the facility on [DATE]. The annual MDS assessment reference date 03/26/22, documented a Brief Interview for Mental Status (BIMS) score of 11, indicating Resident #16 was moderately cognitively impaired. Additionally, there was a progress note, dated 03/30/22 at 1:53 PM, that documented, 'Resident #16 was alert with forgetfulness. He uses a wheelchair for mobility. He was able to self-propel upon household.' On 03/29/22 at 9:41 AM, an observation was conducted in the resident's room, located at the Key West unit. It was revealed that the medication cabinet towards the right side of the room was observed to be left unlocked and unattended. There was a [MEDICATION(S)] insulin pen in the cabinet. During this time, the surveyor had informed Staff C-RN that the medication cabinet was left unlocked. Staff C stated, The cabinet was supposed to be locked. Resident #16, who resided in this room, was observed self-propelling using wheelchair. Photographic evidence obtained. On 03/29/22 at 10:00 AM, the Assistant Director of Nursing (ADON) was made aware of the concerns regarding medication cabinets left unlocked in the rooms of Resident #66 and Resident #16. Photographic evidence was shown to the ADON. On 03/29/22 at 10:05 AM, the Director of Nursing (DON) was also made aware of the findings. Photographic evidence was shown to the DON. 1c. During an observation on 03/28/22 at 02:08 PM in Resident #57's room, the bottom right cabinet door of the bedside medication cabinet for Resident #57, was observed to be unlocked. This cabinet contained at least two tubes of Hydrocortisone cream, extra batteries, four containers of inhalers and at least one tube of [MEDICATION(S)] cream. Resident #57 was observed independently ambulating with his rolling walker to and from his room numerous times, passing by the medication cabinet. Resident #57 was cognitively impaired with a Brief Interview for Mental Status score of 01, on a 0 to 15 scale, as per the Social Worker assessment of 03/29/22, indicating severe cognitive impairment. The roommate, Resident #91, was also observed self-propelling in his wheelchair, in and out of his room which passes by the medication cabinets, throughout the survey week. Resident #91 had a BIMS score of 06, indicating he was severely cognitively impaired as well. 2. On 03/31/22 at 11:58 AM, the Bueno Vista medication cart was audited and observed. There were two unidentified pills noted in a plastic medicine cup, unlabeled, in the top drawer of the medication cart. The attending nurse, Staff E, a license practical nurse (LPN), stated she did not put the medication there; she thought it was from the night shift. Staff E stated, The medications should not have been stored in a medicine cup, unlabeled. 3. During an observation of the [NAME] Villa medication cart on 03/31/22 at 9:42 AM, a random narcotic count was conducted with Staff I-LPN. Resident #44 had a Individual Patient Narcotic Record for [MEDICATION(S)] that had 53 tablet left. The label for this medication documented, 03/23/22 [MEDICATION(S)]-Acetaminophen Tablet 37.5-325 mg (milligrams), take one tablet by mouth at bedtime and one tablet daily as needed for pain. The corresponding bubble pack label, with the 53 tablets, documented the same information. Review of the current orders included the following two orders: 01/26/21, [MEDICATION(S)]-Acetaminophen Tablet 37.5-325 MG Give 1 tablet by mouth at bedtime for moderate pain and give 1 tablet by mouth one time only for routine pain for 1 day. 01/26/22, [MEDICATION(S)]-Acetaminophen Tablet 37.5-325 MG Give 1 tablet by mouth every 6 hours as needed for moderate pain not to exceed 3,000 grams in 24 hrs. During an interview on 03/31/22 at 10:34 AM, Staff I-LPN agreed with the confusion and lack of consistent labeling. Staff I phoned the pharmacy to determine the order on their records. Review of their order documented a third set of directions as follows: 10/07/21, [MEDICATION(S)]-Acetaminophen 37.5 - 325 mg take one tablet by mouth at bedtime and one tablet daily as needed for pain. During a subsequent interview on 03/31/22 at 11:07 AM, Staff I explained that the physician for Resident #44 would usually have his office staff call in a new prescription for narcotics directly into the pharmacy.

Based on observation, interview, record review and CDC (Center for Disease Control) recommended guidance, the facility failed to implement their new resident admission policy related to Covid-19 and CDC guidance for 1 of 1 sampled resident, Resident #292; and failed to consistently screen staff upon arrival at the [NAME] and when entering the nursing home. The findings included: Review of the undated Infection Control Policy, for new resident admissions, provided by the Infection Control Preventionist (ICP) on 03/30/22, revealed: all not fully vaccinated residents returning or newly admitted . from a hospital stay / or outing 24 hours or greater will be rapid tested immediately upon arrival and will be admitted /readmitted to a private room if available on droplet-based isolation or to a semi-private shared with a resident on the same droplet-based isolation precautions for 14 days and will be rapid tested every other day for 14 days. Review of the CDC guidance for Newly admitted or readmitted Residents at the CDC website, https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, updated February 2, 2022, documented: In general, all residents who are not up to date with all recommended COVID-19 vaccine doses and are new admissions and readmissions should be placed in quarantine, even if they have a negative test upon admission, and should be tested as described in the testing section above; COVID-19 vaccination should also be offered. Facilities located in counties with low community transmission might elect to use a risk-based approach for determining which of these residents require quarantine upon admission. Decisions should be based on whether the resident had close contact with someone with [CONDITION(S)]-CoV-2 infection while outside the facility and if there was consistent adherence to IPC practices in healthcare settings, during transportation, or in the community prior to admission. Residents . who are not up to date with all recommended COVID-19 vaccine doses: These residents should generally be restricted to their rooms, even if testing is negative, and cared for by HCP using an N95 or higher-level respirator, eye protection (goggles or a face shield that covers the front and sides of the face), gloves and gown. They should not participate in group activities. Residents who are not up to date with all recommended COVID-19 vaccine doses and who have had close contact with someone with [CONDITION(S)]-CoV-2 infection should be placed in quarantine after their exposure, even if [CONDITION(S)] testing is negative. HCP caring for them should use full PPE (gowns, gloves, eye protection, and N95 or higher-level respirator). Residents can be removed from Transmission-Based Precautions after day 10 following the exposure (day 0) if they do not develop symptoms. Although the residual risk of infection is low, healthcare providers could consider testing for [CONDITION(S)]-CoV-2 within 48 hours before the time of planned discontinuation of Transmission-Based Precautions. Residents can be removed from Transmission-Based Precautions after day 7 following the exposure (day 0) if a [CONDITION(S)] test is negative for [CONDITION(S)]-CoV-2 and they do not develop symptoms. The specimen should be collected and tested within 48 hours before the time of planned discontinuation of Transmission-Based Precautions. 