Independence Manor Care Center

Based on observation, interview, and record review, the facility failed to employ sufficient dietary staff and support personnel with the appropriate competencies and skill sets to safely and effectively carry out the functions of the food and nutrition service, taking into consideration residents' dietary assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with professional standards for food service safety. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who ate food from the kitchen. The facility's census was 54 residents with a licensed capacity for 99 residents at the time of the survey.
1. Review of the facility's dietary documentation for the month of December, 2023, provided by the Dietary Manager (DM), showed the following:
-Meals were scheduled three time a day on menus that rotated on a four week basis.
-Each meal had at least three main food items with a choice of beverage.
-There were separate menus for mechanically altered and pureed textured diets.
-Individual resident diet cards were used that addressed their different required textures, allergies, religious and/or cultural preferences, and any special instructions.
-For residents who may not want the main meal scheduled there was an Always Available sheet with numerous additional items to choose from daily for lunch or dinner.
-The staffing sheet for the month showed there was one cook, one dishwasher, and the DM scheduled for days, and one cook, one dishwasher, and a dietary aide scheduled for nights.
Observation on 12/4/23 between 8:44 A.M. and 11:41 A.M. during the initial kitchen inspection showed there was one day cook, a dishwasher, and the DM present.
During an interview on 12/4/23 at 9:43 A.M. the DM said the following:
-The kitchen had been short-staffed for about a month.
-There was also one dietary aide out with a long illness.
-The day cook and him/her were covering extra shifts.
-He/she was filling in doing dinner meal passes.
During an interview on 12/4/23 at 11:33 A.M. the Day [NAME] said after food was transferred from the stove and/or oven to the steam table, the whole table was unplugged and it was physically taken from the kitchen to the back dining room with a large beverage cart and the table plugged in for the meal service there, and then it was returned to the kitchen and re-plugged in there for the front dining room's meal service.
During an interview on 12/7/23 at 9:27 A.M. the DM said the following:
-If they lost a staff member for some reason it could be weeks before they even got an applicant.
-He/she was also very picky about whom they hired as well.

Based on observation, interview, and record review, the facility failed to ensure the residents' prescribed medications were stored in the medication refrigerator; to ensure the residents' prescribed medications that had been opened, had the date written that they had been opened written on the container; and to ensure non medical items were not stored with the residents' medications. The facility census was 54 residents.
Review of the facility's policy, Administering Medications, dated December 2012 showed:
-The Director of Nursing Services would supervise and direct all nursing personnel who administer medications and/or have related functions.
-When opening a multi-dose container, the date opened should have been recorded on the container.
Review of the facility's policy, Storage of Medications, dated April 2007 showed:
-Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location.
-Medications must be stored separately from food and must be labeled accordingly.
-The nursing staff would be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.
1. Observation on 12/5/23 at 3:30 P.M. of the medication refrigerator in the medication room with Licensed Practical Nurse (LPN) B showed:
-A resident's Daptmomycin (an antibiotic) 500 milligram (mg) intravenously (IV medication administered through a tube through the skin into a vein) medication was in same refrigerator with the resident's food.
-There was a separate medication refrigerator in the medication room.
During an interview on 12/5/23 at 3:35 P.M. LPN B said:
-The residents IV medication should not have been in the residents' refrigerator with the resident's opened food and drinks.
-The IV medication should have been stored in the medication refrigerator not in the refrigerator with food in it.
2. Observation on 12/5/23 at 3:40 P.M. of the Cherry/Peach Certified Medication Technician (CMT) medication cart with CMT A showed:
-A resident's prescribed Levetiracetam (an anti seizure medication) a 16 ounce bottle was opened without an opened date written on it.
-Two resident's prescribed Potassium Chloride (a mineral supplement used to treat low levels of Potassium), 473 milliliter (ml) bottles were opened without an opened date written on it.
-A 24 ounce bottle of chocolate syrup was in with the residents' medications.
3. Observation on 12/5/23 at 3:50 P.M. of the Orange hall CMT medication cart showed:
-A residents prescribed Potassium Chloride, a 473 ml bottle was opened without an opened date written on it.
4. During an interview on 12/5/23 at 3:55 P.M. CMT A said:
-Refrigerated medications should go in the medication refrigerator.
-The resident's medications should have had a date it was opened written on it.
-Who ever opened the medication should have written the date it was opened on it.
-Each person who used the medication cart was responsible to keep it clean and there should not be other items in the medication cart, like the chocolate syrup.
-The Director of Nursing (DON) was responsible to ensure the medications were taken care of as they should be.
During an interview on 12/6/23 at 7:30 A.M. the DON said:
-The resident's IV mediation should not have been in the resident's food refrigerator.
-The IV medication should have went in the medication refrigerator.
-Medications that have been opened should have had the date they were opened written on it.
-If the chocolate syrup was used to give the medications it should have been in it's own compartment not in with the residents' medications.
-The charge nurse should have been auditing the medication refrigerator and carts.

Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) worked for eight consecutive hours per day, seven days a week for four or more days for the previous four quarters of the last fiscal year July 2022 through June 2023 and from November 16, 2023, through December 4, 2023, for this survey look back. The facility census was 54 residents.
Review of the facility's Nursing Services-RN policy dated 11/23/2022 showed:
-It was the intent of the facility to comply with RN staffing requirements.
-The facility would utilize the services of a RN for at least eight consecutive hours per day seven days per week.
-The facility would designate a RN to serve as the Director of Nursing (DON) on a full-time basis.
-The DON may serve as a charge nurse only when the facility had an average daily occupancy of 60 or fewer residents.
-The facility was responsible for submitting timely and accurate staffing data through the Centers for Medicare and Medicaid Services (CMS) Payroll-Based Journal (PBJ) system.
1. Review of the PBJ of the fiscal year of quarter 4 of 2022 (July 1-September 30) showed no eight-hour consecutive RN coverage the following dates:
-Three days in July:
--Thursday 7/7/22.
--Friday 7/8/22.
--Thursday 7/24/22.
-Three days in September:
--Saturday 9/3/22.
--Sunday 9/4/22.
--Friday 9/30/22.
Review of the PBJ of the fiscal year of quarter 1 of 2022 (October 1 through December 31) showed no eight-hour consecutive RN coverage the following dates:
-Six days in October 2022:
--Saturday 10/8/22.
--Monday 10/17/22.
--Tuesday 10/18/22.
--Friday 10/21/22.
--Saturday 10/22/22
--Sunday 10/23/22.
-Four days in November 2022:
--Friday 11/4/22.
--Monday 11/7/22.
--Saturday 11/26/22.
--Sunday 11/27/22.
-Six days in December 2022:
--Saturday 12/10/22.
--Sunday 12/11/22.
--Friday 12/16/22.
--Saturday 12/24/22.
--Sunday 12/25/22.
--Saturday 12/31/22.
Review of the PBJ of the fiscal year of quarter 2 of 2023 (January 1-March 31) showed no eight-hour consecutive RN coverage the following dates:
-Five days in January 2023:
--Sunday 1/1/23.
--Saturday 1/7/23.
--Sunday 1/8/23.
--Saturday 1/21/23.
--Sunday 1/22/23.
-Four days in February 2023:
--Saturday 2/4/23.
--Sunday 2/5/23
--Saturday 2/18/23.
--Sunday 2/19/23.
-Eight days in March 2023:
--Saturday 3/4/23.
--Sunday 3/5/23.
--Saturday 3/11/23.
--Sunday 3/12/23.
--Saturday 3/18/23.
--Sunday 3/19/23.
--Saturday 3/25/23.
--Sunday 3/26/23.
Review of the PBJ of the fiscal year of quarter 3 of 2023 (April 1-June 30) showed no eight-hour consecutive RN coverage the following dates:
-Seven days in April 2023:
--Wednesday 4/5/23.
--Monday 4/10/23.
--Tuesday 4/11/23.
--Saturday 4/15/23.
--Sunday 4/16/23.
--Saturday 4/29/23.
--Sunday 4/30/23.
---Received documentation from the facility of RN coverage by the DON and/or the Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility staff for care planning) Coordinator, who was an RN for the following three April dates from above:
----Wednesday 4/5/23.
----Monday 4/10/23.
----Tuesday 4/11/23.
-Four days in May 2023:
--Saturday 5/13/23.
--Sunday 5/14/23.
--Saturday 5/27/23.
--Sunday 5/28/23
-Six days in June 2023:
--Thursday 6/8/23.
--Friday 6/9/23.
--Saturday 6/10/23.
--Sunday 6/11/23.
--Monday 6/12/23.
--Saturday 6/24/23.
---Received documentation from facility of RN coverage by the DON and/or the MDS Coordinator, for the following three June dates from above:
----Thursday 6/8/23.
----Friday 6/9/23.
----Monday 6/12/23.
Review of staffing sheets from November 16, 2023, through December 4, 2023, showed no eight-hour consecutive RN coverage the following days:
-Thursday 11/23/23.
-Friday 11/24/23.
-Saturday 11/25/23.
-Sunday 11/26/23.
During an interview on 12/7/23 at 8:55 A.M., the Administrator said:
-The facility had three RN's which included the DON and the MDS Coordinator.
