Every finding on record at Willowbrooke Ct Skilled Care Buckingham's Choice

Based on medical record review and staff interview, it was determined that facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 8 (#21, #1, #19, #7, #22, #5, #16, #30) of 19 residents reviewed during the recertification/complaint survey.The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1) On 2/12/26 at 12:45 PM a review of Resident #21's medical record was conducted. Review of Resident #21's January 2026 Medication Administration Record (MAR) revealed Resident #21 received Metformin every morning and evening for diabetes and Gabapentin 3 times per day. Gabapentin is classified as an anticonvulsant drug and is commonly used to treat nerve pain as well as partial seizures. Metformin is a medication that primarily is used as a first-line treatment for type 2 diabetes. Review of Resident #21's MDS assessment with an assessment reference date (ARD) of 1/26/26, Section N0415 (High-Risk Drug Classes), failed to capture the hypoglycemic (Metformin) and anticonvulsant (Gabapentin). On 2/17/26 at 12:45 PM Staff #3, MDS coordinator was interviewed and stated that he was not aware that Gabapentin was an anticonvulsant. He confirmed the errors. 2) On 2/17/26 at 10:12 AM a review of Resident #1's medical record was conducted and revealed an October 2025 MAR that documented Resident #1 received the medication Gabapentin for polyneuropathy three times per day. Continued review of the October 2025 MAR documented that Resident #1 also received the Abrysvo (RSV) vaccine via injection on 10/22/25. Respiratory syncytial virus (RSV) causes infections of the lungs and respiratory tract. Review of Resident #1's MDS assessment with an ARD of 10/24/25, Section N0415, failed to capture Gabapentin as an anticonvulsant and failed to capture the injection in section N0300 (injections). Review of Resident #1's MDS assessment with an ARD of 1/22/26 also failed to capture Gabapentin in Section N0415. On 2/17/26 at 12:45 PM Staff #3, MDS coordinator confirmed the errors. 3a) On 2/17/26 at 10:41 AM a review of Resident #19's medical record was conducted and revealed an October 2025 MAR that documented Resident #19 received Aspirin 81 mg. every day and received Naproxen (NSAID) on 10/21/25 at 10:05 AM for pain. Aspirin is primarily classified as a nonsteroidal anti-inflammatory drug (NSAID) and an anti-platelet agent. Additionally, Resident #19 received the injection, Abrysvo (RSV) vaccine on 10/22/25. Review of Resident #19's MDS with an ARD of 10/22/25, Section N0415 failed to capture the anti-platelet Aspirin and the injection in Section N0300. Review of Section J0100, Pain Management, B. received PRN (when needed) pain medications, was coded, 0. The facility failed to capture the Naproxen that was given on 10/21/25 at 10:05 AM for a pain level of 5 on a 1 to 10 scale. b) Review of Resident #19's January 2026 MAR documented that Resident #19 received Aspirin every day, Naproxen on 1/14/26 at 22:01 (10:01 PM) and Tylenol on 1/15/26 at 8:51 PM. Review of Resident #19's MDS with an ARD of 1/20/26, Section N, failed to capture the use of the antiplatelet drug Aspirin. Additionally, Section J0100, failed to capture the PRN use of Tylenol and Naproxen. On 2/17/26 the MDS Coordinator confirmed the findings. 4) On 2/17/26 at 12:54 PM a review of Resident #7's medical record was conducted and revealed a November 2025 MAR that documented Resident #7 received the medication Gabapentin (anticonvulsant) and Metformin every day. Review of Resident #7's MDS with an ARD of 11/10/25, Section N0415, failed to capture the anticonvulsant and hypoglycemic medications. On 2/17/26 at 12:45 PM Staff #3 confirmed the findings. 5) On 2/17/26 at 12:57 PM a review of Resident #22's medical record was conducted. Review of Resident #22's November 2025 MAR documented that the Prevnar vaccine (injection) was administered on 11/10/25. Review of Resident #22's admission MDS with an ARD of 11/14/25, Section N0300, Injections, documented the resident did not receive any injections. The facility failed to capture the injection. On 2/17/26 at 12:50 PM the MDS coordinator confirmed the findings. On 2/17/26 at 1:00 PM the DON was informed of the MDS concerns. 6) Review of Resident #5's medical record on 2/13/26 revealed the Resident had a fall on 8/12/25 with injury. Review of Resident #5's Quarterly MDS dated [DATE] Section J Health Conditions revealed Section J1800 titled Any falls since admission/entry or reentry or prior assessment is coded no. Interview with the MDS Coordinator on 2/13/26 at 9:42 AM confirmed Resident #5 should have been coded yes in Section J1800 for the 8/12/25 fall on the 8/25/25 Quarterly MDS Assessment. 7) Review of Resident #16's medical record on 2/13/26 revealed the Resident had a fall on 8/4/25 and 8/5/25. Review of Resident #16's Annual MDS dated [DATE] Section J Health Conditions revealed Section J1900 Number of falls since admission/entry or reentry or prior assessment is coded one. Interview with the MDS Coordinator on 2/13/26 at 9:42 AM confirmed Resident #16 should have been coded for two falls in Section J1900 8/28/25 Quarterly MDS Assessment. 8) Review of Resident #30's medical record on 2/13/26 revealed the Resident was admitted to hospice on 1/12/26. Review of Resident #30's Significant Change MDS dated [DATE] Section O Special Treatments, Procedures and Programs K1 Hospice Care revealed the Resident was coded no. Interview with the MDS Coordinator on 2/13/26 at 9:00 AM confirmed Resident #30 should have been coded yes in Section O K1 Hospice Services on the 1/22/26 Significant Change MDS.

Based on medical record review and interview, it was determined that the facility staff failed to ensure that the attending physician visit residents at the required intervals . This was evident for 3 (Resident #14, #16, #9) of 19 residents reviewed during an recertification/complaint survey.The findings include: 1) Review of Resident #14's medical record on 2/13/26 revealed the Resident was admitted to the facility on [DATE]. Review of Resident #14's physician notes for the first 90 days revealed the Resident was seen by the physician on 7/18 and 8/22/25. There are no physician notes for September 2025. The next physician note for Resident #14 is on 10/23/25. Interview with the Director of Nursing on 2/13/26 at 9:31 AM confirmed Resident #14 was not seen by the physician every 30 days for the first 90 days since admission on [DATE]. 2) Review of Resident #16's medical record on 2/13/26 revealed the Resident was admitted to the facility in 2022. Review of Resident #16's physician notes in 2025 revealed the Resident was seen by the physician on 4/24/25 and then not again until 9/25/25, Interview with the Director of Nursing on 2/13/26 at 9:33 AM confirmed Resident #16 was not seen by the physician every 60 days in 2025. 3) On 2/12/26 at 1:45 PM a review of Resident #9's medical record revealed Resident #9 was admitted to the facility in August 2021. Review of the documentation section of Resident #9's medical record revealed physician notes that were uploaded into the system. The physician's notes that were uploaded were dated 1/20/25. There were no other physician's notes in Resident #9's medical record until the 9/15/25 physician's visit. There were no physician visits in the paper medical record. After 9/15/25 there were no other physician's visits until 12/18/25. On 2/12/26 at 1:42 PM an interview was conducted with the DON regarding the physician visits. The DON stated that it was unusual that there were no notes in the system and that the 2 staff members that uploaded the physician's notes switched doing the task. On 2/12/26 at 2:14 PM the DON stated that the only other physician's note she found was dated 2/17/25 that she had the physician's office send over. The DON stated that another facility had a data breach and maybe the physician was using another way to document. On 2/17/26 at 1:00 PM the issue was reviewed again with the DON. The DON stated she did not have any answers and that she had already started working on a plan of correction and talked with the physician.