1. On 03/30/22 at 9:45AM, an isolation cart was observed outside of the room of Resident #292. There was no signage on the door, and the social worker was noted in the room within 6 feet of Resident #292, who was standing up with her walker. The door to Resident #292's room was open. When the social worker left the room, she was asked what the isolation cart was for. The social worker stated, I don't know. You would have to ask the nurse. On 03/30/22 at 9:55 AM, an interview was conducted with Staff I, the attending nurse, a Licensed Practical Nurse (LPN). When asked what the isolation cart outside of Resident #292's room was for, Staff I stated, the DON told me to put it there because Resident #292 was a new admission, so she needed to be on isolation. When asked about signage for the door, Staff I stated, I am looking for a droplet precautions sign now. Staff I confirmed Resident #292 was admitted over the weekend on 03/26/22. When asked if that was something that should have been done upon admission, Staff I was unsure. When asked if Resident #292 was vaccinated, Staff I stated, I think so. On 03/30/22 at approximately 10:20 AM, Staff I informed the surveyor that she was just informed from Independent Living (IL) that Resident #292 was not vaccinated. On 03/30/22 at 11:42 AM, an interview was held with the Infection Control Preventionist (ICP). When asked whether Resident #292 was vaccinated, the ICP revealed that the facility was unaware of Resident #292's vaccination status until Monday 03/28/22, when the facility obtained Resident #292's records from IL. The ICP further added that Resident #292 was admitted during the weekend on 03/26/22, the IP was not there but the admitting nurse should have asked Resident #292 about her vaccination status as she was alert and oriented, so she (the nurse) could determine the infection control process. The ICP voiced that when she came in Monday morning (03/28/22), she sent an email to Resident #292's nurse at the IL to obtain information regarding the resident's vaccination status. The ICP voiced the nursing home also has access to the IL computer system for immunization record. On 03/30/22 at 11:52 AM, an interview was held with Staff A, a LPN, and when asked about the process and protocols for new admissions relating to infection control status post [MEDICAL RECORD OR PHYSICIAN ORDER] . On 03/30/22 at 4:23 PM, Resident #292 was observed walking from her room to the door of the outdoor patio without a face mask, to the double doors of the neighborhood, and then over to the surveyor who was in the dining room. Resident #292 voluntarily stated, They are re-evaluating my Covid status because I can't get the vaccine and they just discovered that today. When asked if she was on isolation, Resident #292 stated, they haven't said anything to me about that. When asked about a face mask, Resident #292 stated, I have one, it's in my room, they haven't said anything to me. 2. During the infection control review process, the Infection Control Preventionist / Assistant Director of Nursing (ICP/ADON) revealed there was a staff who tested positive for Covid-19 on 02/12/22, Staff O, a Certified Nursing Assistant (CNA). A request of one week of screening reports for Staff O was made for days that she worked, prior to the positive result. The ADON provided the screening records. Review of the screening records revealed they were incomplete, with no temperature and no answers to the surveillance questions. The ICP stated that visitors and staff were to be screened at the [NAME] and at the nursing home and are to ask the surveillance questions and take temperatures. The screening records were as follows: The screening record dated 02/08/22 with check in time of 6:47 AM for Staff O, recorded no temperature and no answers to the surveillance questions. The surveillance questions were as follows: 'signs and symptoms, have you been exposed to anyone with a positive COVID-19 diagnosis? Have you been tested for COVID-19? Have you returned from any of the following (travel) withing 14 days?' There were no answers in the record for any of these questions. The record documented Staff O was allowed to work. The screening record dated 02/09/22 with check in time 6:44 AM for Staff O, recorded no temperature and no answer to the same surveillance questions. The record documented Staff O was allowed to work. The screening record dated 02/10/22 with check in time 6:51 AM for Staff O, recorded no temperature and no answer to the same surveillance questions. The record documented Staff O was allowed to work. The screening record dated 02/11/22 with check in time 6:47 AM for Staff O, recorded no temperature and no answer to the same surveillance questions. The record documented Staff O was allowed to work. The screening record dated 02/12/22 with check in time 6:33 AM for Staff O, recorded no temperature and no answer to the same surveillance questions. The record documented Staff O was allowed to work. The ADON who is also the ICP reviewed the screening records and agreed with the findings. Staff O was unavailable for interview by the surveyor. The ICP stated that Staff O had no signs and symptoms and tested positive after residents she cared for had tested positive.

Based on policy review, record review and interview, the facility failed to ensure screening for the pneumococcal immunization for 3 of 5 sampled residents, Residents #8, #9, and #14. The findings included: The policy, titled, Influenza and Pneumococcal Education and Consent for Residents, documented to strive to inform and educate the residents in WillowBrooke Court (WBC) of the legislative requirement for: offering the influenza and the pneumococcal immunization. Documenting offering, education, administration or refusal of the influenza and pneumococcal immunization. The procedure included: upon admission, the licensed nurse will notify the resident, family and/or responsible party of the legislative requirements that each resident be advised to receive immunization against influenza and pneumonia. 1. Clinical record revealed Resident #8 was admitted to the facility on [DATE]. It was revealed Resident #8 had advance directive of health care surrogate (HCS). During the infection control review process, it was revealed Resident# 8 had not been screened for the pneumococcal immunization / vaccination. There was no evidence of a pneumococcal vaccination screen in the records. During a side-by-side review of Resident #8's record with the infection control preventionist (ICP), she agreed with the finding. 2. Record review revealed Resident #9 was admitted to the facility on [DATE], she had advance directive of HCS. Clinical record review was conducted for Resident # 9, there was no evidence of a screen for the pneumococcal immunization in the record. During a side-by-side review of Resident #9's record with the ICP, she agreed with the finding. 3. Clinical record review for Resident#14 revealed that Resident #14 was screened for the pnuemonoccal immunization in 02/26/20 but refused to receive the pneumococcal vaccine. There was no evidence of a pneumococcal immunization re-screen in 2021. The ICP said Resident #14 should have been re-screened in 2021.