-They just couldn't get any RN's to apply.
-The non-administrative RN works every other weekend along with weekdays.
-They have had in the past some agency coverage.
During an interview on 12/11/23 at 10:05 A.M., the Staffing Coordinator said:
-He/she had a monthly schedule that was a daily schedule for the shifts that the staff usually worked.
-The daily schedule was put out at the nurse's station.
-He/she tried to make up two weeks schedule at a time.
-There was a spot at the top of the staffing sheet to put in the name of the RN who was working for that day.
-There was RN coverage every other weekend that was not Administrative staff.
-On the weekends that were not covered by a RN, the DON or the MDS Coordinator took turns covering.
-Used to use agency staff to cover needed staffing openings except for RN's.
-Have not used agency staffing since July 2023 except for the last couple of weeks with staff being off due to COVID-19.
-Try to get own staff to work an extra shift before calling agency staff.
-The facility did not use a staffing agency to cover the RN in vacancies.
During an interview on 12/11/23 at 10:32 A.M., the DON said:
-He/she had covered a weekend if there was no RN in the past.
-At times it could have been every weekend in a month.
-For most of this year he/she had not come in on a weekend very much.
-He/she doesn't believe the facility had RN coverage every weekend for a long time.
-He/she just had not been asked to cover on a weekend.
-The facility had ads out for RN positions in an online staffing forum, have placed ads in the local newspaper and on social media.
-Just have not had any RN's or nurses apply.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident's oxygen tubing was not on the floor; to ensure the plastic storage bag for the oxygen tubing was not on the floor; to ensure his/her nebulizer (a machine that turned liquid medication into a mist that was easily inhaled) was not on the floor; to ensure the resident's oxygen tubing was changed weekly with the date written on the storage bag for one sampled resident (Resident # 29) out of 14 sampled residents. The facility census was 54 residents.
Review of the facility's undated policy, Oxygen Tubing and Cannula (part of the oxygen tubing that goes into a person's nose) Storage Policy and Procedures, showed:
-Oxygen Tubing and cannulas would be replaced weekly and as needed by the nursing staff.
-When not in use Oxygen tubing or cannulas for each resident would be confined in a bag.
-Any tubing or cannulas found on the floor would be replaced by the nursing staff immediately.
-Storage bags would be dated as to the date the tubing and cannula were replaced.
1. Review of Resident #29's face sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe).
Review of the resident's Significant Change Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning) dated 10/20/23 showed:
-His/her Brief Interview for Mental Status (BIMS) score was 11 out of 15 indicating he/she was moderately cognitively impaired.
-He/she had COPD.
-He/she had a Cardiorespiratory (relating to both the heart and lungs) condition.
Review of the resident's undated care plan showed:
-He/she was on oxygen therapy related to an ineffective gas exchange.
-Staff were to give medications as ordered.
-He/she was on Hospice (end of life care).
Review of the resident's Physician's Order Sheet (POS) dated December 2023 showed:
-After each use, wipe the nebulizer mask with a clean damp cloth.
-Rinse the nebulizer chamber with warm tap water and allow to air dry each shift, dated 1/1/23.
-Change the nebulizer tubing and mask every Tuesday night shift, dated 3/14/23.
-Oxygen at four liters per nasal cannula every shift, dated 4/19/23.
-Change the oxygen tubing, bag, and humidifier every Tuesday night shift, dated 3/14/23.
-Ipratropium and Albuterol (a combination medication used to treat COPD) 0.53(2.5) milligram) (mg)/3 mg one vial inhale orally every four hours related to COPD, dated 4/19/23.
-Ipratropium and Albuterol 0.53(2.5)mg/3 mg one vial inhale orally every three hours as needed related to COPD, dated 4/19/23.
Observation on 12/4/23 at 9:30 A.M. showed:
-The resident was on four liters of oxygen.
-He/she said staff change the tubing out every other week or so.
-The floor in the corner of the resident's room was sticky.
-The oxygen tubing was stuck to the floor and dated 11/7/23.
-The oxygen tubing storage bag was stuck to the floor.
-The nebulizer was stuck to the floor.
Observation on 12/5/23 at 2:00 P.M. showed:
-The floor was still sticky.
-The oxygen tubing was stuck to the floor.
-The oxygen tubing storage bag was stuck to the floor.
-The nebulizer was stuck to the floor.
Observation on 12/6/23 at 7:45 A.M. showed:
-The floor was still sticky.
-The date on the bag the Oxygen tubing was in was 11/7/23.
-The oxygen tubing was stuck to the floor.
-The oxygen tubing storage bag was stuck to the floor.
-The nebulizer was stuck to the floor.
During an interview on 12/6/23 at 7:45 A.M. Certified Nursing Assistant (CNA) C said:
-The oxygen tubing was to have been changed on Tuesdays during the night shift.
-The oxygen tubing was stuck to the floor.
-The oxygen tubing storage bag was stuck to the floor.
-The nebulizer was stuck to the floor.
-The date on the oxygen tubing bag was 11/7/23.
-The house keeper cleaned daily but the floor was very sticky.
During an interview on 12/6/23 at 7:46 A.M. Certified Medication Technician (CMT) A said:
-On Tuesday nights they change out the oxygen tubing.
-The date on the oxygen tubing storage bag was 11/7/23.
-The nebulizer should not be on the floor.
-The oxygen tubing should not have been on the floor.
-The oxygen tubing storage bag should not have been on the floor.
-Housekeeping cleaned daily and should have cleaned that corner where the residents nebulizer was.
During an interview on 12/6/23 at 10:15 A.M. Licensed Practical Nurse (LPN) A said:
-Housekeeping cleaned the residents' rooms daily.
-The floor should not have been sticky.
-Oxygen tubing should not have been on the floor.
-The oxygen tubing storage bag should not have been on the floor.
-The nebulizer machine should not be on the floor.
-On Tuesday nights the CNA's change the oxygen tubing.
-The CNA's should have written the date on the bag when it was changed.
During an interview on 12/11/23 at 11:15 A.M. the Director of Nursing (DON) said:
-Oxygen tubing should have been changed weekly by the night CNA's on Tuesdays.
-The date it was changed should have been written on the storage bag.
-The nebulizer should never have been on the floor.
-The oxygen tubing should never have been on the floor.
-The oxygen tubing storage bag should have never been on the floor.
-Housekeeping cleaned the floors daily it should not have been sticky.
-The nurses were responsible to ensure the oxygen tubing, oxygen concentrator, and nebulizer were kept clean.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure there was documentation of the contracted hospice (end of life care) company's visits for one sampled resident, (Resident #29) out of 14 sampled residents. The facility census was 54 residents.
Review of the facility's policy, Coordination of Hospice Services, dated 11/23/22 showed:
-The facility maintained written agreements with hospice providers that specify the care and services that were to have been provided and the process for hospice and the nursing home communication of necessary information regarding the resident's care.
-The facility would maintain communication with hospice as it related to the resident's plan of care and services to ensure each entity was aware of their responsibilities.
1. Review of Resident #29's face sheet showed he/she was admitted on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD - a group of lung diseases that make it hard to breathe).
Review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) dated 10/20/23 showed:
-He/She had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 indicating he/she was moderately cognitively impaired.
-He/she had Cardiorespiratory (heart and lung) conditions.
-He/she had COPD.
-He/she had a condition that may result in life expectancy of less than six months.
-He/she was on hospice care.
Review of the resident's Physician Order Sheet (POS) dated December 2023 showed:
-The resident was admitted to a hospice company on 7/13/23 for COPD.
-The resident was a Do Not Resuscitate (DNR no life saving measures if the heart stops) status.
Review of the resident's undated care plan showed:
-He/she had a DNR code status.
-He/she was utilizing hospice services.
Review of the resident's hospice collaboration log on 12/4/23 at 9:43 A.M. showed no documentation from 7/13/23 to 12/4/23.
Review of the resident's hospice notebook for the resident on 12/4/23 at 9:45 A.M. showed:
-Last documentation of cares done with the resident on Hospice sheet was 11/3/23.
-There was only one sheet filled out documenting cares in the notebook from 7/13/23 to 12/4/23.
During an interview on 12/6/23 at 1:30 P.M. Licensed Practical Nurse (LPN) A/Charge Nurse (CN) said:
-They (facility staff) were given an oral report and never looked at the book.
-They (facility staff) were not able to verify when the hospice staff visited the resident.
-The resident was seen weekly by the hospice company.
-There was documentation only on 11/3/23 of their visit.
-They were to document what they did on their visits collaboration log each time they came.
-The hospice nurse was to visit the resident at least weekly and as needed.
-The Home Health Aide was to have come once or twice a week to bathe the resident.
-It should have been on his/her care plan.
-The Director of Nursing (DON) was ultimately responsible for ensuring documentation had been done.
During an interview on 12/7/23 at 12:00 P.M. the resident said:
-He/she has been on hospice services for a few months.
-He/she did not know how often they came.
-A nurse would come sometimes.
-A Home Health Aide would come to bathe him/her once or twice a week.