Based on observation, medical record review, and interview, it was determined the facility failed to provide respiratory services in accordance with professional standards of practice. This was evident for 1 (Resident #9) of 2 residents reviewed for respiratory care during the recertification/complaint survey.The findings include: On 2/11/26 at 9:09 AM observation was made of Resident #9 sitting in his/her room. Resident #9 was receiving 3.5 L (liters) of oxygen via nasal cannula. On 2/12/26 at 9:09 AM a second observation was made of Resident #9 receiving oxygen at 3.5 L per nasal cannula. On 2/12/26 at 11:16 AM Resident #9's medical record was reviewed and revealed Resident #9 had diagnoses that included chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, atrial fibrillation, acute diastolic (congestive) heart failure, aphasia, and late onset Alzheimer's Disease. Review of February 2026 physician's orders revealed that the resident was to have oxygen administered at 2 liters per minute. Review of a 1/19/26 physician's note documented that Resident #9 had, chronic respiratory failure, oxygen after COVID in 2020, intermittent upper airway wheezing not responsive to steroids. Review of Resident #9's care plan, have an altered cardiovascular status r/t CHF (congestive heart failure), hypertension, Afib had the intervention, I may need to use oxygen. Follow settings per physician order. The care plan was created on 7/20/23. A second care plan, have altered respiratory status and utilize oxygen due to shortness of breath r/t COPD (chronic obstructive pulmonary disease) had the intervention, administer my medication/inhalers as ordered. Review of Resident #9's February 2026 Treatment Administration Record (TAR) documented that every shift the nurses were signing off that Resident #9 was receiving oxygen at 2 liters per minute, not 3.5 liters per minute. On 2/12/26 at 11:22 AM LPN #6 was asked to come to Resident #9's room with the surveyor. LPN #6 was asked how many liters of oxygen Resident #9 was supposed to be receiving. LPN #6 stated, 2 liters. LPN #6 looked at the oxygen concentrator and confirmed that Resident #9 was receiving 3.5 liters. On 2/17/26 at 1:00 PM the surveyor went over with the Director of Nursing (DON) that Resident #9 was not receiving the correct amount of oxygen and that the nurses were signing off that the resident was receiving 2 liters. The DON stated that she was aware of the issue and did not think the oxygen concentrator was working properly so they switched it out and got the resident another one.

Based on medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 2 (Resident #5 and #6) of 19 residents reviewed during a recertification/complaint survey.The findings include. A medical record is the official documentation of a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. 1) Review of Resident #5's medical record on 2/12/26 revealed the Resident was admitted to hospice services in September 2025. Further review of Resident #5's medical record on 2/13/26 with the Director of Nursing (DON) revealed there are no hospice notes in the Resident's medical record after 10/22/25 from the hospice nurse or hospice GNA (geriatric nursing assistant). Interview with the DON on 2/13/26 at 10:26 AM confirmed there are no hospice notes in Resident #5's medical record after 10/22/25. On 2/13/26 at 11:15 AM the DON brought the nurses' hospice notes from the following dates: 10/31/25, 11/07/25, 11/10/25, 11/14/25, 11/19/25, 11/21/25, 11/24/25, 12/11/25, 12/15/25, 12/24/25, 12/31/25, 1/5/26, 1/8/26, 1/12/26, 1/19/26, 1/26/26, 2/2/26 and 2/9/26 to the Surveyor after the DON stated she obtained the notes from the Hospice Nurse. During interview with the Hospice Nurse on 2/17/26 at 10:14 AM, the Hospice Nurse stated she comes and sees the Resident once or twice a week usually and the Hospice GNA sees the Resident twice a week. The Hospice Nurse stated she does have good communication with the facility staff but will now make sure the hospice notes are in the Resident's medical record. 2) During interview with Resident #6 on 2/11/26 at 9:45 AM, Resident #6 stated that he/she has a left top tooth that is broken. Resident #6 stated he/she is not in any pain. Resident #6 stated he/she was seen by someone in the facility and also a dentist outside the facility for his/her teeth but unsure what is next. Review of Resident #6's medical record on 2/13/26 revealed the Resident was admitted to the facility in 2023 and there were no dental visit notes documented in 2025 or 2026. The Director of Nursing (DON) was made aware on 2/13/26 at 10:30 AM the Surveyor could not find any dental visit notes and the Resident was complaining of a broken upper left tooth. The DON stated he/she was not aware of the Resident stating his/her tooth is broken. On 2/13/26 at 11:15 AM, the DON stated they do not have any notes from the dental visits and the Resident's spouse is the one that takes the Resident to his/her dental visits. The Surveyor advised the DON the Resident stated he/she was also seen by someone in the facility. On 2/17/26 at 8:10 AM the DON provided the Surveyor with notes from a dental visit on 6/20/25 at the facility and from an outside dental visit in November 2025. The DON stated she had contacted both dental providers and was able to obtain the dental provider's notes. The DON confirmed the dental provider notes were not in the Resident's medical record on 2/13/26. The DON also stated she has followed up with Resident #6's spouse regarding future dental treatment.

Based on record reviews, interviews and a review of the facility's investigation, it was determined that the facility failed to accurately code the Minimum Data Set (MDS) assessments for: 1) the use of residents' 1/8 grab bars and 2) the resident's status after a fall. This was evident for 5 residents (Resident #5, #15, #23, #2 and #231) of 18 residents reviewed during the annual survey. The findings include: Minimum Data Set (MDS) is a core set of screening, clinical, and functional status data elements, including common definitions and coding categories, which form the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. The data elements (also referred to as items) in the MDS standardize communication about resident problems and conditions within nursing homes, between nursing homes, and between nursing homes and outside agencies. MDS assessments need to be accurate to ensure each resident receives the care they need. Physical restraints are any manual method, or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care Activities of Daily Living (ADL) are activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating. Falls with injury (except major) Includes skin tears, abrasions, lacerations, superficial bruises, hematomas, and sprains; or any fall-related injury that causes the resident to complain of pain. 1a) A review of Resident #5's medical record was conducted on 11/20/24 at 07:51 AM. The review revealed a physician's order for 1/8 rail grab bar to be provided to promote independence with bed mobility and repositioning while in bed. A review of the ADL Care Plan for Resident #5 included an intervention for bilateral grab bars to promote independence with bed mobility and repositioning while in bed. A continued review of the medical records confirmed Resident #5 had a Side Rail assessment dated [DATE] that listed the bedrails as Mobility Aids and enablers. A review of Resident #5's MDS Section P-0100 for Physical Restraints, it was revealed that the bedrails were inaccurately identified. The MDS record stated the bedrails were used daily as Physical Restraints on 8/28/24, 5/30/24, 2/29/24, and 11/29/23. During an observation conducted on 11/21/24 at 08:23 AM, the Surveyors and Assistant Director of Nursing (ADON) observed the bedrails on Resident #5's bed. The ADON confirmed the bedrails were physician-ordered 1/8 grab rail bars for mobility. 1b) During a review of medical records conducted on 11/20/24 at 11:26 AM, it was found that Resident #15 had a physician's order for 1/8 rail grab bars to promote independence with mobility and repositioning while in bed. On 11/20/24 at 11:30 AM a review of Resident #15's medical records was conducted. The review revealed an ADL Care Plan that included an intervention for bilateral grab bars to promote independence with bed mobility and repositioning while in bed. A continued review of the medical records confirmed Resident #15 had a Side Rail assessment dated [DATE] for grab bars to be used as Mobility Aids. A review of the Resident's MDS Assessment Section P - P0100 Physical Restraints, documented that bedrails were being used daily as restraints on 09/12/24, 6/12/24, & 3/12/24. During an observation conducted on 11/21/24 at 08:25 AM, the Surveyors and Assistant Director of Nursing (ADON) observed the bedrails on Resident #15's bed. The ADON confirmed that the bedrails were the physician ordered 1/8 grab rail bars for mobility. 1c) On 11/20/24 at 8:57 AM, a review of Resident #23's order written on 06/18/2024 revealed Bilateral 1/8 rail grab bars to promote independence with bed mobility and repositioning while in bed, define parameter of bed every shift. Further review of records revealed that the quarterly bed rail assessment completed on 8/28/2024, indicated The use of siderails has been requested by the resident to aid in mobility, however, Resident #23's Quarterly MDS record with an Assessment Reference Date (ARD) of 8/28/24 revealed that the bed rail was coded in Section P- Restraints and Alarms as used daily. 1d) On 11/20/24 at 10:01 AM, a review of Resident #2's order written on 01/03/2024 revealed Bilateral 1/8 rail grab bars to promote independence with bed mobility and repositioning while in bed, define parameter of bed every shift, however, Resident #2's quarterly MDS with an ARD 10/10/24 revealed that the bed rail was also coded in Section P- Restraints and Alarms as used daily. On 11/20/24 at 10:33 AM, in an interview, the MDS Coordinator stated that when completing an MDS assessment, he/she utilizes the medical record and physically assess the resident. The surveyor asked the MDS Coordinator what his/her understanding in coding restraints on the MDS. He/she confirmed that no one in the building was on restraints, and bed rails were only used as an enabler/for bed mobility. He/she added that he/she utilized the Resident Assessment Instrument (RAI) manual in PCC for coding guidance. The surveyor informed the MDS coordinator that Residents #23 and #2's use of bed rails were inaccurately coded as restraints in the MDS assessments. On 11/20/24 at 11:01 AM, during an interview with the Director of Nursing (DON), she stated that the facility had no residents who were on restraints but had used side rails for bed mobility. The DON was notified of the concern that bed rails were inaccurately coded as restraints in the MDS assessments. She stated that she will ask the MDS nurse to correct the assessments. 2) On 11/21/24 at 5:00 PM, a review of MD00190943 revealed that on 4/4/2023 at 7:31 PM, Resident #231 had a fall while walking towards campus security and was noted with skin tear to right eyebrow. The discharge MDS assessment with an ARD of 4/11/2023 Section J1900- Number of falls since admission /entry or reentry, revealed an inaccurate coding of No injury- no evidence of any injury is noted on physical assessment by the nurse or primary care clinician. On 11/22/24 at 11:17 AM, during an interview with the MDS nurse, he/she stated that when coding falls in the MDS, he/she referred to the incident reports and any related documentation. The MDS nurse was made aware of the inaccurate coding of Resident #231's section J of the discharge assessment. He/she confirmed that he had incorrectly coded the section. On 11/22/24 at 11:26 AM, the DON and the Regional Clinical director were made aware of the inaccurate coding for falls with minor injury. 51491 :