Based on record review and interview, the facility failed to ensure the required Interdisciplinary Team members (IDT) involvement in the process of care planning for 7 of 28 sampled residents (Resident #15, #39, #41, #47, #49, #56 and #75). The findings included: 1. Record review for Resident #15 revealed the care plan review and revision was started and completed on 12/30/20. There was no record found for evidence of a care conference for this care plan review. There was no evidence of required IDT team attendance to this care plan review. On 03/26/21, at 9:02 AM during the review process of Resident #15's records with the Minimum Data Set coordinator (MDS) and interview, the MDS coordinator acknowledged the lack of evidence of the care conference documentation in Resident #15's chart. She had the medical record staff looked for the record and it was not found. The MDS coordinator was given an opportunity to provide the care conference record, she did not provide it. 2. Record review for Resident #39 revealed the care plan review and revision was started and completed on 02/04/2021. On 03/26/21 at 9:06 AM, during the review process of Resident #39's records with the MDS coordinator, the MDS coordinator presented a care conference record that had evidence of signatures of the following attendees to the care plan review included: Activity staff, a floor nurse, PTA (Physical therapy assistance), and Dietitian. There was no evidence of certified nursing assistance (CNA), Physician or ARNP participation to this care plan review. During the review process, an interview was conducted with the MDS coordinator, who acknowledged the lack of evidence of the required staff members to the review of this care plan. 3. Record review for Resident #41 revealed the care plan review and revision was started and completed on 02/04/21. On 03/26/21 at 9:09 AM, during the review process of Resident #41's records with the MDS coordinator, the MDS coordinator presented a care conference record that had evidence of signatures of the following attendees to the care plan review included: Social Services, Activity staff, Dietary, and the MDS coordinator. There was no evidence of CNA, direct care nurse, physician or ARNP participation to this care plan review. During Resident #41's record review process, an interview was conducted with the MDS coordinator, who acknowledged the lack of evidence of the required staff members to the review of this care plan. 4. Record review for Resident #47, it was revealed the care plan reviews and revision was started and completed on 02/11/21. On 03/26/21 at 9:13 AM, during the review process of Resident #47's records with the MDS coordinator, the MDS coordinator presented a care conference record that had evidence of signatures of the following attendees to the care plan review included: Social Services, Activity staff, Dietitian and MDS. There was no evidence of direct care nurse, CNA, physician or ARNP participation to this care plan review. During Resident #47's record review process, an interview was conducted with the MDS coordinator, who acknowledged the lack of evidence of the required staff members to the review of this care plan. 5. Record review for Resident #49 revealed the care plan reviews and revision was started and completed on 02/16/21. On 03/26/21 at 9:18 AM, during the review process of Resident #49's records with the MDS coordinator, the MDS coordinator presented a care conference record that had evidence of signatures of the following attendees to the care plan review included: Social Services, Dietitian, Activity staff, and floor Nurse. There was no evidence of CNA, physician or ARNP participation to this care plan review. During Resident #49's record review process, an interview was conducted with the MDS coordinator, who acknowledged the lack of evidence of the required staff members to the review of this care plan. 6. Record review for Resident #56 revealed the care plan reviews and revision was started and completed on 02/22/21. On 03/26/21 at 9:23 AM, during the review process of Resident #56's records with the MDS coordinator, the MDS coordinator presented a care conference record that had evidence of signatures of the following attendees to the care plan review included: Social Service, Dietitian, Activity staff, and Therapy Director. There was no evidence of CNA, direct care nurse, physician or ARNP participation to this care plan review. During Resident #56's record review process, an interview was conducted with the MDS coordinator, who acknowledged the lack of evidence of the required staff members to the review of this care plan. 7. Record review for Resident #75 revealed the care plan reviews and revision was started and completed on 03/08/21. On 03/26/21 at 9:28 AM, during the review process of Resident #75's records with the MDS coordinator, the MDS coordinator presented a care conference record that had evidence of signatures of the following attendees to the care plan review included: Social Services, Activity staff, Dietitian and MDS Coordinator. There was no evidence of direct care nurse, CNA, physician or ARNP participation to this care plan review. During Resident #75's record review process, an interview was conducted with the MDS coordinator, who acknowledged the lack of evidence of the required staff members to the review of this care plan.

Based on record review and interview, the facility failed to provide appropriate interventions to minimize the risk of elopement for a severely cognitively impaired resident with known wandering behaviors for 1 of 1 sampled resident, reviewed for elopement (Resident #237). The findings included: Resident #237 was admitted to the facility on [DATE] for short term rehabilitation. She was discharged to the community on 01/15/21. Review of Resident #237's Minimum Data Set (MDS) admission assessment dated [DATE] showed the resident had a Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impairment. Review of Resident #237's comprehensive care plans showed care plans related to: -12/09/20: ' .I was recently in the hospital and they sent me here. I wandered at home but I don't remember doing that. I have cognitive impairment but I am not aware I have confusion and forgetfulness. I walk with no assistance and my issue is with cognition .' -12/09/20: 'I may wander and/or seek exits related to impaired safety awareness, dementia. I am looking for my husband. I will remain in a safe, supervised environment through the review date and I will be free from injury or distress related to wandering/exit seeking through the review date. Interventions included: Assess me for fall risk; Distract me from wandering by offering pleasant diversions, structured activities, food conversation, television, book I prefer; Identify my pattern of wandering: Is wandering purposeful, aimless, or escapist? Am i looking for something? Does it indicate the need for more exercise? Intervene as appropriate; Monitor me for fatigue and weight loss; Monitor my location frequently. Document my wandering behavior and any attempted diversional interventions in behavior log; Provide me with structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes; WANDER ALERT: check for function and placement every shift and record in Treatment Administration Record.' -12/09/20: 'I have impaired cognitive function or impaired through processes related to dementia.' -12/09/20: 'I am a fall risk related to muscle weakness, impaired vision, dizziness, poor safety awareness, incontinence.' -12/21/20: 'I have impaired visual function.' Review of Resident #237's Wander Risk Assessments showed: -12/08/20 score =17 high risk to wander. has wandered within the home without leaving grounds has history of wandering (past hospitalization or history from resident/family). -12/11/20 score=16 high risk. has wandered in past month. -01/11/21 score=14 high risk. Review of Resident #237's progress notes showed documentation of wandering including: -12/16/20 at 2:03 (AM) .Resident frequently out of bed wandering, looking for spouse, distressed at not knowing where or why she is here. Resident can be redirected and able to self calm -12/24/20 at 21:48 (9:48 PM) .resident continues wandering the halls asking for [spouse] and she frequently wanders into other residents' rooms. She was found earlier in another resident's bed. but was re-oriented back to her own room, will continue to monitor. -12/25/20 at 8:27 (AM) .received phone call from security at 4:45 (AM) that there was a resident that fell outside; upon exiting the front door, resident could be observed walking toward building entrance with security. Resident with abrasions and skin tears noted bilateral upper extremities and right lower extremities. injuries consistent with falling forward onto hands and knees resident assessed from head to toe, minor abrasions noted on hands, arms, and right lower extremity; resident declined offer to assist with wheelchair back other room; Resident brought into her room and wet socks and gown removed, warmed blanket provided; wounds cleaned with normal saline, steri-strips and dry gauze bandages applied to wounds; resident VSS (vital signs stable), no visible injuries to head, neck or back; resident is not on blood thinners; resident placed on Q-15 min checks (every 15 minutes); warm clothing and non-skid socks put on; spouse contacted for permission to utilize wanderguard; Wanderguard explained, permission obtained and bracelet. -12/28/20 .Monthly summary: resident is alert and oriented times self; has frequent confusion and forgetfulness; wandered into the parking lot 12/25/20 and sustained abrasions and a skin tear .requires constant observation. -12/29/20 .resident alert with confusion; attempted several times to exit the building; resident found in the kitchen trying to exit through elevator several times; she was also found going into other residents' room; assist resident back to bed and encourage her to stay in room; will continue to monitor and ensure safety measures are maintained. -12/30/20 at 00:45 (12:45 AM) .resident visibly upset, looking for spouse; resident