During an interview on 12/7/23 at 2:00 P.M. the Administrator said:
-The hospice company was not doing weekly documentation.
-There was no documentation from the hospice company since 11/3/23.
-The DON was responsible to ensure the company was documenting their visits.
During an interview on 12/11/23 at 11:15 A.M. the DON said:
-The facility had a contract for hospice to provide services for the resident.
-The hospice staff should have been documenting what was done during their visits.
-The documentation should have been in the communication binder.
-The hospice staff should have documentation for every time they visited the resident and they have not been doing it for this resident.
-He/she was ultimately responsible and had not checked the documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide an ongoing program of activities to meet the interests as well as the physical, mental and psychosocial well-being for four sampled residents (Residents #17, #47, #30 and #42) out of 14 sampled residents. The facility census was 54 residents.
Review of the facility's Activity Evaluation Policy, dated June 2018, showed:
-To promote the physical, mental and psychosocial well-being of the residents, an activity evaluation was conducted and maintained for each resident at least quarterly and with any change of condition that could affect his/her participation in planned activities.
-An activity evaluation was conducted as part of the comprehensive assessment to help develop any activities plan that reflected the choices and interests of the resident.
-The residents activity evaluation was conducted to evaluate functional level, cognition and medical conditions that may affect the residents participation in activities.
-The residents lifelong interests, spirituality, life goals and roles, strengths, needs and activity pursuit patterns and preferences were included in the evaluation.
-The activities director was responsible for completing, directing and or delegating the completion of the activities component of the comprehensive assessment.
-The activity evaluation was used to develop an individual activities care plan that allowed the resident to participate in activities of his/her choice and interests.
1. Review of Resident #17's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 6/26/23 showed:
-The resident scored a 00 on the Brief Interview for Mental Status (BIMS an assessment tool that shows a score between 3 of 15 which shows the resident's mental status. This tool helps determine the resident's attention, orientation and ability to register and recall new information. These items are crucial factors in care planning decisions).
--This showed the resident was severely cognitively impaired.
-The resident was diagnosed with:
--Dementia (progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking).
--A stroke.
--Hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing).
Review of the resident's Individual Resident Daily Participation Record dated September 2023 showed:
-On 9/5/23, 9/17/23 and 9/24/23 the resident participated in one-on-one activities.
-On 9/5/23, 9/14/23 and 9/28/23 the resident participated in sports games.
-On 9/27/23 the resident participated in one hospice activity.
-On 9/29/23 the resident participated in one movie/TV activity.
Review of the resident's Care Plan, dated 9/12/23, showed:
-The problem identified was, the resident was dependent on staff for meeting emotional, intellectual, physical, and social needs related to dementia and multiple comorbidities.
-The goal was, the resident would maintain involvement in cognitive stimulation, social activities as desired through review date.
-The approaches were:
--Ensure that the activities the resident was attending were compatible with physical and mental capabilities; compatible with known interests and preferences; adapted as needed (such as large print, holders if resident lacks hand strength, task segmentation); compatible with individual needs and abilities; and age appropriate.
--Establish and record the resident's prior level of activity involvement and interests by talking with the resident, caregivers, and family on admission and as necessary.
--Introduce the resident to residents with similar background, interests and encourage/facilitate interaction.
--Invite the resident to scheduled activities.
--The resident had impaired cognitive function or impaired thought processes related to dementia.
--Engage the resident in simple structured activities that avoid overly demanding tasks.
--Provide a program of activities that accommodates the resident's abilities.
Review of the resident's Quarterly/Annual Participation Review, dated 9/25/23, showed:
-The resident participated in some group activities and one on one activities.
-The resident enjoyed watching TV with snacks, listening to music, playing games that involved balls and being read to.
Review of the resident's Individual Resident Daily Participation Record dated October 2023 showed:
-On 10/9/23 and 10/30/23 the resident participated in one-on-one visits.
-On 10/9/23 the resident participated in exercise.
-On 10/20/23 the resident participated in a movie or TV activity.
-On 10/25/23 the resident participated in sing-along's and a hospice activity.
-On 10/27/23 the resident participated in a sports game.
Review of the resident's Individual Resident Daily Participation Record dated November 2023 showed:
-On 11/3/23, 11/17/23 and 11/24/23 the resident participated in one-on-one activities.
-On 11//5/23, 11/14/23 and 11/28/23 the resident participated in sports games.
-On 11/27/23 the resident participated in a hospice activity.
-On 11/29/23 the resident participated in a movie or TV activity.
Observation on 12/05/23 at 10:18 A.M. showed:
-Certified Nursing Assistants (CNA's) and other staff were doing activities with residents.
-The resident was in front of the TV, no one asked if he/she wanted to participate in any type of game or activity.
Observation on 12/05/23 at 10:46 A.M., showed CNA A moved the resident in his/her wheelchair from one table to the lunch table to get ready for lunch, which was to be served at 12:00 P.M.
During an interview on 12/06/23 at 8:02 A.M., CNA A said:
-He/she tried to get the resident involved as much as he/she could.
-The resident liked music.
-He/she tried coloring with the resident, but the resident didn't seem to have much interest.
-The resident liked the music most, clapped his/her hands, tapped his/her feet and moved his/her head.
-The resident did not show any restlessness.
Observation on 12/06/23 at 7:04 A.M. showed:
-The resident was sitting at table in his/her wheelchairs, awake, looking round.
-Breakfast was to be served at 7:30 A.M.
-The resident was not engaged in any form of activity.
During an interview on 12/07/23 at 9:24 AM. CNA B said:
-The resident liked music.
-The resident liked snacks and to eat.
-It was difficult for the resident to do activities.
-The resident was stubborn and only participated when he/she wanted to.
-He/She tried to keep the resident involved but the resident did not participate.
During an interview on 12/07/23 at 10:44 A.M., Licensed Practical Nurse (LPN) A said:
-The resident could not hold a conversation.
-The resident liked to hum to himself/herself or to music.
-The resident did not like activities.
-Even when the resident was more mobile, he/she did not do activities.
-The resident seemed content with being in the dining area and liked to be a people watcher.
-The resident was constantly moving his/her hands.
-Staff tried to get him/her to fold towels, but the resident was not interested.
-The resident did not like to lay down.
-The resident was going to do what he/she wanted to do.
2. Review of Resident #47's MDS dated [DATE] showed:
-The resident scored a 03 on the BIMS.
--This indicated the resident was severely cognitively impaired.
-The resident was diagnosed with:
--Dementia.
--Depression (medical illness that negatively affects how a person felt, thought, acted).
--Cardiorespiratory conditions (a range of serious disorders that affected the heart and lungs).
Review of the resident's annual MDS Preferences for Routine and Activities (Section F), dated 1/9/23, showed:
-It was somewhat important for him/her to have newspapers and magazines to read.
-It was somewhat important for him/her to listen to music.
-It was very important to do his/her favorite activities.
-It was somewhat important to do things with groups of people.
Review of the resident's care plan, dated 10/4/23, showed:
-The resident was dependent on staff for meeting emotional, intellectual, physical, and social needs related to dementia.
-The resident would maintain involvement in cognitive stimulation, social activities as desired through review date.
-All staff were to converse with the resident while providing care.
-Provide a program of activities that was of interest and empowered the resident by encouraging/allowing choice, self-expression and responsibility.
-The resident was an elopement risk related to wandering.
--Distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television and books.
Review of the resident's Individual Resident Daily Participation Record, dated October 2023, showed:
-On 10/3/23 and 10/31/23 the resident participated in food/cooking activities.
-On 10/3/23, 10/17/23 and 10/31/23 the resident participated in a coloring activity.
-On 10/4/23, 10/6/23, 10/9/23 and 10/16/23 the resident participated in exercise.
-On 10/4/23 the resident participated in a library/reading activity.
-On 10/19/23 the resident participated in an entertainment activity.
-On 10/20/23 the resident participated in a movie/television activity.
-On 10/24/23 the resident participated in a hospice activity.
-On 10/25/23 the resident participated in an evening activity and a sing-along activity.
-On 10/27/23 the resident participated in a sports game activity.
Review of the resident's Individual Resident Daily Participation Record, dated November 2023, showed:
-On 11/1/23 the resident participated in a manicure activity.
-On 11/1/23, 11/7/23, 11/16/23 and 11/22/23 the resident participated in an exercise activity.
-On 11/6/23, 11/13/23, and 11/27/23 the resident participated in a coloring activity.
-On 11/8/23, 11/21/23 and 11/22/23 the resident participated in a hospice activity.
-On 11/8/23, 11/21/23 and 11/22/23 the resident participated in a sports game activity.
-On 11/10/23 the resident participated in a movie/TV activity.
-On 11/16/23 the resident participated in an entertainers activity.
-On 11/22/23 and 11/29/23 the resident participated in an evening activity.
Review of the resident's Individual Resident Daily Participation Record, dated December 2023, showed on 12/3/23, 12/4/23, and 12/7/23 the resident participated in one-on-one visits.
Observation on 12/04/23 at 9:33 A.M., showed:
-The resident's room door was closed.
-There was no answer when the door was knocked on.