Based on record reviews and interviews, it was determined that the facility failed to develop and implement comprehensive person-centered care plans for residents residing in the facility for: 1) the use of Hearing Aids 2) Pain 3) Chronic Constipation and 4) the use of bilateral Grab Bars. This was evident for 4 (Resident #233, #230, #5 and #23) of 18 residents reviewed for care planning during the annual survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. Minimum Data Set (MDS) is a core set of screening, clinical, and functional status data elements, including common definitions and coding categories, which form the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. The data elements (also referred to as items) in the MDS standardize communication about resident problems and conditions within nursing homes, between nursing homes, and between nursing homes and outside agencies. MDS assessments need to be accurate to ensure each resident receives the care they need. 1) Resident #233 was admitted to the facility on [DATE] with diagnoses including Muscle Weakness(Generalized), Unsteadiness on Feet, Need for Assistance with Personal Care On 11/18/24 at 9:40AM the surveyor observed Resident #233 who was at risk for falls, hobbling in his/her room moving items around. The surveyor attempted to engage the resident in a conversation, but the resident was having difficulty hearing the surveyor. Upon inquiry, Resident #233 stated that the staff did not provide assistance with his/her hearing aids so he/she was looking for them. The Director of Nursing (DON) who was in the vicinity of the resident's room at the time, was notified by the surveyor. On 11/18/24 at 2:00PM the DON informed the surveyor that Resident# 233's hearing aids were located, and the resident was wearing them. On 11/19/24 a review of Resident #233's clinical record revealed that upon admission, a skilled nursing evaluation and a Baseline Care plan were completed on 11/14/24. Both documents revealed that the resident had impaired hearing to the Right and Left ears. In addition, the skilled nursing evaluation confirmed hearing aids to the resident's Right and Left ears. Further review of Resident#233's clinical record revealed that a care plan was initiated on 1/15/24 with the following: Focus- I have a communication problem relating hearing deficit. Goal: I will be able to make my needs known on a daily basis. Intervention: Refer to Audiology for hearing consult as ordered. The care plan did not reveal the resident's use of hearing aids. In addition, the care plan failed to reveal that the facility developed and implemented specific interventions and approaches to provide Resident #233 with assistance to use his/her hearing aids. In an interview on 11/21/24 at 11.03AM the DON confirmed that interventions relating to the resident's use of hearing aids should be documented in the resident's clinical record and care plan. 2) On 11/18/24 at 9:18AM during rounds, Resident #230 informed the surveyor that he/she had back pain which comes and goes when sitting. The resident stated that the pain is usually releived by Tylenol and he/she would ask the nurse for the medication. The surveyor asked the resident for the level of pain to which the response was 5 in a scale 1-10. On 11/20/24 at 8.05AM a review of Resident #230's clinical record revealed that the resident had been receiving medications Gabapentin at bedtime for leg pain and Tylenol as needed for pain. Further review of the clinical record revealed that the facility failed to develop and implement a care plan for pain to meet the resident's needs. During an interview on 11/21/24 at 10.58AM the DON confirmed that the facility failed to develop a care plan for pain for Resident #230. The DON stated I will take care of that On 11/21/24 11:50AM, the surveyor was given a copy of a care plan which was initiated on 11/21/24 with interventions for pain management for Resident #230. 3) During a review of Resident #5 ' s medical record conducted on 11/20/24 at 12:12 PM, it was noted the resident had a history of Chronic Constipation. A review of the Medication Administration Record (MAR) revealed a physician ' s order for MiraLAX and Colace which had been administered daily. The Resident also had an additional order for Milk of Magnesia for Constipation as needed. During a continued review of the resident ' s medical records it was determined constipation was not included in Resident #5's care plan. In an interview conducted on 11/20/24 at 10:50 AM, the Assistant Director of Nursing (ADON) stated it is the facility's expectation that residents treated for constipation would have it identified in their care plans. 4) On 11/20/24 at 8:57 AM, a review of Resident #23's order written on 06/18/2024 revealed Bilateral 1/8 rail grab bars to promote independence with bed mobility and repositioning while in bed, define parameter of bed every shift. Further review of records revealed that the quarterly bed rail assessment completed on 8/28/2024, indicated The use of siderails has been requested by the resident to aid in mobility On 11/20/24 at 9:09 AM, a review of the MDS significant change in status assessments with an Assessment Reference Date (ARD) of 5/29/24 indicated that bed rails were used daily in Section P-Restraints and Alarms, however, there was no evidence that a care plan was developed since admission. On 11/20/24 at 10:33 AM, in an interview with the MDS Coordinator, he/she stated that when completing an MDS assessment and the Care Area Assessment (CAA) is triggered in Section V, he/ she created the care plan, or communicated to the Director of Nursing (DON), Assistant Director of Nursing (ADON) and to the other disciplines such as Dietary, Rehabilitation, Recreation and Social Services that a care plan needed to be developed. On 11/20/24 at 11:01 AM, the DON was notified that Resident #23 had no care plan for side rails. On 11/21/24 at 8:33 AM, a review Resident #23's care plan indicated that on 11/20/24, a care plan was added after surveyor intervention which indicated Bilateral 1/8 rail grab bars to promote independence with bed mobility and repositioning while in bed, define parameter of bed. 50504 51491