disassembled medicine cabinet in room, glass shelves removed for resident safety, ward-robe drawers pulled out of cabinet by resident and placed onto floor; resident searching kitchen, elevators, lobby for spouse; 1:1 for 45-minutes before resident self-calmed; resident stating that her back is hurting; medicated x1 with Tylenol; resident then assisted back to bed; room temperature, adjusted from 76 degrees with heat to 72 degrees; resident positioned in bed with feet slightly elevated, stating improvement in pain; resident encouraged to breath and was reassured that she is not bleeding from the face; resident repeatedly talking about the children doing something unsafe, how could that happen; resident grasping onto bed linens with clenched fists, after 30 minutes of 1:1 and medication resident able to relax, occasional calls/yelling-out for her husband; her body is more relaxed and she is now able to close her eyes; call bell in reach, room picked up and cabinet doors closed; will continue to monitor; resident continues with Q-15 min checks at this time -12/30/20 at 05:03 (AM) .Resident awoke at 4 AM, attempting to shower in spa, removed all linens from bed, dressed in every clothing item she owns; Post walking, snack and water, resident assisted in remaking her bed. Resident then laid down; call bell in reach. will continue to monitor. -01/03/21 at 1900 (7 PM) .Resident continues wandering into other resident's bedrooms, taking items such as clothing and glasses out from other resident's rooms, tried to take writer's badge and stethoscope; very anxious and wound up this shift; writer spoke with spouse and spouse requested [Doctor] be faxed about anxiety medication; Response pending; resident currently resting in bed now; will continue monitor. Review of Resident #237's physician's orders showed an order was received for a Wanderguard on 12/25/20 after the elopement incident. Further review of Resident #237's clinical record showed she had a previous short term admission from 09/19/20 to 10/06/20. Review of her progress notes during this admission showed: -09/21/20 Resident voicing wanting to go home and wanting to find a way out of here, exiting seeking out of [unit] noted x1. Spouse aware and has spoken with resident to redirect. -09/22/20 .alert with confusion. easily re-oriented .exit seeking early this shift looking for her husband . -10/02/20 wanderguard in place due to exit seeking . -10/03/20 .wanderguard in place. The Wander Risk assessments from her previous admission showed: -09/19/20: high risk to wander score=12 -9/22/20: high risk score=12. Review of facility documentation showed an elopement on 12/25/20 at 4:26 AM involving Resident #237. The information included: 'Resident #237 exited her unit through double doors into the lobby. She then exited the front entrance of the facility. 12/25/20 at 4:26 AM Resident #237 found lying in Willow Brooke Court (WBC) parking lot by security guard. Security Guard called Registered Nurse A (RN) at WillowBrooke Court. RN A met security guard and Resident #237 in the parking lot with a wheelchair. When asked why she was outside Resident #237 stated, I was picking up a book for my husband. Resident #237 declined to use wheelchair and was accompanied back to WBC by RN A. Nursing assessment reveals some abrasions to palms and knees. First aid administered. No other injuries were observed. Resident's husband notified at 5:30 AM and gave permission to apply wanderguard on wife's wrist. Resident's physician notified and ordered a urinalysis. Resident #237 had last been seen by RN-A at 4 AM when putting her back to bed. Resident #237 had been in corridor looking for her husband. According to RN-A, Resident #237 had been informed and likely spoke with husband earlier in the day that he would be coming to pick her up Christmas morning. RN-A reported that any time husband calls, resident becomes restless and begins looking for him. Resident #237 was placed on 15-minute checks for 72 hours related safety. Resident care plan was reviewed. Wanderguard applied 12/25/20 and added to care plan. Urinalysis was normal.' An interview was conducted with Certified Nursing Assistant G (CNA) on 03/25/21 at 2:30 PM. She stated she did not remember Resident #237. She did explain that if a resident has wandering behavior, staff try to talk to them to see if they can tell staff what they need or want. Staff also try to direct the resident to their room and sit with them. When worn, wanderguards set off the alarms on the doors. Staff then go and see who is trying to leave the unit or is coming in from another unit. An interview was conducted with Licensed Practical Nurse H (LPN) on 03/25/21 at 2:35 PM. She stated she remembered Resident #237 had wandering behavior. She would come outside her room and ask for her husband but she was easy to redirect. LPN-H never witnessed her trying to get out. LPN-H stated Resident #237 walked with a walker but was fast. Staff-H said, in general, if a resident has a wanderguard, the alarms go off. Specific codes are entered into the doors to stop the alarm. Staff also check wanderguards every shift. An interview was conducted on 03/25/21 at 2:40 PM with RN-I. RN-I explained facility protocol was all new admissions are given a wanderguard for the first three days. Staff continue to assess for wandering behaviors. If a resident is admitted without wandering behaviors and begins to wander then the wanderguard would remain. If a resident is wandering, then staff will do vitals each shift and implement urinary tract infection prevention protocols. If the wanderguard alarms go off staff immediately go and get the resident. An interview was conducted with the Assistant Director of Nursing (ADON) on 03/25/21 at 4:14 PM. The ADON explained the facility's wanderguard policy and said the policy was recently updated within the last few weeks. She stated the previous policy was upon admission, all residents get a wandering assessment and depending on the assessment and any behaviors they would receive a wanderguard. If a resident started demonstrating that behavior staff would get an order and consent. Initially staff were just looking at exit seeking behaviors because alot of residents wander through the unit or halls but only some actively exit seek to get out. For these residents it would depend on how far they wander. If they could get lost or get on the stairwell they would receive a wanderguard. The ADPN said the new policy says on admission every resident gets a wanderguard placed for 72 hours regardless of admission wandering assessment. Another assessment is done after 72 hours then the wanderguard will be removed if the resident does not meet criteria for continued use. Residents sleep with wanderguards on. If a resident has a wanderguard on, the exit to each unit will alarm and the front door will automatically lock. Patio doors also lock. Staff doors do not open. The main door in the lobby does not open automatically until the wanderguard is removed from the area. The expectation is for the staff to see who is exiting and redirect them back. The residents still go to activities independently. A few residents are alert and oriented enough to go to activities independently but every now and then they get confused and try to go to their car. If the resident is going to an activity the staff would turn the alarm off and assist them to the activities. Activities will usually get a list of who wants to go. Usually if they are going to take them they will let the activities person know to help them get back to their unit. An interview was conducted with RN-A on 03/25/21 at 3:49 PM regarding Resident #237's elopement. RN-A explained that Resident #237 had urges to return home and had baseline confusion. That night she was talking about getting books for husband. Two CNAs were assigned to Resident #237's unit and RN-A split her time between this unit and the unit upstairs. Resident #237 did not have a wanderguard on that night. She had not previously attempted to leave the unit and mostly wandered to search rooms. After the incident, a wanderguard was put on her. RN-A further explained it was Christmas Eve, activities had been going on during the day and Resident #237 was anticipating a visit from her husband. Resident #237 wanted to get something for her husband. She had been searching in her room earlier. RN-A had been back and forth between units and received a phone call from security. RN-A had been in Resident #237's room earlier. The automatic doors in the front lobby allowed a person to exit but couldn't return in. There was no other door bell or chime on the front lobby doors, only the wanderguard alarm. Resident #237 was found in the parking lot in front of the building. An interview was conducted with CNA-J on 03/25/21 at 5:20 PM, who stated she had not been assigned to Resident #237 but remembered her. CNA-J stated Resident #237 wandered but never tried to leave the unit when CNA-J worked on the unit. An interview was conducted with the Administrator / Risk Manager on 03/25/21 at 5:30 PM. Review of the facility documentation showed RN-A stating Resident #237 was wandering in the hall anticipating a visit from her husband and was brought back to bed around 4:00 AM. CNA-C was on break and CNA-B was assisting another resident in the bathroom when Resident #237 left. Staff acknowledged that Resident #237's wandering increases after speaking with her husband. A wanderguard was placed on Resident #237 after the incident. In general, Resident #237 was considered easily redirected and once in bed was usually okay. She was not described as exit seeking prior to this incident. The Administrator said she started working at the facility at the end of October 2020. She was unaware Resident #237 had had a recent previous admission where she was given a wanderguard. The Administrator was unable to explain the decision to not provide Resident #237 with a wanderguard upon this admission. A follow up interview was conducted with the Administrator on 03/26/21 at 11:56 AM. The Administrator re-opened her investigation into the incident.