Observation on 12/04/23 at 12:08 P.M., showed:
-The resident was eating in his/her room.
-The resident's TV was on, he/she was sitting on the bed with lunch on the bedside tray table.
During an interview on 12/06/23 at 8:02 A.M., CNA A said:
-The resident was on isolation in his/her room due to being COVID-19 (disease caused by a coronavirus, with symptoms of fever and cough and is capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) positive.
-When the resident was able to leave his/her room he/she liked bingo, tick tack toe and coloring.
-Sometimes he/she just wanted to be in his/her room.
-Not sure of any individual activities in room being done.
During an interview on 12/07/23 at 9:24 A.M., CNA B said:
-The resident liked to dance and color and would play bingo.
-He/she liked snacks and puzzles.
-He/she gave the resident color pages.
During an interview on 12/07/23 at 9:38 A.M. Certified Medication Technician (CMT) B said:
-The resident was kind of a busy body.
-The resident was currently on isolation due to being COVID-19 positive.
-He/she was unaware if activities staff went in the resident's room.
-Before isolation the resident was very busy and active.
During an interview on 12/07/23 at 10:44 A.M., LPN A said the resident:
-Did not really like activities.
-Liked to sit and look out the window.
-Drank tea and coffee.
-Used to be a bar fly before coming to the facility.
-Flirted with other residents when he/she was in the common area.
3. During an interview on 12/07/23 at 1:31 P.M., the Activities Director said:
-The Assistant Activities Director did most of the activities.
-He/she helped with parties, events and did the activity planning.
-He/she did all activity assessments with each resident.
-He/she let CNA's know what the resident preferences were.
-Twice a month he/she planned movies and snacks.
-The CNA's did color pages and word searches with the residents.
-The residents on the dementia unit enjoyed arts and crafts.
-The residents on the dementia unit played bingo on Thursdays.
-He/she printed off short stories, word searches and cross word puzzles for residents in isolation.
-The activities assistant took something to them every day that he/she or the CNA's did with the residents.
-He/she sanitized anything that was brought into and taken out of the resident's rooms.
-Resident #47 liked big inflatable balls and any activity involving music and getting his/her hair done.
During an interview on 12/11/23 at 11:22 A.M. the Director of Nursing (DON) said:
-He/she would have to get with the activities director for specific information on individual residents.
-The activities staff or CNA's did one on one activities or went in and read with the residents on isolation.
-He/she expected the activities staff to bring activities to the residents on isolation on a daily basis.
-He/she was aware the activities staff brought a ball in to one of the residents' room one day.
4. Review of Resident #30's care plan dated 1/21/23 showed:
-The resident was dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits.
-The goal was that the resident would maintain involvement in cognitive stimulation and social activities as desired.
-Instructions to:
--Encourage ongoing family involvement.
--Invite the resident's family to attend special events, activities and meals.
--Establish and record the resident's prior level of activity involvement and interests by talking with the resident, caregivers, and family on admission and as necessary.
--Invite the resident to scheduled activities.
--Provide the resident the activities calendar and notify the resident of any changes to the calendar of activities.
--Thank the resident for attendance at activity function.
-The resident required stand-by supervision with a walker for walking.
-The resident required supervision to touching assistance of one staff to move between surfaces.
-The resident could be resistive to cares related to dementia (a progressive mental disorder characterized by memory problems, impaired reasoning and personality changes).
-The resident had a communication problem related to a cognitive communication deficit.
-The resident had impaired cognitive function and impaired thought processes related to dementia.
-Some of the resident's diagnoses included an anxiety disorder (psychiatric disorder that involves extreme fear, worry and nervousness) and depression (a mood disorder that consists of intense sadness and a loss of interest or loss of pleasure in activities and/or life).
Review of the resident's psychiatrist progress note dated 6/15/23 showed:
-The resident was impulsive and angry.
-The resident did things like look for his/her parents.
-The resident was confused.
Review of the resident's activities initial review dated 8/7/23 showed:
-The resident wished to participate in activities while in the home.
-The resident did not wish to participate in group activities.
-The resident participated in no activities, interests or hobbies.
-The resident enjoyed visits with his/her spouse.
-The resident wanted one-one-one activities with staff.
-The resident did not like independent activities such as reading, doing puzzles, etc.
-The resident was pleasantly confused.
-The resident would need reminders of activities.
-No prior interests, activities or hobbies were included.
Review of the resident's activities quarterly participation review dated 11/12/23 showed:
-Sometimes we can work with (the resident) one-on-one.
-The resident had no favorite activities or interests.
-The resident was disruptive and loud at times.
Review of the resident's significant change MDS dated [DATE] showed the following assessment of the resident:
-Did not have hearing impairment.
-Wore glasses.
-Had clear speech.
-Usually understood others and others usually understood him/her.
-The resident had long-term and short-term memory impairment.
-Had moderately impaired decision-making skills, inattention and disorganized thinking.
-Had no negative mood indicator or negative behaviors.
-Participating in his/her favorite activities was somewhat important to the resident.
-Had no range of motion impairment.
-Used a walker.
-Required supervision when transferring from one surface to another.
-Required partial to moderate assistance when going from sitting down to standing.
-Some of the resident's diagnoses included dementia, anxiety and depression.
Review of the resident's Individual Resident Daily Participation Record dated November 2023 showed:
-The resident participated actively in:
--Resident Council once.
--Arts and crafts once.
--Hospice activity three times.
--Movies/television once.
--One on one visits three times.
--Evening activity twice.
-The resident had 21 days out of 30 with no documented activities.
Observation on 12/4/23 showed:
-At 11:16 A.M.:
--The resident was sitting on the couch in the common area.
--Music was playing on the television screen.
--The resident was talking loudly (to no one in particular) but was not really understandable.
--The resident started saying, La, la, la, la, la loudly.
-At 12:37 P.M., the resident was having lunch in the dining room.
-At 12:48 P.M., the resident was sitting at the dining room table leaning forward, with his/her hands are on his/her lap and his/her face is on top of his/her hands.
-At 12:49 P.M., staff walked the resident out of the dining room and told the resident he/she could lie down for a nap.
-At 1:18 P.M., the resident was in a recliner in his/her room with his/her eyes closed.
-At 2:21 P.M., the resident was sitting at a dining room and was talking to a staff member.
-At 2:34 P.M., the resident was talking to another resident.
-At 2:36 P.M., staff pushed the resident that the resident was talking to out of the dining room, leaving the resident alone at the table with no activity.
-At 2:47 P.M. through 2:58 P.M., the resident was talking incoherently to Resident #2.
Observation on 12/5/23 at 9:58 A.M., the resident was asleep in his/her bed.
Continuous observation on 12/6/23 from 9:37 A.M. to 10:55 A.M. showed:
-At 9:37 A.M., the resident was asleep on a couch in the common area.
-At 10:22 A.M., staff assisted the resident in getting up from the couch and walked him/her to dining room chair at a dining room table where the resident sat alone with no activity.
-At 10:55 A.M., the resident was given a beverage.
Continuous observation on 12/7/23 from 9:47 A.M. to 10:52 A.M. showed:
-At 9:47 A.M.:
--The resident was sitting on a couch in the common area and was singing La, la, la.
--A Christmas movie was on the television. The resident was not watching the movie.
--The resident said loudly Who is working on the stove?
-At 10:40 A.M., the resident was singing La, la, la again.
-The resident remained on the couch with no activity.
Review of the resident's Individual Resident Daily Participation Records showed there was no record for the resident for December 2023.
During an interview on 12/8/23 at 9:28 A.M., the Activity Director said:
-He/she asked residents when they first came to the facility what their interests were.
-If the resident could not provide the information, he/she tried to talk to family of the resident to get the information.
-If there were staff who spent a lot of time with a resident, he/she asked them what the resident liked to do.
-He/she tried to ask more details like what they like to read, what games they like, what television shows or movies they like, etc.
-He/she did the activity assessments, progress notes and logged activity participation.
-He/she had to work one-on-one with the resident.
-The resident watched movies and ate snacks.
-The resident's spouse visited.
-The resident's spouse said the resident liked to knit and sew.
-The resident did not want to do things he/she had offered the resident.
-The resident yells out.
-The Activity Assistant did sensory things with the resident in the past.
-They currently did not have an activity assistant.
-They did have a CNA who was on light-duty who was helping with activities.
-There was a basket of towels the resident would mess with, but he/she had not seen it recently.
During an interview on 12/11/23 at 10:29 A.M., CMT B said:
-The resident liked to watch television, listen to live music and liked to talk to anybody.
-The resident participated in activities at times.
During an interview on 12/11/23 at 11:23 A.M., the DON said:
-He/she did not know of anything that interested the resident.
-Sometimes the resident would watch a movie.
-He/she didn't think the resident understood how to participate in activities.
-The resident talked but his/her words were incoherent.
-Activities should get information on residents' previous hobbies.
-Activities should be based on the resident's likes, dislikes and preference as much as possible.
5. Review of Resident #42's care plan updated 8/24/23 showed:
-The resident was dependent on staff for meeting emotional, intellectual, physical, and social needs related to dementia and cognitive deficits.