Based on interview and observation, it was determined that the facility failed to ensure that food was delivered to residents at an appropriate and palatable temperature. This was evident for 1 out of 1 observation of test tray temperatures. This practice has the potential to affect all residents who eat food prepared by the facility. The findings include: On 11/19/24 at 7:53 AM, in an interview with the Regional Certified Dietary Manager (CDM), she revealed the meal schedule for the [NAME] Brooke Court/ Skilled Nursing Unit are as follows: Breakfast- 8:00 AM Lunch- 12:30 PM Dinner -5:30PM The Regional CDM took the surveyor to the Assisted Living (AL) kitchen which temporarily served the Skilled Nursing Unit and stated that she came to the facility to assist because the facility's CDM recently resigned. On 11/19/24 at 8:01 AM, the surveyor conducted a breakfast line tray observation, and a test tray was requested to be included on the cart going to the Skilled Nursing Unit. On 11/19/24 at 8:10 AM, Staff #9 and # 10 were observed preparing the breakfast trays. As the trays were completed, they were placed one at a time, in an open steel cart, which also included the test tray. The surveyor and the Regional CDM followed the steel cart that was transported at 8:15 AM by Staff #10 via an elevator from the AL kitchen (1st floor- named M) to the Skilled Unit floor (basement, named T). As soon as the steel cart arrived in the Skilled Unit dining area, the trays were then transferred to 2 closed green carts by Staff #10 and the Regional CDM. The 1st and 2nd green carts were out to the floor at 08:19 AM for distribution. The surveyor informed the Regional CDM that it was past the scheduled breakfast. On 11/19/24 at 8:20 AM, the test tray was tested in the presence of the Regional CDM. The temperatures were: cream chipped beef, 110.4 F; Cold Milk, 41 F; Cream of wheat, 123.9 F. The Regional CDM was made aware of the concern of the food temperatures and how the trays were transported from the kitchen to the unit using an open steel cart. She confirmed that trays should have been transported using the closed carts, she added that the staff stated that they used the open steel cart because the closed carts were too heavy for them to transport from one floor to another. On 11/20/24 08:08 AM, the Regional CDM stated that they made a few changes and broke down the distribution of carts to the unit into 3 trips. The findings were also reported to the Nursing Home Administrator (NHA) and the Director of Nursing (DON) during the exit conference on 11/22/2024.

Based on observation and staff interview, it was determined that the facility failed to store and label food items to maintain the integrity of the specific item. This was evident during the initial tour of the Skilled Nursing Unit kitchen. This deficient practice has the potential to affect all residents. The findings include: On [DATE] at 9:03 AM, the surveyor conducted an initial tour of the Skilled Nursing Unit kitchen. The surveyor was assisted by Staff #10. The surveyor observed 4 cartons fat free choco milk labeled use by [DATE] in one of the refrigerators. Staff #10 confirmed that the items were expired. Another refrigerator was also noted with 5 unlabeled and undated white paper cups covered with plastic lids containing white and brown colored ice cream. Staff #10 confirmed the findings and discarded the items in the trash. On [DATE] at 7:53 AM, the Regional Certified Dietary Manager (CDM) was notified of the findings from the initial kitchen tour conducted on [DATE]. She stated that she would be covering until a new CDM was hired. On [DATE] at 8:08 AM, in an interview with the Regional CDM, she updated the surveyor that she had a conversation with the kitchen managers on [DATE] regarding checking of the refrigerators for the expiration dates of food items. On [DATE] at 9:20 AM, the surveyor received documents from the Regional CDM, she stated that the following forms will be utilized by the managers: 1) Opening Inspection Report, To be completed each morning and signed off by the opening manager on duty. Item number 8 of the said document indicated, Refrigerators and freezers checked (all items wrapped and labeled, neat, organized, food properly stored and locked). 2) Closing Inspection Report, To be completed each night and signed off by the closing manager or designee on duty. Item number 9 also indicated Refrigerators and freezers checked (all items wrapped and labeled, neat, organized, food properly stored and locked). The Nursing Home Administrator (NHA) and the Director of Nursing were made aware of the findings during the exit conference held on [DATE].

Based on interviews, record reviews and observations, it was determined that the facility failed to: 1) have quarterly care plan meetings 2) review and revise interdisciplinary care plans to reveal accurate interventions for residents residing in the facility. This was found to be evident for 2 (Resident #5 and #230) of 18 residents reviewed during the survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. Care Plan meetings are meetings with a team of care providers (attending physician, a registered nurse, nursing assistant dietary services, resident, and the resident's representative if applicable) to ensure the plan is continually adjusted to meet the changing needs or concerns of residents. The MDS (Minimum Data Set) is a health status screening and assessment tool used for all residents of long-term care nursing facilities. The MDS is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid-certified nursing homes. This process provides a comprehensive assessment of each Resident's functional capabilities and helps nursing home staff identify health problems. 1) During an interview conducted on 11/18/24 at 12:49 PM, Resident #5's family member stated he/she had not been invited to any care plan meetings. On 11/18/24 at 01:45 PM, an interview was conducted with Resident #5's spouse. The spouse reported he/she was not aware of any care plan meetings for Resident #5. During a medical record review conducted on 11/20/24 at 07:51 AM, it was revealed that Resident #5 had a history of Dementia. The review also revealed Social Service notes that documented a Quarterly Care Plan Meeting with Resident #5's family member on 6/04/2024, 3/28/2023, and 8/24/2022. No additional quarterly Care Plan meetings were documented. During an interview conducted on 11/21/24 at 08:41 AM, the Social Service Coordinator advised that she conducts quarterly Care Plan Meetings based on the Minimum Data Set (MDS) quarterly assessment. The meetings would be documented in the Electronic Medical Record (EMR) under Progress Notes when they are held. The surveyor requested documentation from the Social Service Coordinator for the last 12 months of Care Plan meetings held for Resident #5. On 11/21/24 at 10:53 AM: The Social Services Coordinator provided a sign-in sheet for Care Plan meetings held. There was only one sign-in sheet dated 6/04/24 which included the resident's family in attendance. No additional documented meetings were provided. 2) Resident #230 was readmitted to the facility on [DATE] from the emergency room with diagnoses including Constipation, Dysphagia, Pain in the Leg and Disease of Digestive System. A review of the clinical record on 11/20/24 at 8:05 AM revealed that Resident #230 was receiving speech therapy and was assessed by the dietitian on 11/15/24 for nutritional needs. A further review of the clinical record revealed an active care plan dated 8/29/24 with the Focus I have alteration in nutritional status (1) recent significant weight loss, multifaceted in origin, and relating to resolving lower extremity edema 2+ bilateral noted upon admission to (facility) as well as periods of insufficient intake relating to acute chronic processes. The surveyor also reviewed Resident #230's current clinical record including the admission nursing assessment record dated 11/09/24. The clinical record failed to reveal the presence of edema of the bilateral lower extremities. On 11/21/24 at 8:49AM in an interview with the Registered Dietitian (RD) Staff #6, the surveyor enquired about the care plan dated 8/29/24 which did not accurately reflect the resident's current clinical condition. The RD Staff #6 confirmed that Resident #230, did not have bilateral 2+ lower extremity edema and that the care plan was an old one from a previous admission which the computer automatically pulled into the resident's clinical record. Further, the problem was addressed before but it continued. RD Staff #6 stated that the care plan would be resolved. On 11/21/24 at 11:50AM the DON gave the surveyor a copy of Resident #230's care plan with the interventions resolved pertaining to the resident's bilateral lower extremity edema. 51491