Based on observations, interviews and record review, the facility failed to ensure the Consultant Pharmacist recommendations, related to residents' [MEDICAL CONDITION] drug use, were acted on by not following up with the resident's physician in a timely manner for 1 of 5 sampled residents reviewed for medications (Resident #3). The findings included: Review of the facility's undated written Policies and Procedures from their Resident Health Services Manual, titled, [MEDICAL CONDITION] Medications M-04.16 revealed, inpart, the following: Definition: [MEDICAL CONDITION] medications are defined as medications that affect brain activities associated with mental processes and behavior. These medications include but are not limited to . anti-depressants; anti-anxiety . Standards: 1. The community makes every effort to comply with state and federal regulations related to the use of [MEDICAL CONDITION] medications including regular review for the continued need, appropriate dosage, side effects, risks and/or benefits of the medication. 5. Efforts to reduce the dosage or discontinue [MEDICAL CONDITION] medications are gogoing, as appropriate, for the clinical situation. Procedure: 5. The physician should review the pharmacy consultant's recommendations and take appropriate follow-up action including the reason if a recommendation is declined. 11. The review of the use and reduction in usage of [MEDICAL CONDITION] medications will be part of the quality assurance/quality improvement (QAPI) process on a continuing basis. Review of written Policies and Procedures from the facility's Resident Health Services Manual (revised February 2019), titled, Drug Regimen Review D-01WB revealed, in part, the following: Policy: To strive to improve resident safety by conducting a drug regimen review (DRR) upon the residents' admission, and on an ongoing basis through their stay, to identify any clinically significant medication issues, risks or problems, and to address these issues in a timely manner when identified. 4. When identified potential or actual clinically significant medication issues are identified, they must be promptly communicated (via two-way communication) to the physician/prescribing practitioner. a. Two-way communication between the clinician(s) and the physician/prescribing practitioner can be: i. In person ii. By telephone iii. Voice mail iv. Electronic means v. Facsimile vi. Or by any other means that appropriately conveys the resident's status 5. The physician/prescribing practitioner's recommended actions, in response to the medication issue, must be carried out by midnight of the next calendar day. 6. This drug regimen review process is an ongoing process throughout the resident's stay to ensure that clinically significant medication issues are identified and addressed in a timely manner. 7. Documentation in the medical record should include that the DRR was conducted, whether there were any potential clinically significant medication issues identified, when the physician was notified, any physician recommendations/orders and when those orders were carried out. Review of Resident #3's clinical records conducted on 03/25/21 revealed the following: The resident was admitted to the facility on [DATE] and resides here for long-term care. The resident's pertinent [DIAGNOSES REDACTED]. The resident also has history of heart failure, [MEDICAL CONDITIONS], and arthritis. Resident #3 was observed and interviewed throughout the survey conducted 03/23/21 through 03/26/21. The resident was mostly observed having breakfast or lunch; she was alert, friendly and cooperative in conversations. In an interview conducted on 03/26/21 at 11:05 AM, Staff-E, a Licensed Practical Nurse (LPN) assigned to Resident #3, stated the resident [MEDICAL CONDITION] that is metastasizing all over her body, and she has chronic pain issues; although she tries to stay in good spirits. Staff-E confirmed the resident receives routine Buprofin and [MEDICATION NAME] for depression, [MEDICATION NAME]. In an interview conducted on 03/26/21 at 11:25 AM, Staff-F, a Certified Nurse Aide (CNA) assigned to the resident, Staff-F stated the resident is very pleasant although her arm hurts and sometimes she doesn't want to get out of bed, or she will stay in her room. Review of Resident #3's current Health Care Provider's orders, and the resident's medication administration records, revealed the resident currently receives the following medications on a routine basis: 1. A 11/19/19 prescription called for [MEDICATION NAME] ([MEDICATION NAME]) 0.25 milligrams (MG) daily for anxiety 2. A 10/22/20 prescription called for [MEDICATION NAME] HCL SR ([MEDICATION NAME]) 15 MG daily for major [MEDICAL CONDITION] 3. A 05/22/18 prescription called for [MEDICATION NAME] HBR ([MEDICATION NAME]) 40 MG daily for major [MEDICAL CONDITION] 4. A 12/4/19 prescription called for [MEDICATION NAME] (Ambien) 5 MG daily for [MEDICAL CONDITION]. Review of Pharmacy Consultant recommendations for Resident #3 conducted 03/25/21 revealed a Pharmacist Recommendation, dated 11/18/20 that included: Comment: (Resident #3) has received [MEDICATION NAME] and [MEDICATION NAME] and both are due for (gradual dose reduction). Recommendation: Please attempt a gradual dose reduction (GDR) on at least one of these while concurrently monitoring for reemergence of target behaviors and/or withdrawal symptoms. Rationale for Recommendation: A GDR should be attempted in 2 separate quarters, with at least 1 month between attempts, within the first year in which an individual is admitted on a [MEDICAL CONDITION] medication or after the facility had initiated such medication and then annually unless clinically contraindicated. If this therapy is to continue, it is recommended that a) the prescriber document an assessment of risk versus benefit, indicating that it continues to be a valid therapeutic intervention for this individual; b) the record contains documentation of the dose reduction history, specific target behavior(s), desired outcomes(s), and the effectiveness of individualized nonpharmacological interventions (e.g., cognitive behavioral therapy); and c) the facility Interdisciplinary team ensures ongoing monitoring for effectiveness and potential adverse consequences (e.g., drowsiness, nausea, headache). Physician's Response: I decline the recommendation(s) above because GDR is CLINICALLY CONTRAINDICATED for this individual as indicated below. Continued use is in accordance with the current standard of practice and a GDR attempt at this time is likely to impair this individual's function or cause psychiatric instability by exacerbating an underlying medical condition or psychiatric disorder AS DOCUMENTED BELOW. Please provide CMS REQUIRED patient-specific rationales describing why a GDR attempt is likely to impair function or cause psychiatric instability in this individual: The physician wrote in, Resident is stable on current dose. The form was signed on 03/16/21, 117 days after the date of the pharmacy recommendation. A facsimile receipt, dated 12/09/20 at 3:31 PM, showed two pages were sent and included an image of the cover page from the facility to the Doctor related to Resident #3, that read, Hello, Please review, sign and return. Thank you. Nothing was attached to the facsimile receipt, and no other related information was located, making it not possible to verify what was sent to the Doctor. Further record review conducted on 03/25/21 and 03/26/21 revealed no documentation showing the facility received a response from the Doctor related to this identified potential or actual clinically significant medication issue identified by their Pharmacy Consultant. There was no documentation showing facility nursing staff followed up with the Doctor related to this pharmacy recommendation for a GDR received by the facility at the end of November 2020. The pharmacy recommendation was not dated as reviewed and signed as responded to by the attending Doctor until 03/16/21, more than 90 days after the recommendation was received by the facility. Facility staff did not follow facility protocols related to compliance with state and federal regulations related to the use of [MEDICAL CONDITION] medications including regular review for the continued need, appropriate dosage, side effects, risks and/or benefits of the medication. Facility staff did not follow facility protocols related to ongoing monitoring, and reduction or discontinuance of [MEDICAL CONDITION] medications. In an interview conducted on 03/25/21 at 4:10 PM, the Director of Nursing (DON) stated they looked in to it, and the only thing they could figure out was that the recommendation was sent to the doctor but no response was received back, but they have no documentation to support that. In a follow-up interview conducted on 03/26/21 at 12:54 PM, the DON stated she would check further for any follow-ups by staff with the doctor as the staff usually re-faxes it multiple times. At 1:50 PM, the DON presented the 12/09/20 facsimile mentioned above. She acknowledged there was no proof of what was attached, or if the doctor responded, and if not, no proof showing facility staff followed up with the doctor. By the time of exit conference, no additional documentation or information was received related to this concern.

Based on record review and interview, the facility failed to ensure dental services were obtained timely for 1 of 1 sampled resident (Resident #85) reviewed for dental services. The findings included: Review of Resident #85's clinical record on 03/24/2021 showed a nutrition note dated 03/04/21, written by the Dietitian, which included: Resident's son, (name) was notified of recent weight loss. He was notified Resident is refusing the snacks which he has brought in for her. (Son) stated she was covering her mouth during recent facetime, wondering if she might have tooth pain. He requested she be seen by dentist. Nursing has been notified of Resident's request. The record indicated the resident had a Brief Intterview for Mental Status (BIMS) of 3, indicating severe cognition impairment. Further review of Resident #85 progress notes did not show any evidence of follow up to the family request for a dental visit. A request was made on 03/26/21 in the morning for any evidence of follow-up regarding the request for dental services. An interview was conducted with the Assistant Director of Nursing (ADON) on 03/26/21 at 12:07 PM. The ADON stated the primary nurse should make the appointment. The ADON stated she spoke with the nurse today and the nurse stated Resident #85 was seen before by the dentist, but her son did not want anything done. Resident #85 has several broken teeth. The nurse did not contact Resident #85's son or the dentist regarding his request on 03/04/21.

Based on record review and interview, the facility failed to ensure a staff member was tested for COVID19 according to parameters set forth by the Secretary for a facility under outbreak status for 1 of 4 sampled staff members (Employee #3). The findings included: Review of the August 26, 2020 CMS ( Centers for Medicare & Medicaid Services) Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements and Revised COVID-19 Focused Survey Tool showed: For outbreak testing, all staff and residents should be tested , and all staff and residents that tested negative should be retested every 3 days to 7 days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result. A review of the facility's employee roster was conducted on 12/28/2020. Four employees were sampled from the roster and their COVID19 testing dates were requested. Document review conducted on 12/28/2020 showed Employee #3 last had a COVID19 test on 12/13/2020. The results were negative at this time. Review of Employee #3's work schedule showed since 12/13/2020 she worked shifts on 12/26/2020 and 12/27/2020. An interview was conducted with the Administrator and the Infection Control Preventionist (ICP) on 12/28/2020 at 02:41 pm. The ICP and the Administrator stated the facility has been on weekly testing parameters based on outbreak status since the beginning of December. The ICP confirmed Employee #3's last COVID19 test was on 12/13/2020 and was not tested again prior to working shifts on 12/26/2020 and 12/27/2020. The Administrator stated security should have stopped her at the gatehouse during the screening process. The facility has a computerized system that allows communication between the facility and the security guard at the gate for any alerts or concerns during the screening process.