-The goal was that the resident would maintain involvement in cognitive stimulation, social activities as desired through review date.
-The resident needed assistance/escort to activity functions.
-Instructions to:
--Ensure the activities the resident was attending were compatible with physical and mental capabilities, known interests and preferences, individual needs and abilities.
--Ensure the activities the resident was attending were adapted as needed (such as large print, holders if resident lacks hand strength, task segmentation).
--Ensure the activities the resident was attending were age appropriate.
--Invite the resident to scheduled activities.
--Provide the resident with materials for individual activities as desired.
--Provide the resident an activities calendar and notify the resident of any changes to the calendar of activities.
--Thank the resident for attendance at activity function.
-The resident likes the following independent activities: (SPECIFY) - none were specified.
Review of the resident's significant change MDS dated [DATE] showed the following staff assessment of the resident:
-Did not have hearing impairment.
-Wore glasses.
-Had clear speech.
-Usually understood others and others usually understood him/her.
-The resident had long-term and short-term memory impairment.
-Had no negative mood indicator or negative behaviors.
-Used a wheelchair.
-Had no range of motion impairment.
-Some of his/her diagnoses included dementia and depression.
-The activities that were somewhat important to him/her included music, pets, group activities and participating in his/her favorite activities.
Review of the resident's quarterly activities participation review dated 10/12/23 showed:
-The resident participated in group activities of his/her choice.
-The resident sometimes participated in one on one activities and some parties.
-The resident enjoyed morning exercise, some games, wheeling up and down the halls, book club, socializing with other residents and with staff and watching television and/or movies.
-No information regarding prior hobbies or interests.
Review of the resident's Individual Resident Daily Participation Record dated November 2023 showed:
-The resident participated actively in:
--Exercise 13 times.
--Arts and crafts three times.
--Hospice activity three times.
--Television/Movie once.
--Beauty salon twice.
--Evening activity once.
--Entertainment once.
--Games twice.
-The resident had 13 days out of 30 with no documented activities.
Review of the facility's list of residents who were COVID-19 positive in November 2023 and December 2023 showed the resident tested positive for COVID-19 on 11/29/23.
Review of the resident's Physician's Order Sheet (POS) dated December 2023 showed physician's orders for contact precautions/isolation dated 11/29/23 for ten days.
Observation on 12/4/23 showed:
-At 11:09 A.M.:
--The resident was not in his/her room.
--A red sign was on the wall outside the resident room that said to report to the nurses' station before entering the resident's room and there was an isolation cart outside the resident's room.
-At 11:15 A.M., the resident was talking to Resident #12 in the dining room.
-From 1:06 P.M. to 1:16 P.M.:
--The resident self-propelled away from the dining room table and over to this writer/state surveyor.
--The resident was talking but most of it did not make any sense.
--The resident pointed to a flower painting on the wall and said it was pretty.
--The resident offered this writer/state surveyor the food on the dining room table.
--The resident started humming to the music on in the dining room.
--The resident asked, Where was I going to go?
-From 2:21 P.M. to 2:58 P.M.:
--At 2:21 P.M.:
---The resident was in the dining room with his/her eyes closed with no activity.
---Staff tried to take the resident's vitals but the resident did not them want to.
-At 2:37 P.M., staff took the resident's vitals.
-At 2:47 P.M., the resident was talking to another resident.
--The resident had no activities during the time of observation.
Continuous observation on 12/5/23 from 9:54 A.M. to 10:37 A.M. showed:
-At 9:54 A.M., the resident was sitting at a dining room table eating a honey bun and talking to another resident for a couple of minutes.
-At 10:11 A.M., the resident was sitting in the dining room with no activity.
-At 10:15 A.M., the resident propelled to a table where another resident was playing tic-tac-toe with staff and watched them play.
-At 10:20 A.M., the resident propelled to another and talked to another resident.
-At 10:33 A.M., the resident propelled to a table where a staff member was feeding another resident.
-At 10:35 A.M., the resident propelled back to the original table with no activity.
Continuous observation on 12/6/23 from 6:54 A.M. to 7:35 A.M. showed:
-At 6:54 A.M., the resident was in his/her wheelchair in the dining room, propelling around holding an insulated coffee cup.
-At 7:02 A.M., the resident was propelling around the dining room.
-The resident stopped and asked another resident if it was time for breakfast.
-The resident wheeled down the hall toward his/her room.
-At 7:25 A.M., the resident returned to the dining room and sat in the dining room with no activity.
-At 7:35 A.M., the resident was served breakfast.
Continuous observation on 12/6/23 from 9:28 A.M. to 10:55 A.M. showed:
-At 9:28 A.M.:
--The resident was wheeling around in the dining room.
--The resident stopped behind another resident where audio exercise instructions were playing.
--Two residents were present in the area and were participating in the exercises.
--No staff were in the area where the audio exercise instructions were playing.
--The resident did not participate and wheeled away to another part of the dining room.
-At 9:44 A.M., a staff member asked the resident if he/she wanted to play Jenga and the resident said no.
-The resident propelled over by a table where three other residents were and then wheeled around the dining room.
-At 10:24 A.M., the resident wheeled to the nurses' station, then over to a table where four other residents were sitting.
-The resident wheeled to another table with no activity.
Continuous observation on 12/07/23 from 9:45 A.M. to 10:52 A.M. showed:
-At 9:45 A.M.:
--The resident was in his/her wheelchair in the dining room where two staff and two other residents were.
--The other two residents were coloring.
--The resident had no activity.
--The resident wheeled away from that table.
-At 9:51 A.M., the resident wheeled up to another dining room where he/she sat alone with no activity.
-At 9:58 A.M., the resident was propelling around in the dining room with no activity.
-At 10:00 A.M., the resident was resting his/her head on the palm of his/her hand with his/her eyes closed.
-At 10:06 A.M., the resident wheeled over to table where two staff and two other residents were, then wheeled toward one of the halls and then returned to the same table.
-At 10:20 A.M., the resident was eating a honey bun.
-At 10:28 A.M., the resident wheeled another table and was sitting with no activity.
-At 10:40 A.M.:
--The resident wheeled out of the dining room and down one of the halls.
--The resident wheeled back into the dining room and sat next to another resident with no activity.
Review of the resident's Individual Resident Daily Participation Records showed there was no record for the resident for December 2023.
During an interview on 12/8/23 at 9:28 A.M., the Activity Director said:
-He/she asked residents when they first came to the facility what their interests were.
-If the resident could not provide the information, he/she tried to talk to family of the resident to get the information.
-If there were staff who spent a lot of time with a resident, he/she asked them what the resident liked to do.
-He/she tried to ask more details like what they like to read, what games they like, what television shows or movies they like, etc.
-He/She did the activity assessments, progress notes and logged activity participation.
-The resident did exercises about 80% of the time in morning and would watch if not actively participating.
-The resident did some coloring and some arts and crafts, if encouraged.
-The resident would stay at an activity for a while, may wander off but usually came back.
-The resident's spouse is unable to visit very often.
-The resident's spouse said the resident did housecleaning.
-He/she gave the resident things, and he/she would mess with them, try to take it apart or put it together.
During an interview on 12/11/23 at 10:29 A.M., CMT B said:
-The resident liked to color.
-The resident did not watch television.
-They had crosswords available for something to do with the residents.
During an interview on 12/11/23 at 11:23 A.M., the DON said:
-It was difficult to get the resident to do anything.
-He/she would have to brainstorm with staff to think of things the resident might do.
-It was difficult to keep the resident's attention for any amount of time.
-He/she saw the resident play a game with a ball in which he/she threw the ball and then wandered off.
-The resident had conversations, but it usually didn't make any sense.
-Activities should be based on the resident's likes, dislikes and preference as much as possible.
-The activities staff or CNA's were t

Based on interview and record review, the facility failed to include parameters for monitoring a resident's pulse when monitoring for medication administration and for failing to clarify a physician's order for administering an as needed blood pressure medication when the resident's blood pressure was elevated for one sampled resident (Resident #35) out of five residents sampled for medication review. The total sample was 14 residents. The facility census was 54 residents.
Review of the facility's policy titled Medication Orders dated September 2014 showed it did not address parameters or order clarification.
1. Review of Resident #35's care plan dated 2/16/23 and updated on 7/30/23 showed the resident had high blood pressure and included instructions to staff to administer blood pressure medications as ordered and monitoring the resident's blood pressure.
Review of the resident's consultant pharmacist's recommendation dated 6/13/23 showed instructions to add Do not crush to the resident's Flomax (tamsulosin) (used to improve urination in men with an enlarged prostate) order.
Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff and used for care planning) dated 10/26/23 showed the following staff assessment of the resident:
-Moderately cognitively impaired.
-Had a diagnosis of high blood pressure.
Review of the resident's Medication Administration Record (MAR) dated November 2023 showed:
-A physician's order dated 6/15/23-11/10/23 for Tamulosin 0.4 milligrams (mg), one capsule, one time a day. Do not crush.
-A physician's order dated 11/10/23 for Tamulosin 0.4 milligrams (mg), two capsules, one time a day.