Based on review of the facility investigation, record review, observation and interview. It was determined that the facility failed to provide a safe environment to prevent an elopement incident from occurring. This was evident for 1 (Resident # 231) of 2 residents reviewed for elopement during the survey. The findings include: Wander guard is a wandering management system that monitors residents using a wearable bracelet. The system relies on three components: bracelets that residents wear, sensors that monitor doors, and a technology platform that sends real-time safety alerts. When a resident with a bracelet approaches a monitored door, the system alerts. On 11/21/24 at 5:30 PM, the surveyor reviewed Facility Self-Reported incident MD00190943. The review revealed that Resident #231 had an elopement incident on 4/4/23. The facility's interview with Licensed Practical Nurse (LPN #1) revealed that the door alarm sounded at 7:27 PM and upon assessment, he/she observed a family member entered the unit. Resident #231 could not be found in his/her room. While LPN #1 was contacting the campus security, he/she was informed by the security that Resident #231 was observed walking outside on the facility campus at approximately 7:31pm. As Resident #231 was walking towards campus security, he/she had a fall and sustained a minor skin tear to his/her right eyebrow. First aide was provided by LPN #1. Resident #231 was assessed and escorted safely back to the unit. Further review of the elopement investigation revealed the following interventions that were put in place after the incident: - The resident was assessed (including neuro checks) and escorted back to the room. - The resident representative was updated - Physician was notified - 1 on 1 sitter for 48 hours was initiated - Wander guard checked - Signage was posted as a reminder to visitors to keep the door secure and closed behind them when entering and exiting the unit - 6 staff members were interviewed - Door alarms and wander guard system were tested - Inservice was conducted on: 4/20/23, Elopement training and drill code silver, attended by 42 staff members - Elopement drill was conducted on 5/24/22, which was attended by 18 staff members. On 11/21/24 at 5:00 PM, a review of Resident #231's medical record revealed a BIMS score of 99.0 on 3/31/2021 (Resident is rarely/never understood). Brief Interview for Mental Status (BIMS) is a screening tool used to assess basic cognitive function in patients in long-term care facilities. A BIMS score of 99 signifies that the BIMS assessment was not able to be finished due to the patient's inability to engage or provide adequate answers. An elopement assessment was conducted on 3/29/24 with a score of 6 which meant at risk to wander. Another elopement assessment was performed on 4/1/23 with a score of 17 which meant a high risk to wander. A wander alert device was then added as an intervention and checked for function and placement regularly. On 11/22/24 at 8:25 AM, in an interview with the Director of Nursing (DON) she stated that Resident #231 used the door located on the left side when exiting the skilled unit double doors. She added that the door was not part of the skilled unit and had no lock. Based on another surveyor's observation, the unmanned double doors of the skilled unit were approximately 15 steps from the unlocked door that lead to outside premises. On 11/22/24 at 8:37 AM, the DON performed a wander guard system test with the surveyors. The DON walked with the wander guard towards the double doors that were opened, and the alarm went off. Again, the DON walked with the wander guard but this time the double doors were closed, the doors locked but did not alarm. The DON explained that the double doors would alarm if a resident with a wander guard passed through the double doors that had been opened, such as when a staff or visitor exited/entered the unit. If a resident with a wander guard walked near the double doors that were closed, a clicking sound would be heard which meant the doors locked and wouldn't alarm. On 11/22/24 at 8:51 AM, in an interview with Staff #12, he/she stated that the facility had used the wander guard system for 4-5 years. He/she added if a resident had a wander guard and walked near the double doors, the doors wouldn't open unless the code was entered, or someone opened the doors. He/she stated that the door located on the left side leading to the Independent Living (IL) when exiting the double doors, locked from outside but not from the inside. On 11/22/24 at 9:47 AM, during an interview LPN #1, he/she narrated to the surveyors that on 4/4/2023, he/she heard the alarm and looked for Resident #231, he/she ran to the door and saw family members walking out and said they saw the resident, other staff members also looked for the resident. He/she stated that Resident #231 was found near the entrance by the security area and added that the alarm system alerted the nurses' pager with the resident's identifier number. On 11/22/24 at 9:54 AM, an interview with the DON revealed that they learned that Resident #231 was missing when LPN #1 stated that visitors walked down the hallway and assumed that the resident went with them. However, based on the initial facility investigation, LPN #1 stated that he/she observed a family member entered the unit. On 11/22/24 at 11:26 AM, the DON and the Regional Clinical Director were notified of the surveyor's concern that the facility failed to prevent the elopement incident. They enumerated a few interventions that were put in place for the current residents who wandered and were at risk for elopement: random audits, elopement committee meetings, frequent residents' assessments and behavior monitoring. On 11/22/24 at 11:55 AM, the DON stated that the facility added an intervention on 11/22/24: double doors automatically closed from 6:00 PM to 8:00 AM. Anyone who wanted to get in the skilled unit will have to call the number indicated on the signage.

Based on surveyor observation and staff interview, it was determined that the facility staff failed to properly label, and date food items stored in the main kitchen. This was evident during the initial tour of the kitchen and on a subsequent visit to the kitchen.,The findings include: On 8/12/19 at 7:45 AM, an initial tour of the kitchen was conducted. Observation of the refrigerator located between the condiments and juice dispenser revealed a tray that had 11 gray plastic bowls that were covered with a plastic lid and appeared to contain pudding. The bowls were not labeled with the date they were prepared. Also, in this refrigerator were 6 small, plastic juice glasses, containing juice and covered with a plastic lid, that were not labeled with a date. Observation of the main refrigerator revealed a ¾ full, quart size bottle of Cloverland heavy whipping cream that was not labeled with the date it was opened. Observation of the refrigerator located on the left corner of the kitchen, next to the wall and near a handwashing sink, revealed a ¾ full, quart size bottle of Cloverland heavy whipping cream that was not labeled with the date it was opened. On 8/12/19 at 8:00 AM, the Nutrition Services Manager, Staff #11, confirmed the findings. On 8/16/19 at 12:40 PM, during a subsequent visit to the kitchen, accompanied by Staff #10, the Culinary Services General Manager, an observation of the kitchen's main refrigerator revealed a ½ full, gallon container of Cloverland whole milk that was not labeled with the date opened. Staff #10 confirmed the finding at that time.

Based on record review and staff interview, it was determined that the facility failed to develop policies and procedures to ensure that all residents were offered pneumococcal vaccination when indicated. This was evident for 3 (#4, #15, and #3) of 3 residents reviewed for pneumococcal vaccination records and had the potential to affect all residents, visitors, volunteers, and staff in the facility. The findings include: Pneumococcal Vaccination requires two types of vaccines for immunity. The Centers for Disease Control provides guidance to providers for administration of these vaccinations to achieve immunity in vulnerable adults. This guideline indicates how to proceed when a person has a known vaccination history or when it is unknown. 1) A review of Resident #4's paper record on 8/13/19 at 9:27 AM, revealed a summary from his/her primary care doctor that did not contain immunization records. Review of the electronic medical record (EHR) revealed that, under the preventative care tab, there was no documentation regarding immunizations. 2) During a record review for Resident #15 on 8/13/19 at 9:35 AM, a hospital discharge summary dated 7/26/19 was noted that documented that the resident had a pneumococcal vaccination in 2010. However, review of the progress notes, physician order [REDACTED]. 3) Review of Resident #3's medical record on 8/13/19 at 9:40 AM, revealed on a hospital discharge summary dated 2/12/19, that the resident had a pneumococcal vaccination in 2013. However, review of the progress notes, physician order [REDACTED]. An interview with the Assistant Director of Nursing (ADON) on 8/16/19 at 9:14 AM, revealed that the facility failed to have policies and procedures in place to review vaccination history and offer additional pneumococcal vaccinations as indicated. On 8/16/19 at 11:44 PM, during an interview with the Medical Director she confirmed that the facility was working on policies and procedures to obtain the resident's immunization history and offer pneumococcal vaccinations to residents when indicated. On 8/19/19 at 11:34 AM, it was noted that the Director of Nursing was aware that the facility did not have current policies and procedures in place for pneumococcal vaccination, and stated that they were being developed at the time of the survey.