Based on interview and record review, the facility failed to provide adequate supervision and coordination of care to prevent a fall by a resident exhibiting combative behaviors for 1 of 3 sampled residents (Resident #10). The findings included: During the fall investigation conducted on Resident #10 during the survey process, review of clinical record revealed a progress note dated 07/05/19 at 22:24 hours (10:24 PM) written by Staff D, an LPN (licensed practical nurse) that documented 'As this writer (nurse) had just returned from break, CNA (certified nursing assistant / Staff E) came down the hall and stated that she needed help with the resident, to give hygiene care because he's not being cooperative. This writer informed her to ask her co-worker, (Staff F, CNA) to assist. Within a few minutes, Staff F came down the hallway and informed this writer that the resident was on the floor. Upon arrival to the resident's bathroom, noted the resident on the floor lying on his left side and saying ah, help me. Noted floor was wet with resident's urine and denture noted on the floor next to resident's left leg. This writer (nurse), Staff E, and Staff F used stand up lift and transferred resident from floor to bed where both Staff [NAME] and Staff F administered hygiene care and left resident in bed. On 07/17/19 at 1:28 PM, the surveyor conducted an interview with Staff E, CNA, who attended to Resident #10 the day of the fall on 07/05/19. During the interview, Staff [NAME] revealed that on 07/05/19 at approximately 8 PM, she was in the process of toileting Resident #10, and the resident was very combative, yelling, screaming, trying to hit her, name calling, and cursing. Staff [NAME] added it was a safety concern for her and the resident. Staff [NAME] voiced, she put the emergency bathroom light on for about 10 minutes and nobody came to help her, therefore she left the resident sitting on the toilet unattended and went to get help. She came across Staff D, the nurse who was scheduled to Resident #10 that day. She noted Staff D (nurse) standing next to the medication cart doing something in the computer. Staff [NAME] informed the nurse she needed help with Resident #10, that Resident #10 was exhibiting combative behavior, and she couldn't handle him alone. The nurse said, 'I can't help right now, go get your co-worker to help.' Staff [NAME] went down the other hall to go find Staff F. By the time Staff [NAME] and F went to Resident #10's room, he was found on the floor, with urine on the floor. On 07/17/19 at 3:14 PM, an interview was conducted with Staff D, the nurse who attended to Resident #10 the day of the fall (07/05/19). She explained shortly after she came from break, she was standing at the Naples Villa unit, next to the medication cart while doing something in the computer, when Staff [NAME] came to her and requested help with Resident #10. Staff D revealed that Staff [NAME] informed her that Resident #10 was exhibiting combative behaviors and she could not handle him. She told the CNA to go find her co-worker to help her. During this interview process, Staff D stated, 'the CNAs are always coming to her for help, if she doesn't watch it, she will end up having to do their work for them'. When asked how many staff were working at the Naples Villa unit during the time of the fall, Staff D stated, 'The facility scheduled 3 CNAs and 1 Nurse at the Naples Villa unit during the 3 PM - 11 PM shift but on Fridays by 6 PM, the facility sends 1 CNA home.' Staff D revealed that at the time of the fall, there were 2 CNAs and 1 nurse working. The Naples Villa unit had 20 residents.' Staff D further added that most of the residents on the Naples Villa unit have dementia and were confused. She revealed the CNAs have been trained to care for difficult residents, and Staff [NAME] should have been able to handle Resident #10. On 07/17/19 at 2:10 PM, an interview was conducted with the DON (Director of Nursing), and she was made aware of the findings and concerns. Additional clinical record review revealed Resident #10 was admitted to the facility on [DATE]. The admitting [DIAGNOSES REDACTED]. Resident #10 had the following Physician orders [REDACTED]. The quarterly MDS (minimum data set) assessment reference date 04/16/19 revealed a BIMS (brief interview for mental status) score: 03, that indicated that Resident #10 was severely cognitively impaired. This MDS indicated Resident #10 exhibited verbal behavior towards others included: threatening others, screaming at others, and cursing at others. This MDS also revealed Resident #10 required extensive assistance 1 person physical assist with transfer, toilet use, and personal hygiene. Additional record review revealed a care plan that indicated the resident may express needs by demonstrating behaviors such as yelling, cursing, hitting staff, refusing care, aggressiveness toward staff and private aide. Intervention included: Intervene as necessary to protect the rights and safety of others. Resident #10 had a care plan that indicated: Resident at fall risk related to confusion, unaware of safety needs, impaired vision, incontinence, side effects of medication, history of falls, poor safety awareness, combativeness behaviors, secondary parkinsonism. Intervention included: resident would like a prompt response to all requests for assistance.

Based on observation, interview and record review, the facility failed to ensure proper labeling of medications related to the frequency of administration on the medication package and on the controlled substance book for 1 of 4 sampled residents (Resident #84); failed to provide evidence of continued monitoring of refrigerator temperatures used to store medications on 3 of 6 facility units; and failed to ensure the medication name was documented on the controlled substance book for 1 of 4 randomly sampled residents (Resident #96). The findings included: 1. A medication storage observation was made on 07/15/19 at 12:07 PM, of the Key West Place medication cart, with Staff A, a Licensed Practical Nurse (LPN). Review of the label on the Controlled Medication Utilization Record for Resident #84 documented [MEDICATION NAME] / [MEDICATION NAME]-[MEDICATION NAME] 5-325 milligrams (mg), give one tablet by mouth every four hours (hrs) as needed. The corresponding bubble pack with the tablets documented to give one tablet by mouth every 4 hours as needed for non-acute back pain. Review of the current order documented [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg, Controlled Drug, Give one tablet by mouth every four hours as needed for pain, Not to exceed 3 G/24 hrs. of [MEDICATION NAME] from all sources; Give two tablets by mouth every four hours as needed for breakthrough pain and give one tablet by mouth every morning. During this observation, Staff A was asked the facility process when the frequency is changed for a medication. The LPN explained that a 'Direction Change' sticker was to be placed on the label. There was no sticker observed on the label. An interview conducted on 07/17/19 at 9:52 AM with the DON (Director of Nusring) who stated I was made aware of this yesterday. We wrote a performance intervention plan (PIP); 'Directions change' referred to chart label was to be placed on different orders, if nurses are to use same 'bubble pack', and the written order must be the exact way on the Controlled Medication Utilization Record and the eMAR (electronic medication administrion record). 2. During the medication storage observation conducted on 07/15/19 at 12:07 PM, on Key West Place, missing refrigerator temperatures were identified on the Key West Place temperature log. There were also missing temperatures idenditied on the temperature log in Buena Vista Place and Naples Place. Missing temperature dates were identified that included the following: On Key West House: 07/01/19, 06/17/19, 06/26/19 and 05/20/19. On Naples Villa House: 06/02/19, 06/03/19, 06/21/19 On Buena Vista House: 07/12/19. On 07/17/19 at 9:52 AM, the Director of Nursing stated that each House has multiple refrigerator logs which could potentially be affected. She confirmed there were 18 refrigerators, in which medications can be stored, and three refrigerators on this section (Key West Place) . She said 'I was made aware of this yesterday. We wrote a performance intervention plan (PIP), re-education with our nursing staff-night shift nurse supervisor responsible for audits. She said, she is 'pretty sure it is our per diem night shift nurses who forget to document. We do not know the real reason why there is the lack of documentation. Our policy clearly indicated the medication refrigerator temperatures should be checked daily. We just had an inspection with the department of health, and everything was okay. We know we have a documentation system problem.' 3. During the medication storage review conducted on 07/15/19 at 10:23 AM at the Naples Villa unit, a random record, Resident #96, was selected for review from the controlled substance book. The controlled substance sheet lacked evidence of documentation of the drug name. The documentations on the controlled substance sheet were as follows: name of resident, name of Doctor, drug dosage (without the name of the drug), Pharmacy and Directions. The record revealed four nurses' signature that indicated medication was removed from the controlled lock box on the following dates: 07/11/19, 07/12/19, 07/13/19 and 07/15/19. On 07/17/19 at 1:50 PM, a side by side review and interview was conducted with the DON (Director of Nursing), and she acknowledged the finding.