--NOTE: The order did not include the instructions do not crush.
-A physician's order for Amlodipine (a medication used to treat high blood pressure) 10 mg, one tablet one time a day and it included blood pressure and pulse monitoring (the time was not indicated for this order) with no parameters indicated.
--On 11/4/23, the resident's blood pressure was 169/72.
--On 11/5/23, the resident's blood pressure was 165/87.
--On 11/18/23, the resident's blood pressure was 199/96.
--On 11/19/23, the resident's blood pressure was 185/90.
-A physician's order for Clonidine (a medication that lowers blood pressure and heart rate) 0.1 mg, give one tablet two times a day with no blood pressure parameters indicated.
-A physician's order to monitor the resident's blood pressure two times a day. If the systolic blood pressure (SBP-The top number measures the pressure in the arteries when the heart beats) was less than 100, hold all blood pressure medications and notify the resident's physician. If the SBP was greater than 160, give as needed Clonidine.
--On 11/4/23 during the A.M., the resident's blood pressure was 169/87.
--On 11/5/23 during the A.M., the resident's blood pressure was 165/87.
--On 11/18/23 during the A.M., the resident's blood pressure was 199/96.
--On 11/18/23 during the P.M., the resident's blood pressure was 197/88.
--On 11/19/23 during the A.M., the resident's blood pressure was 185/90.
--On 11/25/23 during the P.M., the resident's blood pressure was 168/92.
-No order for as needed Clonidine.
-A physician's order dated 10/18/23-11/24/23 for Hydralazine (a medication used to treat high blood pressure) 50 mg, give one tablet four times a day with blood pressure and pulse monitoring.
---On 11/4/23 at 8:00 A.M., the resident's blood pressure was 169/87
--On 11/9/23 at 8:00 P.M., the resident's blood pressure was 165/84.
--11/18/23 at 8:00 A.M., the resident's blood pressure was 199/96.
--11/18/23 at 5:00 P.M., the resident's blood pressure was 197/88.
--11/19/23 at 8:00 A.M., the resident's blood pressure was 185/90.
--11/19/23 at 8:00 P.M., the resident's blood pressure was 162/98.
-A physician's order dated 11/24/23 for Hydralazine 100 mg, give one tablet three times a day with blood pressure and pulse monitoring.
-The resident's blood pressure medications were administered on every occasion above but no as needed Clonidine was administered on every occasion the resident's SBP was over 160 as there was no physician's order for as needed Clonidine.
Review of the resident's notes dated November 2023 showed no notes regarding the resident's SBP being over 160 or anything about the as needed Clonidine order.
Review of the resident's MAR dated December 2023 showed:
-A physician's order dated 11/10/23 for Tamulosin 0.4 (mg), two capsules one time a day.
--NOTE: The order did not include the instructions do not crush.
-A physician's order for Amlodipine 10 mg, one tablet one time a day and it included blood pressure and pulse monitoring (the time was not indicated for this order) with no parameters indicated.
-A physician's order for Clonidine 0.1 mg, give one tablet two times a day with no blood pressure parameters indicated.
-A physician's order to monitor the resident's blood pressure two times a day. If the SBP was less than 100, hold all blood pressure medications and notify the resident's physician. If the SBP was greater than 160, give as needed Clonidine.
--On 12/6/23 during the P.M., the resident's blood pressure was 187/96.
-A physician's order dated 11/24/23 for Hydralazine 100 mg, give one tablet three times a day with blood pressure and pulse monitoring.
--On 12/6/23 at 8:00 P.M., the resident's blood pressure was 187/96.
--On 12/7/23 at 8:00 A.M., the resident's blood pressure was 167/78.
-No order for as needed Clonidine.
-The resident's blood pressure medications were administered on every occasion above but no as needed Clonidine was administered on every occasion the resident's SBP was over 160 as there was no physician's order for as needed Clonidine.
Review of the resident's notes dated December 2023 showed no notes regarding the resident's SBP being over 160 or anything about the as needed Clonidine order.
During an interview on 12/08/23 at 1:21 P.M., Licensed Practical Nurse (LPN) A said:
-The resident had an as needed order for Clonidine in the past.
-He/she didn't know if the as needed order was discontinued.
-Nursing staff should have clarified the orders with the resident's physician.
-The resident's physician has standing orders to be notified if a resident's SBP is under 100 or the pulse is under 60, and the medication held until the physician determined whether to go ahead and administer the medication or not.
-The resident had an order for Flomax before going to the hospital.
-When the resident returned from the hospital, whoever entered in the resident's orders picked a Flomax order that did not include Do not crush.
-When the resident's SBP was above 160, he/she would have expected the Certified Medication Technicians to look for the as needed Clonidine order and notify the nurse that there was no as needed order.
-Then the nurse should call the physician and clarify the order.
-There were no standing orders for elevated SBP.
During an interview on 12/11/23 at 11:23 A.M., the Director of Nursing (DON) said:
-He/she would have to educate the nursing staff to pick the most recent order upon a hospital return and re-instate the one that said do not crush for Flomax as there were more than one orders in their system for Flomax for the resident.
-If pulse and blood pressure were requested on the MAR, he/she would expect there to be parameters for both.
-He/she would expect the nursing staff to call the doctor and verify the Clonidine orders as to whether there still should have been an as needed order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's Perineal (area between the genitals and anus) Care Policy, dated February 2018, showed:
-The purpose of this procedure was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation and to observe the resident's skin condition.
-Preparation:
--Review the resident's care plan.
--Assemble the equipment and supplies needed.
-Equipment and supplies included:
--Wash basin.
--Washcloths.
--Personal protective equipment (PPE - gowns, gloves, mask as needed).
-Procedure:
--Place the equipment on the bedside stand, arrange supplies so they can be easily reached.
--Wash and dry hands thoroughly.
--Fill wash basin.
--Fold bedspread or blanket toward the of the bed.
--Raise the gown or lower the pajamas.
--Put on gloves.
--Wet washcloth and soap the skin.
--Wash perineal area front to back.
--Rinse wash cloth and gently dry the area.
-Discard disposable items, remove gloves and discard.
-Wash and dry hands thoroughly.
Review of the facility Infection Prevention and Control Program policy, dated 5/12/23, showed:
-The purpose of the policy was to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and help prevent the development and transmission of communicable diseases and infections.
-All staff were responsible for following all policies and procedures related to the program.
-A resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current CDC guidelines.
Review of the facility's Handwashing/Hand Hygiene policy, dated August 2019, showed:
-The facility considered hand hygiene the primary means to prevent the spread of infection.
-All staff followed the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors.
-Staff were to use an alcohol-based hand rub containing at least 62% alcohol; or soap and water for the following situations:
--Before performing any non-surgical invasive procedures.
--Before putting on sterile gloves.
--Before moving from a contaminated body site to a clean body site during resident care.
--After contact with a resident's intact skin.
--After contact with blood or bodily fluids.
--After handling used dressings, contaminated equipment, etc.
--After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident.
--After removing gloves.
-Hand hygiene was performed before applying non-sterile gloves.
Review of Resident #17's face sheet, undated, showed the resident had the following diagnoses:
-Stroke.
-Dementia (progressive or persistent loss of intellectual functioning, especially with impairment of memory).
-Muscle weakness.
Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 6/26/23, showed:
-The resident scored a 00 on the Brief Interview for Mental Status (BIMS an assessment tool that shows a score between 3 and 15 which shows the resident's mental status. This tool helps determine the resident's attention, orientation and ability to register and recall new information. These items were crucial factors in care planning decisions).
--This indicated the resident was severely cognitively impaired.
Review of the resident's Functional Abilities and Goals (section GG) dated 6/26/23 showed:
-The resident required assistance for toileting.
-The resident was totally dependent on staff for urinary incontinent care.
-The resident was always incontinent of urine.
Review of the resident's Care Plan, undated, showed the resident had bowel and bladder incontinence related to dementia and impaired mobility.
Observation on 12/06/23 at 1:00 P.M., Certified Nursing Assistant (CNA) A and CNA B were performing incontinence care for the resident:
-Both CNA's washed their hands and put gloves on.
-CNA A pulled side room curtain down to bottom of bed and then moved bed out some.
-CNA A did not change gloves or wash/sanitize hands.
-Both CNA's removed the resident's disposable brief.
-CNA B handed CNA A the wipes.
-CNA A started cleaning the resident with same gloves which touched items in the room.
-CNA A removed gloves but did not wash/sanitize hands.
-CNA A put on new gloves.
-CNA A cleaned the resident's buttocks and placed a new disposable brief next to the resident.
-CNA A then re-wiped the resident's perineal area.
-CNA A removed his/her gloves.
-CNA A did not wash or sanitize his/her hands.
-CNA A put on new gloves.
-CNA A positioned the disposable brief under the resident.
-Both CNA A and CNA B rolled the resident to the right side and pulled the disposable brief under the resident.
-Both CNA A and CNA B fastened the disposable brief and repositioned the resident and made sure he/she was comfortable.
-Both CNA A and CNA B removed their gloves and washed their hands.
During an interview on 12/06/23 at 8:02 A.M., CNA A said:
-He/she changed gloves all of the time when changing the resident.