Based on medical record review and staff interview, it was determined that the facility staff failed ensure that a resident's current wishes related to life-sustaining treatment were up to date by failing to void previous MOLST ([NAME]land Medical Order for Life Sustaining Treatment) forms when a new MOLST was created. This was evident for 1 (#23) of 1 residents reviewed for advanced directives. The findings include: On [DATE] at 11:55 AM, review of Resident #23's paper medical record (chart) revealed that Resident #23 had 2 physician signed MOLST forms (documentation of a person's wishes regarding cardiopulmonary resuscitation (CPR) and other life-sustaining treatments) in the same plastic sleeve: 1) In the front of the plastic sleeve was a MOLST form, signed and dated [DATE], that revealed documentation that Resident #23 elected No CPR, Option B, Palliative and Supportive Care: Prior to arrest, provide passive oxygen for comfort and control any external bleeding. Prior to arrest, provide medications for pain relief as needed, but no other medications. Do not intubate or use [MEDICAL CONDITION] or [MEDICAL CONDITION]. If cardiac and/or [MEDICAL CONDITION] arrest occurs, do not attempt resuscitation (No CPR). Allow death to occur naturally. Page 2 of the [DATE] MOLST documented the resident's preferences that applied to other situations other than cardiopulmonary arrest. 2) In the back of the plastic sleeve, Resident #23 had a second MOLST form that was signed and dated [DATE]. Page 1 of the MOLST revealed documentation that Resident #23 elected No CPR, Option A-2, do not intubate (DNI): comprehensive efforts may include limited ventilatory support by [MEDICAL CONDITION] or [MEDICAL CONDITION], but do not intubate. Page 2 of the [DATE] MOLST was blank such that Resident #23's preferences for situations other than cardiopulmonary arrest had not been assessed or the resident had not elected preferences. The practitioner failed to void the MOLST, dated [DATE], when the most recent MOLST, dated [DATE], had been created. Failing to void the previous MOLST could result in confusion as to Resident #23's wishes related to CPR and other life-sustaining treatments. The Director of Nurses confirmed these findings on [DATE] at 12:20 PM. On [DATE] at 9:40 AM, a review of Resident #23's paper chart revealed a MOLST, signed and dated [DATE], in a plastic sleeve, indicating that a new MOLST had been created for Resident #23. In the back of the chart was Resident #23's MOLST form, dated [DATE] and Resident #23's MOLST form, dated [DATE]. Both of these MOLST forms had a diagonal line drawn through them and the date, [DATE], was handwritten next to the line, indicating the MOLST forms had been voided on [DATE]. However, continued review of the resident's paper chart, revealed, in the consult section, there was a copy of page one of Resident #23's MOLST dated [DATE] and that MOLST form had not been voided. On [DATE] at 9:44 AM, during an interview with the Social Worker (SW) and the Assisted Director of Nurses (ADON), the SW and ADON were made aware that a copy of Resident #23's MOLST dated [DATE] was found in the resident's chart and it had not been voided. The ADON stated that the [DATE] MOLST was in the hospital paperwork and confirmed it should have been voided.

Based on medical record review and staff interview, it was determined that the facility staff failed to immediately notify the physician of multiple resident refusal of a prescribed treatment. This was evident for 1 (#1) of 5 residents reviewed for unnecessary medication. The findings include: On 8/14/19 at 8:35 AM, a review of Resident #1's medical record revealed that Resident #1 often refused to wear a palm protector splint (aids in preventing finger contractures and skin breakdown in the palm), as ordered by the physician. Review of Resident #1's (MONTH) 2019 TAR (treatment administration record) revealed an order for [REDACTED].#1's (MONTH) 2019 TAR revealed an order for [REDACTED]. Continued review of the medical record failed to reveal evidence that the physician had been notified of Resident #1's refusal to wear his/her left palm protector splint as ordered by the physician. The Assistant Director of Nurses was made aware of these findings on 8/14/19 at 2:00 PM.

Based on observation and staff interview, it was determined that the facility staff failed to provide residents with a clean, homelike environment. This was evident for 2 (#8 and #230) of 28 residents reviewed during the initial process. The findings include: On 8/12/19 at 9:47 AM, an observation of Resident #8's room, revealed water stains on the ceiling tile inside the room door and multiple scuff marks covering the front panel of the heater/cooling system. On 8/12/19 at 10:14 AM, an observation of Resident #230's room revealed approximately a 1 inch by 1/2 inch hole in the window screen on the right window. Maintenance Technician #12 was made aware of the concerns on 8/16/19 at 12:51 PM and offered no rationale for why these areas were not maintained.

Based on medical record review and staff interview, it was determined the facility staff failed to conduct an accurate, assessment by failing to assess a resident's cognition and mood on a quarterly MDS assessment and failing to timely complete a resident's quarterly assessment. This was evident for 1 (#11) of 1 residents reviewed for activities. The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on these individualized needs, and that the care is provided as planned to meet the needs of each resident. The findings include: On 8/19/19 at 10;35 AM, Resident #11's medical record was reviewed. Review of Resident #11's quarterly MDS with an assessment reference date (ARD) of 6/17/19, revealed Section C, Cognition and Section D, Mood was not completed. On 8/19/19 at 11:05 AM, during an interview, Staff #6 stated that Resident #11's Cognition and Mood sections on the MDS had not been assessed because it was late. Continued review of Resident #11's quarterly assessment, with an ARD of 6/17/19, revealed that the quarterly MDS assessment with a reference date of 6/17/19 was not completed timely. Review of Section Z, 0500B revealed that the RN Assessment Coordinator signed the assessment as complete on 7/23/19, which was greater that 14 days after the ARD.

Based on medical record and staff interview, it was determined that the facility staff failed to develop baseline care plans that included instructions needed to provide effective and person-centered care and failed to provide residents/representatives with a copy of their baseline care plan and medication list. This was evident for 2 (#22 and #230) of 14 residents in the final sample. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. A medical record review on 8/15/19 at 11:39 AM, for Resident #22 revealed a baseline care plan that documented the resident was admitted on [DATE]. However, it was not signed by the resident as being reviewed with him/her until 7/29/19. Further review of the baseline care plan revealed that it was a checklist for initial goals and objectives on admission orders [REDACTED]. These goals did not have a goal date. Review of the medical record for Resident #230 on 8/14/19 at 2:52 PM, revealed a baseline care plan that was not resident-centered. As stated above the same types of goals were checked, Improve physical condition and overall condition, Maintain weight-bearing precautions, and Maintain universal and isolation precautions. There was no goal dates listed. In addition, the goal for Maintain weight-bearing precautions was marked for both residents, however, it did not provide staff with the instructions for weight-bearing precautions, such as, no weight-bearing or partial weight-bearing. Furthermore, review of the resident's current order summary and current care plan revealed that facility staff failed to further document what level of weight-bearing precautions. An interview with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Resident Assessment Coordinator (RAC) #6, revealed that the DON's expectation was that facility staff use the baseline care plan check list and attach the physician's orders [REDACTED]. The ADON reported that, as they learn more about the resident, they enter the resident-centered care plan data in the comprehensive care plan in the electronic medical record. At this time the DON, ADON, and RAC #6 were made aware of the surveyor's concerns.