Based on observation, interview and record review, the facility failed to develop a care plan for use of antibiotic and wound infection for 1 of 3 sampled residents, as evidenced by Resident #53 who had a wound infection located to the right lower leg, was receiving antibiotic, and there was no care plan in place to reflect Resident # 53's status. The findings included: During an interview conducted with Resident #53 on 07/15/19 at 9:57 AM, she revealed her daughter's dog scratched her right lower leg and she obtained a skin tear to the area during visit at her daughter's house. She added the wound became infected. During this time, an observation was made of Resident # 53's right lower leg. The area was noted with soiled steri strips, which had dried old blood, and the steri strips were peeling off. There was drainage coming down from the wound. Clinical record review evidenced a progress note, dated 07/06/19 at 23:01 (11:01 PM), that indicated that Resident (#53) returned from family visit with skin tear on right lower leg. Resident states the family dog jumped up on her and caused the skin tear. Additional record review revealed a progress note, dated 7/11/19 at 13:02 (1:02 PM), that indicated 'new orders received for [MEDICATION NAME] (antibiotic) 100 mg twice a day for 7 days.' Another progress note, dated 07/11/19 at 22:23 (10:23 PM), revealed 'right lower leg reddened and swollen, warm to touch, scabbed, steri strips intact. Antibiotic started this PM.' During additional clinical record review, it was revealed that Resident #53's records lacked evidence of care plans to reflect the resident status relating to use of antibiotic and wound infection. On 07/17/19 at 2:10 PM, a side by side review and interview conducted with the DON (Director of Nursing) revealed the DON acknowledged the lack of care plan relating of the use of antibiotic and wound infection. On 07/17/19 at 2:15 PM, an interview was conducted with Staff G, an RN (Registered Nurse). Staff G acknowledged that there wasn't any care plan in place for the use of antibiotic and the wound infection for Resident # 53. Staff G voiced a care plan should have been generated at the time the antibiotic order was received (07/11/19).

Based on observation, interview and record review, the facility failed to honor resident rights and promote dignity, as evidenced by the facility staff's failure to knock on residents' doors and obtain permission from the resident prior to entering the resident's room for 4 of 41 sampled residents (Resident #13, #57, #73 and #250); failure of the Maintenance Director to knock on all the residents' doors and obtain permission to enter resident's room during tour for 4 of 6 units; and Staff referred to sampled Resident #13 as a feeder. The findings included: 1. During observations of Resident #57 on 06/12/18 at 8:16 AM, Staff C walked into resident's room when the surveyor was in room making observations. Staff C did not knock or request permission to enter room. This resident has a private aide 24 hours a day. The private aide states that some of the staff knock but some do not. During an interview on 06/12/18 at 8:24 AM with Staff C, the surveyor asked what is the procedure when going into the resident's room? She said to knock she then said she knocked but did not ask permission to enter room, she just walked into room. Observation on 06/13/18 at 3:11 PM, revealed Staff B was observed entering into Resident's #57 room without knocking when the surveyor was in room, Staff B then left the room and the surveyor walked out of room standing outside doorway. Staff B was then observed at 3:14 PM, and knocked on the resident's door and walked in without requesting to enter. During an interview with Staff B the surveyor asked the Staff B what is the appropriate way to enter a residents room. She stated I knocked on the door and typically go in the room. but I do not say, can I come in. The surveyor then asked the nurse do you ever ask permission to enter the residents room?. The nurse stated I was not aware we have to ask the resident permission. During an interview on 06/13/18 at 3:25 PM with DON (Director of Nurses), the surveyor asked the DON if they have a policy on staff entering a resident's room. She stated it is the standard of care with the resident rights, right to privacy. We train the staff about resident rights. We talk about all the different resident rights and we discuss privacy and what it means. We don't have a policy, we have training on resident rights but it is a video. I can't give you the video but only documentation that they did the training. 2. Observations on 06/12/18 at 11:41 AM, Surveyor observed staff coming into Resident #250 room without knocking when surveyor was interviewing resident. During an interview on 06/13/18 at 11:30 AM with Resident #250 revealed the staff do not knock prior to coming in. She says sometimes they will tap but they come so often they will just come in they do not ask to come in. 3. During an interview on 06/11/18 at 1:25 PM with Resident #73, he says the staff will knock but they never ask to come in, they will walk right in. 4. An observation was conducted on 06/14/18 at 7:58 AM with Resident #13. The surveyor was in the resident's room when Staff D, Certified Nursing Assistant, walked into the resident's room. The staff did knock on the door prior to entering the resident's room. An interview was conducted on 06/14/18 at approximately 1:00 PM with Staff D, who confirmed she did not knock on the door when she entered the resident's room. Another earlier observation was conducted on 06/12/18 at 8:32 AM, when the resident was sitting in his Broda chair in the sitting room. Staff E, Certified Nursing Assistant, came into the sitting room and reached for the resident's Broda chair. The surveyor asked Staff E if Resident #13 had had breakfast yet. Staff E stated, No he hadn't because He is a feeder, so we have to wait until one of the aides is available to feed him. 5. During environmental tour conducted with the Facility's Maintenance Director, on 06/13/18 beginning at approximately 2:00 PM, he failed to knock on any of the resident's room doors that were inspected on 4 of the 6 units of this facility. He just walked in each resident's room. This surveyor knocked on doors and awaited a response from the residents, after the Maintenance Director had already just walked in to their rooms. The Facility's Maintenance Director continued to just enter residents rooms without knocking (rooms: 126B; 202B; 220A; 227B; 228B; 229A, 230B, and 247B).

Based on clinical record review, observation and staff interview, the facility failed to ensure the Comprehensive Assessment completed on the resident is accurate and is reflective of the resident's status at the time of the assessment for 1 of 41 sampled residents, Resident # 92. The findings included: The clinical record for Resident # 92 revealed a 05/21/18 quarterly Minimum Data Set Assessment (MDS) documented that the resident required supervision of one staff to walk in room and walk in corridor; required supervision of two staff for locomotion on unit; supervision of one staff for locomotion off unit; toileting use extensive assistance of one staff for toilet use and was extensive assistance of two staff for performance of her personal hygiene. Observations of the resident throughout the survey revealed the resident ambulating with a rolling walker in her room and in the hall with and without staff supervision. Also, an observation on 06/14/18 at 9:04 AM with Staff G, the staff ambulated with the resident from the dining room, down the hall to the bathroom in her room. In the bathroom, the resident transferred to the toilet. After using the toilet, Staff G provided personal hygiene care. The resident then ambulated to the sink using the rolling walker, with one staff supervision, and then into her bedroom and washed her face and hands at the sink in the bedroom. An interview was conducted with Staff G, Certified Nursing Assistant, who confirmed that the resident ambulates with the rolling walker and she will walk beside the resident for supervision. The resident does not require two staff to ambulate or to perform personal hygiene. She further confirmed, that the resident has been the same amount of care since her admission in February. An interview was conducted on 06/14/18 at 11: 21 AM with Staff H, Registered Nurse Care Coordinator. The surveyor and Staff H reviewed the data inputted for the look back period associated with the above MDS assessment. Staff H confirmed that the MDS is inaccurate for Locomotion on unit and Personal Hygiene. The resident does not require 2 person assist in those areas.