-He/she used sanitizer between taking off the soiled brief and putting on a clean one.
During an interview on 12/07/23 at 9:24 A.M., CNA B said:
-He/she checked and changed the resident every two hours.
-He/she started the changing procedure by letting the resident know what he/she was about to do for the resident.
-He/she turned the resident, wiped and put wipes in the trash can.
-Then he/she put the clean brief back on the resident.
-He/she changed gloves when they were soiled and after changing the resident.
-He/she pulled the curtain closed before he/she started the procedure.
-He/she closed curtains on the windows.
During an interview on 12/07/23 at 10:44 A.M., Licensed Practical Nurse (LPN) A said:
-CNA's were responsible for incontinence care, but anyone of the nursing staff could provide incontinence care.
-The expectation was to take the resident to their room.
-Wash hands and put gloves on.
-Help the resident stand and move to the toilet or have them lay down in bed.
-Take off old brief and remove gloves.
-Put on new gloves, wipe the perineal area.
-Remove gloves, wash hands and prepare new brief.
-Put on new gloves and put on new brief, degloved and wash hands.
During an interview on 12/11/23 at 11:22 A.M., the Director of Nursing (DON) said:
-During peri-care he/she expected staff to change gloves every time they went from something dirty to something clean.
-If staff touched something dirty, they should change their gloves.
-Staff should remove their gloves after touching the curtain or the bed, sanitize and put on clean gloves.
-He/she was unaware of when the last handwashing/hand hygiene training was but believed it was in the last couple of months.
3. Review of the facility's policy, Transmission-Based (Isolation) Precautions dated 2023 showed:
-Residents on transmission-based precautions (precautions for diseases spread by direct or indirect contact) should remain in their rooms except for medically necessary care.
-An order for transmission-based precautions/isolation would specify the type of precaution and the reason for the transmission-based precaution.
-The duration would depend upon the infectious agent or organism involved.
-Signage that included instructions for use of specific PPE would be placed in a conspicuous location out side the resident's room, wing or facility-wide.
-Healthcare personnel caring for residents on Contact Precautions (precautions used to prevent the transmission of infectious agents, which were spread by direct or indirect contact with the patient or the patient's environment) would wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment.
-Donning (putting on) PPE upon room entry and discarding before exiting the room was done to contain pathogens (a virus that can cause disease), especially those that have implicated in transmission.
Review of the facility's policy ,Infection Prevention and Control Program, dated 5/12/23 showed:
-Hand hygiene should have been performed in accordance with out facility's established hand hygiene procedures.
-Limit transport and movement of the resident outside the room to medically essential purposes.
-Health Care Professionals who enter the room of a resident with confirmed COVID-19 infection should have adhered to standard precautions and use a N-95 respirator, gown, gloves, and eye protections.
Review of the facility's COVID-19 Prevention, Response and Reporting policy, dated 5/12/23, showed:
-Source control measures included:
--A National Institute for Occupational Safety and Health (NIOSH) approved mask with an N95 (is a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) rating or higher.
--A barrier face covering.
--A well fitted face mask.
-Source control was recommended for health care settings who had suspected or confirmed COVID-19 infections.
-Staff who entered the room of a resident with a confirmed COVID-19 infection should use an approved N95 mask, gloves, gowns and eye protection.
Review of Resident #47's quarterly MDS dated [DATE], showed:
-The resident scored a 03 on the BIMS.
--This indicated the resident was severely cognitively impaired.
Review of the resident's care plan, dated 10/9/23, showed there was nothing noted regarding the resident's COVID-19 status.
Review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated November 2023 showed no documentation of staff performing COVID-19 screenings or assessments.
Review of the list of COVID-19 positive residents, undated, showed the resident tested positive for COVID-19 on 11/29/23.
Review of the resident's MAR and TAR dated December 2023 showed no documentation of staff performing any COVID-19 screenings or assessments.
Review of the resident's COVID-19 Assessment Sheets that were completed after the resident had tested positive for COVID-19 that indicated his/her symptoms showed:
-There was no COVID-19 assessment completed that indicated the resident's symptoms on 11/29/23.
-There was no COVID-19 assessment completed that indicated the resident's symptoms on 11/30/23.
-There was no COVID-19 assessment completed that indicated the resident's symptoms on 12/1/23.
-There was no COVID-19 assessment completed that indicated the resident's symptoms on 12/2/23.
-There was no COVID-19 assessment completed that indicated the resident's symptoms on 12/3/23.
-There was no COVID-19 assessment completed that indicated the resident's symptoms on 12/4/23.
Observation on 12/4/23 at 9:33 A.M., showed:
-The resident's room door was closed.
-There was a supply cart outside of the room with gloves, shields, masks and gowns.
-There was a piece of red paper posted outside the door that indicated to please report to the nurse's station before entering the room.
Observation on 12/4/23 at 12:08 P.M., showed:
-CNA A brought a lunch tray into the resident's room.
-CNA A came back out of the room into the hall and took a gown out of the bin outside of the resident's room.
-CNA A entered the resident's room and put on the gown.
-He/she was wearing a N-95 mask.
-He/she was not wearing gloves or a face shield.
-He/she removed the gown in the hallway.
-He/she took the gown down the hall and threw it away in a trash can in an unidentified room on the hallway.
During an interview on 12/4/23 at 12:08 P.M., CNA A said he/she forgot to put on the PPE.
Observation on 12/6/23 at 7:32 A.M., showed CNA B:
-Delivered a breakfast tray to the resident's room.
-He/She did not put on any PPE.
-He/she returned to the hot food serving table and retrieved another tray and delivered it to another room which had a resident who had tested negative.
-He/she was not observed to use hand sanitizer.
-He/she walked back down the hall to the hot food serving table.
-He/she picked up a tray and walked down the hall and entered room [ROOM NUMBER] which had a resident who had tested positive.
--He/she did not put on any PPE.
-He/she exited the room, walked down the hall toward the dining area, sanitized his/her hands then returned to the hot food serving table and continued to deliver trays to the residents in the dining room.
4. Observation on 12/4/23 at 12:30 P.M. of the lunch meal in the main dining room showed:
-Of the 15 residents in the dining room only two had worn a mask to the meal.
-Residents who needed to have been fed were not six feet apart.
-Staff were not observed encouraging the residents to wear a mask when they left the dining room.
Review of the list of COVID-19 positive residents on 12/4/23 from the DON showed the following rooms had residents who had tested positive for COVID-19:
-Rooms six, eight, 10, 11, 15, 16, 23, 24, 27, 29, 30, 32, 33, 44, 45, and 49.
Observation on 12/4/23 at 1:21 P.M. showed:
-room [ROOM NUMBER] had a red sign on the door, See Nurse before entering.
-There was an isolation cart at the door.
-The door was open and the resident was inside the room.
-There was no sign showing what PPE was required to enter the room.
Observation on 12/4/23 at 1:30 P.M. showed:
-A resident came out of room [ROOM NUMBER] (positive for COVID-19) with his/her mask below his/her chin.
-He/she started to talk to another resident from across the hall who had come out of their room (not positive).
-The two residents were within one foot from each other.
-A female staff member walked by the two residents and passed them on his/her way down the hallway.
-When asked if the two residents were both negative for COVID-19 the staff member said no the resident who had come out of room [ROOM NUMBER] was positive and should not be out of his/her room.
-The staff member then assisted each resident back to their room.
Observation on 12/07/23 at 10:15 A.M. showed:
-room [ROOM NUMBER]'s door was open with a resident inside.
-There was a red sign on the door that indicated, See the Nurse.
-There was an isolation cart outside the door.
Observation on 12/4/23 at 1:40 P.M. showed Physical Therapist (PT) A:
-Came out of room [ROOM NUMBER] with his/her soiled PPE in his/her hand.
-He/she was looking up and down the hallway trying to find a trash can.
During an interview on 12/4/23 at 1:45 P.M. PT A said:
-He/she knew to remove his/her PPE when exiting a COVID-19 isolation room.
-There was no sign on the door what staff was expected to wear for PPE when entering a COVID-19 isolation room, but he/she had education on what to wear.
-There was no trash can in the room to throw his/her soiled PPE away.
-He/she would have to find one.
-He/she carried the soiled PPE down the hallway in his/her bare hand to find somewhere to throw it away.
Based on observation, interview, and record review, the facility failed to establish and maintain a comprehensive, infection prevention and control program designed to help prevent the development and transmission of water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease), and failed to provide documented assessments for such an outbreak with accepted response protocols, in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility. Additionally, the facility failed to ensure staff were following isolation (being apart from other people) policies for COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) positive residents for five sampled residents (Resident #17, #47, #50, #12, and #42) and one supplemental resident (Resident #43) out of 14 sampled residents and one supplemental residents; and to demonstrate standard infection control practices while performing incontinence care (assistance with clean up urine or feces) for one sampled resident (Resident #17). The facility census was 54 residents with a licensed capacity for 99 residents at the time of the survey.