Based on medical record review and staff interview, it was determined that the facility failed develop resident centered, comprehensive care plans. This was evident for 7 (#20, #1,#10, #26, #28, #23, #11) of 16 residents reviewed during the survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. Review of Resident #20's medical record on [DATE] revealed that the resident was admitted to the facility following right total hip replacement. Review of the Initial Fall Risk Assesment, that was completed on [DATE], documented that the resident had a history of [REDACTED]. The fall risk score was 16 which indicated the resident was a high risk for falls. Surveyor review of a physicial therapy note, dated [DATE], revealed the following precautions/contradications: right hip replace-anterior precautions, fall risk. Review of all care plans for the resident failed to have a fall's risk care plan in place. On [DATE] at 9:30 AM, the ADON was asked if the resident was a fall's risk she said, yes, because therapy saw him/her walking into the bathroom unassisted. The ADON acknowledged that there wasn't a falls risk care plan and there should have been one. 2) On [DATE] at 8:35 AM, review of Resident #1's medical record revealed that Resident #1 often refused to wear a left palm protector splint (aids in preventing finger contractures and skin breakdown in the palm), as ordered by the physician. Review of Resident #1's (MONTH) 2019 TAR (treatment administration record) revealed an order for [REDACTED].#1's (MONTH) 2019 MAR indicated [REDACTED]. Review of Resident #1's care plans revealed a care plan Resident has contracture left hand, bilateral legs r/t (related to) [MEDICAL CONDITION] and is at risk for injury and has impaired selfcare ability with the goal resident will not develop complication r/t contracture that had approaches that included apply tan palm protector at all times except for skin checks and hygiene. The facility staff failed to follow the care plan by not ensuring that Resident #1 wore the palm protector, as ordered. The ADON was made aware of these findings on [DATE]. Refer to F 580 3) On [DATE] at 9:14 AM, Resident #10's medical record was reviewed. On [DATE] in a progress note, the physician documented that Resident #10 had a history of [REDACTED]. The physician wrote that he/she would restart the morning dose of [MEDICATION NAME] since it assisted him with his/her morning quality of life and minimized the resident's psychotic symptoms of hitting and severe agitation. A review of Resident #10's (MONTH) 2019 MAR indicated [REDACTED]. Continued review of the medical record failed to reveal a comprehensive, resident centered care plan that addressed Resident #10's behaviors for which the antipsychotic, [MEDICATION NAME] had been prescribed. 4) On [DATE] at 8:59 AM, review of Resident #26's medical record revealed that, in (MONTH) 2019, Resident #26 was admitted to the facility in (MONTH) 2019 following an acute hospital stay and discharged from the facility on [DATE]. On [DATE], in a History and Physical note, the physician documented that Resident #26 had a medical history that included recurrent UTI (urinary tract infection). The physician documented that, while in the hospital, Resident #26 was treated for [REDACTED]. Review of Resident #26's (MONTH) 2019 MAR (medication administration record) revealed a [DATE] physician order [REDACTED].#26's care plans failed to reveal that a comprehensive, resident centered care plan had been developed to address Resident #26's urinary elimination and recurrent urinary tract infections. Continued review of the resident's (MONTH) 2019 MAR indicated [REDACTED]. The MAR indicated [REDACTED]#26's blood glucose 3 times a day, before meals, and to administer [MEDICATION NAME] Insulin per sliding scale, which was discontinued on [DATE] and an order. Review of Resident #26'1 care plans failed to reveal a comprehensive, resident centered care plan had been developed to address Resident #26's diabetes. On [DATE] at 10:49 AM, the Assistant Director of Nurses was made aware of these findings. 5) On [DATE] at 10:53 AM, a review of Resident #28's closed medical record revealed Resident #28 had a rectal mass with rectal bleeding and received palliative care (medical and nursing care for people with life limiting illness, that focuses on providing comfort care, relief of symptoms, pain, physical and mental stress at any stage of illness) prior to his/her death in the facility. On [DATE] in a progress note, the physician documented that Resident #28 had a rectal mass that was most [MEDICAL CONDITION], that the resident reported blood in his/her stool for many months and the resident declined Hospice. On [DATE] at 1:43 AM, the nurse documented that Resident #28 had small amount of blood mixed with stool and 2 clots in toilet. On [DATE] at 6:02 PM, the physician documented that Resident #28 continued to have intermittent rectal bleeding. On [DATE] at 4:26 PM, the nurse wrote that Resident #28 had a small amount of rectal bleeding and on [DATE] at 2:51 PM, the nurse wrote that Resident #28 had a small amount of rectal bleeding. On [DATE] at 6:54 PM, the physician wrote that Resident #28 had an episode of rectal bleeding, and, on [DATE] at 4:57 PM, the physician wrote that Resident #28 continued with intermittent blood on stool and was getting weaker. Review of Resident #28's care plans failed to reveal a comprehensive, resident centered care plan had been developed that addressed Resident #28's rectal mass, the resident's rectal bleeding or the resident's bowel elimination. Further review of Resident #28's medical record revealed a [DATE] order that for DNR (do not resuscitate/do not transfer); Palliative Care - declines Hospice. The order indicated that if his/her heart stopped, the resident did not want CPR (cardiopulmonary resuscitation) and palliative care should be provided. On [DATE] at 10:25 PM, in a progress note, the nurse documented that comfort care was provided. On [DATE] at 6:07 AM, the nurse document that comfort care was maintained, and, on [DATE] at 1:52 PM, the nurse indicated that Resident #28 was provided palliative care. Continued review of Resident #28's care plans failed to reveal that a comprehensive palliative care plan had been developed, with measurable resident centered goals and interventions, that focused on Resident #28's palliative care needs. 6) On [DATE] at 1:06 PM, Resident #23's medical record was reviewed and revealed the resident returned to the facility in late (MONTH) 2019 following an acute hospital stay. On [DATE], in hospital discharge summary, the physician documented that Resident #23 had a UTI while in the hospital, his/her final [DIAGNOSES REDACTED]. Review of Resident #23's assessment with a reference date (ARD) of [DATE], revealed Resident #23's urinary continence was coded as always incontinent and documented active [DIAGNOSES REDACTED]. Resident #23's (MONTH) 2019 MAR (medication administration record) revealed that the resident received [MEDICATION NAME] by mouth every day from [DATE] to [DATE], every day from [DATE] to [DATE] and the resident's (MONTH) 2019 MAR indicated [REDACTED] Review of Resident #23's care plans failed to reveal a comprehensive, urinary elimination care plan with measurable goals and interventions to address Resident #23's over active bladder, urinary incontinence and recent urinary tract infection. 7) On [DATE] at 10:35 AM, review of Resident #11's significant change assessment with an ARD of [DATE] documented Resident #11's BIMS (brief interview for mental status) score was 5, indicating he/she had severe cognitive impairment. The assessment's Interview for Activity Preferences documented that it was very important for Resident #11 to listen to music he/she liked, and it was somewhat important for Resident #11 to be around animals such as pets, to do favorite activities, to go outside to get fresh air when the weather is good, and, to participate in religious services or practices. On [DATE] at 11:20 AM, during an interview, when asked if Resident #11's attended activity programs, the Recreation Coordinator stated that Resident #11's representative visited daily, that the resident was on a music therapy list and he/she received one-on-one visits which would be documented in the resident's electronic medical record (EMR). Review of Resident #11's EMR revealed documentation that Resident #11 had been provided with only 2 activities since [DATE]. A Recreational Therapy & Engagement - Leisure Participation report, dated [DATE], documented puzzle/conversation with no other documentation to indicate the resident's participation in the activity and, on [DATE], a Recreational Therapy & Engagement - Leisure Participation report documented daily happenings in the garden with no other documentation to indicate Resident #11's participation in the activity. There was no other documentation in the medical record to indicate that Resident #11 attended any other activity programs, that the resident received one-on-one visits by the activity staff or that the resident received music therapy. Review of Resident #11's care plans revealed a Recreational Therapy & Engagement care plan, Resident #11 has potential for a change in the ability to maintain lifestyle preferences due to recent admission to hospital with the goal, will demonstrate continued interest in enjoyment of programs of choice by next review with the approaches: 1) assess need for adaptive devices: glasses, 2)assist in getting resident to programs and provide escort to programs of interest, music programs, 3) encourage as opportunities for one-on-one visits with as many friends, family, volunteers, pets and staff to visit; appreciates visits and enjoys music therapy visits, 4) encourage (Resident #11) to engage in group programs of interest including reading, games and music programs, 5) provide information about available programming and educate about schedules and locations and encourage to participate,6) support with meeting their individual leisure needs and provide with supplies as needed and 7) Use preferred named to be called: Resident #11's 1st name. The facility staff failed to develop a comprehensive care plan, based on the based upon the goals, interests, and preferences of the resident and failed to ensure that all of the care plan approaches were resident centered and appropriate for a resident with severe cognitive impairment. The care plan goal was not resident specific with measurable objectives. The facility staff failed to follow the care plan by failing to ensure Resident #11 attended activities of interest, received music therapy visits and failing to provide one-on-one visits by the activity staff. The care plan indicated it was reviewed on [DATE], however there was no written evidence in the medical record that the resident's progress or lack of progress towards meeting his/her goal had been evaluated. Staff #9 was made aware of these findings on [DATE] at 11:30 AM.

Based on medical record review and staff interview, it was determined the facility failed to failed to evaluate, and revise care plans was resident care needs became apparent, changed over time or with each assessment. This was evident for 3 (#4, #23, and #6) of 16 residents reviewed in the final sample. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. 1) Review of facility documentation revealed that Resident #4 was observed face down on the bedroom floor. The resident was assessed and stated that he/she tripped and fell . Further review revealed the resident sustained [REDACTED]. It is a break or crack in the long bone that attaches to the pinky finger which is the fifth metacarpal. Review of Resident #4's care plan, at risk for falls as evidenced by the nursing assessment and fall risk assessment tool revealed the care plan was created on 3/4/19 and had 4 approaches that were started on 3/4/19 which included, bed will be in low position whenever resident is in it, call light will be in reach at all times, keep needed items within reach and resident will wear non-skid footwear. The care plan has a date of 7/23/19 that it was reviewed, however there is no written evaluation of the care plan and the care plan was not updated to reflect any new interventions that were put in place to prevent a future fall. The Assistant Director of Nursing (ADON) was interviewed on 6/13/19 at 10:38 AM and stated, the evaluation is done by the IDT (interdisciplinary team). The ADON confirmed that there were no evaluation notes and that the care plan was not updated to reflect new fall interventions. 2) On 8/16/19 at 1:06 PM , a review of Resident #23's medical record revealed that the resident returned to the facility in late (MONTH) 2019 following an acute hospital stay. On 7/25/19, in a hospital discharge summary, the physician documented that Resident #23 had a history of [REDACTED]. On 7/30/19, in a History and Physical note, the physician documented that Resident #23 was seen for readmission after hospitalization and documented the [DIAGNOSES REDACTED].#23 included [MEDICAL CONDITIONS], gradual weight gain was noted, the resident's [MEDICATION NAME] and [MEDICATION NAME] were held due to [MEDICAL CONDITION] and to monitor for [MEDICAL CONDITION] symptoms of SOB, cough, wheezing and weight gain. On 7/30/19 at 6:33 PM, in a progress note, the nurse documented that Resident #23 had audible wheezing, an occasional cough, [MEDICAL CONDITION] of the left lower leg and right thigh, the doctor was made aware and a new order for [MEDICATION NAME] was given. Review of the resident's (MONTH) 2019 MAR indicated [REDACTED]. Resident #23's (MONTH) 2019 MAR indicated [REDACTED]. Review of Resident #23's care plans revealed a care plan Potential for complications related to diuretic medication usage had the goal resident will not exhibit signs of side effect of complications secondary to diuretic use through the next review date with a goal target date of 8/29/19. The care plan had a last reviewed/revised date of 6/7/19, however, there was no written evaluation of the care plan in the medical record and there was no other evidence that the resident's progress or lack of progress towards meeting his goals had been evaluated since his/her most recent assessment with a reference date of 8/1/19. Continued review of Resident #23's care plans revealed a care plan, Resident is at risk for cardiovascular complication and ineffective breathing pattern r/t [MEDICAL CONDITION], CAD (cardiovascular disease), A-fib (irregular heartbeat, [MEDICAL CONDITION], HLD ([MEDICAL CONDITION]) had the goal, Resident will have an effective gas exchange as evidenced by: clear breath sounds, mental status within normal limits, skin color within normal limits pulse oximetry ranging above 93% on a daily basis through the next review, with goal target date of 8/29/19. The care plan had a last reviewed date of 6/7/19, however, there was no written evaluation of the care plan in the medical record and there was no other evidence that the resident's progress or lack of progress towards meeting his goals had been evaluated since his/her most recent assessment with a reference date of 8/1/19. 3) A record review on 8/16/19 at 9:25 PM, revealed a progress note, dated 3/24/2019 at 7:53AM, that documented Resident #6 was found beside the bed with his/her upper body in the bed and the lower body on floor. Another progress note dated 4/8/19 at 5:27 AM, documented that resident was found beside the bed upper half in the bed and lower half on floor. Both notes were signed by Register Nurse (RN) Staff #3. Further review of the medical record revealed a current care plan with a focus on falls related to Resident #6's history of falling with cognitive impairment weakness, [MEDICAL CONDITION], and poor safety awareness. The goal had a target date of 9/12/19, and multiple interventions were dated 2/12/18, which was prior to his/her last admission on 6/5/18. There were two other interventions, the 1st was dated 9/24/18, for fall mats while in bed, and the 2nd dated 5/1/19, for hipsters to be worn if the resident permits. However, further review of the medical record revealed no documentation that the current goal and interventions for the fall care plan had been evaluated for effectiveness and updated. An interview with RN Staff #1 on 8/14/19 at 11:25, when asked about the process for care plans, revealed that he did not update care plans and questions were referred to the Resident Assessment Coordinator (RAC) #6. On 8/15/19 at 1:34 PM, RAC Staff #6, Assistant Director of Nursing (ADON), and Director of Nursing (DON) revealed that the facility did not have a system in place to evaluate and update care plans quarterly and as needed.

Based on record review and staff interview, it was determined that facility staff failed to provide care and treatment to a resident that met professional standards of quality by failing to provide\complete assessments for residents who had unwitnessed falls. This was evident for 2 (#230 and #6) of 5 residents reviewed for accidents. The findings include: A neurological assessment (neuro check) is completed after a resident has an unwitnessed fall or when a head injury is suspected. The assessment may include, but is not limited to a blood pressure, respirations, pulse, temperature, pupil reactions and size, and check for equal strength in hands and feet. 1) A record review on 8/12/19 at 11:05 AM, revealed a History and Physical, conducted by the attending physician, dated 8/6/19, that Resident #6 was admitted to the facility on [DATE], due to a [MEDICAL CONDITIONS] (commonly referred to as a stroke). The resident suffered [MEDICAL CONDITION] (unable to speak) and had right sided weakness. Further review revealed an event report (document used to report an incident) dated 8/6/19 at 4:49 AM, which Resident #230 was found on the floor beside his bed on 8/5/19 at 11:45 PM and was signed by Registered Nurse (RN) #3. However, there was no documentation that neuro checks were completed as this was an unwitnessed event. The progress note attached to this event report did not indicate the reason that the nurse failed to perform these assessments. In addition, there was an event report, dated 8/9/19 at 7:26 AM, wherein Resident #230 was found on the floor bedside his bed on 8/9/19 at 4:45 AM and it was signed by RN #3. Neuro checks were conducted sporadically and not according to the facility's policy of every 15 minutes times 2, every 30 minutes times 2, every hour times 2, and every 2 hours times 4, and every 4 hours times 4. Review of the progress notes revealed no documentation regarding the neuro checks that were late or not completed. An interview with Assistant Director of Nursing (ADON) on 8/15/19 at 10:51 AM, revealed that she expected staff to complete neuro checks when there was an unwitnessed fall according to the facility policy. She reported that a neuro check flowsheet was kept at the nurses' station to ensure that the information was passed from one shift to the next. She confirmed that Resident #230 did not have a neuro check flowsheet for the 8/5/19 fall. The ADON also reported that, if a resident refuses one neuro check, she would expect them to check with resident again before notifying the doctor and documenting refusal and notification in the resident's record. During an interview with RN #3 on 8/15/19 at 2:06 PM, it was revealed that she attempted to do the neuro check and the resident refused. RN #3 reported that, when she called Certified Registered Nurse Practitioner (CRNP) #7, he gave her an order to stop the neuro checks. However, when asked about the documentation regarding this order, she was unable to provide a rationale for the missing documentation. An interview with CRNP #7 on 8/5/19, (the on-call clinician who had received the phone call regarding Resident #230's fall), revealed that he had not written a progress note that he gave the order to stop the neuro checks. During a review of the resident's status of a new admission, history of a [MEDICAL CONDITION], and the fact that he was on an anticoagulant (increases the risk for a person to bleed), CRNP #7 stated it was unlikely that he would have given an order to stop the neuro checks due to the increased risk for this resident to bleed from a possible head injury. 2) A record review for Resident #6 on 8/16/19 at 9:25 AM, revealed an event report (the document used by the facility to document incidents) dated 3/24/19 at 7:53 PM, that indicated the resident was found on floor next to his/her bed and was signed by RN #3. However, review of the medical record revealed that neuro-checks were not completed and review of the progress notes revealed no documentation for the reason that neuro checks were not completed. During an interview with the Director of Nursing (DON) on 8/15/19 at 2:14 PM, it was revealed that her expectation was that staff complete neuro checks on residents who had unwitnessed falls. When asked what her response would be to a clinician who gave her an order to stop neuro checks on Resident #230, she stated that, given this resident's diagnosis, she would emphasize the resident's [DIAGNOSES REDACTED]. She stated that she would be sure to document all the information in the medical record. DON stated that RN #3 was in need of further education.