1. Observation on 12/4/23 between 8:44 A.M. and 9:47 A.M. during the Life Safety Code (LSC) kitchen inspection showed a three-sink area, a chemical dish-washing machine, a sink food preparation table, a handwashing sink, and an ice machine.
Observation on 12/5/23 between 10:51 A.M. and 1:21 P.M. during the facility LSC room-by-room inspections with the Director of Maintenance (DOM) showed the following:
-There was a facility-wide fire sprinkler system.
-There was a boiler room, two dining rooms, and a beauty shop.
-There were at least 40 resident rooms with sinks and bathrooms, two bathhouses, janitor's closets with mop hopper sinks, and staff and public restrooms.
Review of the facility's emergency preparedness manual entitled Emergency Preparedness - 2023, last reviewed on 2/23/23 and obtained from the front nurses station, with a 23-page section, Water Management Program to Reduce Legionella Growth and Spread in the Facility, revised on 6/13/22 by the Administrator, showed the following:
-There was no facility-specific risk assessment that considered the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) industry standard #188.
-There was no completed Centers for Disease Control (CDC) toolkit including control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens.
-There was no facility-specific infection prevention program or plan to deal with outbreaks of Legionella and/or other waterborne pathogens.
-There were facility maps showing water flow and locations throughout the facility along with a list of system details and outlets, but no assessments of each area's individual potential risk level.
-There was no documentation of any site log book being maintained with any cleanings, sanitizings, descalings, and inspections mentioned.
During an interview on 12/7/23 at 11:09 A.M., the DOM said the following:
-He/she would run the water in vacant resident rooms on a weekly basis.
-He/she also tested the water in those rooms and bathhouses for their PH (Potential for Hydrogen is a measure of how acidic/basic water is. The range goes from 0 - 14, with 7 being neutral. pHs of less than 7 indicate acidity, whereas a pH of greater than 7 indicates a base) content.
Review of the facility's Legionella Testing Log, conducted and provided by the DOM, showed triannual testing of their water's PH Range and Chlorine Range for each hall from 12/1/22 through 12/1/23, but no guidance as to what the actual control limits were or what would be done if those limits were not met.
During an interview on 12/7/23 at 11:41 A.M., the Administrator said the following:
-The Legionella Program was in place when he/she started at the facility a little over a year ago.
-He/she did not know who developed the program or how.
5. Review of Resident #50's admission record showed he/she admitted on [DATE] and re-admitted on [DATE] with the following diagnosis:
-Difficulty in walking dated 3/15/23.
-Unsteadiness on feet dated 8/4/23.
-Muscle wasting and atrophy (characterized by a significant shortening of the muscle fibers and a loss of overall muscle mass) dated 11/2/23.
-COVID-19 dated 11/27/23.
Review of the resident's medical record showed he/she was diagnosed with COVID-19 on 11/27/23 and on isolation precautions until 12/7/23.
Observation on 12/4/23 at 9:25 A.M., showed:
-The resident's room door was open.
-The resident was sitting in a wheelchair with a mask on over his/her mouth only.
-A sign outside the door instructing visitors to report to the nurses' station before entering.
-No sign that indicated any PPE that should be worn when entering the room.
-There was not an isolation cart next to the resident's room door.
-An isolation cart was across the hall.
-Certified Medication Technician (CMT) A entered the room with a KN-95 mask on and gloves no other PPE on such as a protective gown.
-CMT A gave the resident medication, removed his/her gloves in the room and washed his/her hands, then exited the room.
During an interview on 12/4/23 at 9:26 A.M., CMT A said:
-He/she had been gone a week and had just returned today.
-He/she was not sure if room doors were supposed to be open or closed if a resident was COVID-19 positive.
-This resident was a fall risk and that was probably why the door was open.
During an interview on 12/4/23 at 9:31 A.M., the resident said:
-He/she did not see staff wearing yellow covers when they come into the room.
-He/she stayed in the room and sometimes wore a mask.
-He/she ate meals in his/her room.
Observation on 12/5/23 at 9:45 A.M., showed:
-The resident's door was open.
-The resident was in his/her wheelchair and wearing a KN-95 mask.
-An unidentified staff member was in the resident's room without an isolation gown on.
Observation on 12/6/23 at 10:45 AM the resident's door remained open.
During an interview on 12/4/23 at 9:38 A.M., CMT C said:
-If a resident was COVID-19 positive and on isolation precautions staff needed to wear the isolation gown, gloves and a KN-95 mask.
-That was the PPE that was included in the isolation carts outside the rooms of the resident's who had tested positive for COVID-19.
Observation on 12/4/23 at 9:28 A.M., showed CMT A went to a resident room that had an isolation cart outside the door and passed medications without putting an isolation gown on.
6. Review of Resident #43's significant change MDS dated [DATE] showed the following staff assessment of the resident:
-Was severely cognitively impaired.
-Used a wheelchair.
-Had a diagnosis of dementia.
Review of the facility's list of residents who tested positive for COVID-19 in November 2023 and December 2023 showed the resident tested positive for COVID-19 on 11/27/23.
Review of the resident's MAR dated November 2023 showed the resident was on contact precautions for COVID-19 every shift for COVID-19 positive for ten days beginning on the night shift on 11/27/23 through 11/30/23.
Review of the resident's MAR dated December 2023 showed the resident was on contact precautions for COVID-19 every shift for COVID-19 positive for ten days 12/1/23 through the evening shift on 12/7/23.
Review of the resident's undated care plan showed:
-The resident had a diagnosis of COVID-19.
-The resident required contact and droplet isolation precautions (precautions intended to prevent transmission of infectious agents which are spread by speaking, sneezing, or coughing) and other monitoring related to COVID-19 infection.
-Instructions to staff to:
--Encourage the resident to wear a mask if leaving his/her room.
--Encourage the resident to stay in his/her room and away from other people as much as possible due to contact and droplet precautions.
Observation on 12/4/23 at 10:30 A.M. showed:
-The resident was sitting in his/her room in his/her wheelchair with his/her door open and was not wearing a mask.
-There was a red sign on door frame outside the resident's room to report to the nurses' station before entering the room.
-There was an isolation cart outside the resident's room.
Observation on 12/4/23 at 10:32 A.M. showed:
-The Maintenance Director knocked on the resident's door and entered the room.
-The Maintenance Director had on a KN95 mask (personal protective equipment that protect against airborne particles and liquids).
-The Maintenance Director did not wear any other personal protective equipment.
-The Maintenance Director told the resident he/she was there to look at the resident's bed and to try to fix it.
-The Maintenance Director got underneath the resident's bed and began to work on it while the resident remained in the room.
During an interview on 12/11/23 10:36 A.M., the Maintenance Director said:
-He/she did not know the resident was on isolation when he/she went into the resident's room to fix his/her bed.
-He/she knew to wear PPE if there was a red sign and isolation cart outside a resident's room.
-He/she did not think there was an isolation cart outside the resident's door when he/she entered to fix the resident's bed.
During an interview on 12/11/23 at 11:15 A.M. the DON said anyone who went into a room of a resident who was COVID-19 positive expected to wear full PPE.
7. Review of Resident #12's care plan dated 7/21/23 showed (with undated updates):
-The resident had a diagnosis of COVID-19.
-The resident required contact and droplet isolation precautions and other monitoring related to COVID-19 infection.
-The resident was resistive to wearing a mask due for COVID-19 precautions and was also resistive to staying in his/her room for COVID-19 isolation precautions.
-Instructions to staff to:
--Encourage the resident to wear a mask if leaving his/her room.
--Encourage the resident to stay in his/her room and away from other people as much as possible (contact and droplet precautions).
Review of the resident's significant change MDS dated [DATE] showed the following staff assessment of the resident:
-Severely cognitively impaired
-Rejected care one to three days in the past seven days.
-Used a walker.
-Had a diagnosis of dementia.
Review of the facility's list of residents who tested positive for COVID-19 in November 2023 and December 2023 showed the resident tested positive for COVID-19 on 11/27/23.
Review of the resident's Physician's Order Sheets (POS)s and MARs dated November 2023 and December 2023 showed no physician's order for contact precautions for COVID-19 every shift for COVID-19 positive for ten days.
Observation on 12/4/23 showed:
-At 11:01 A.M.:
--There was a red sign on door frame outside the resident's room to report to the nurses' station before entering the room.
--There was an isolation cart outside the resident's room.
--The door was open.
--The resident was not in his/her room.
-At 11:14 A.M.:
--The resident was sitting in a chair at a dining room table talking to Resident #42 and drinking a beverage.
-The residents were sitting right next to each other with approximately one foot between them.
-Neither residents were wearing masks.
-Staff in the area did not say or do anything related to the residents being this close and without masks.
-At 12:43 P.M., the resident was sitting in his/her room eating lunch and the door was open.
During an interview on 12/4/23 at 12:47 P.M., CMT B said:
-The resident was supposed to be in isolation.
-It was hard to get the resident to stay in his/her room and it was hard to keep a mask on him/her.
Observation on 12/4/23 showed:
-At 1:18 P.M. and 2:24 P.M., the resident was sitting in his/her room and the door was open.
-At 2:46 P.M.:
--The resident walked to the nurses' station using his/her roller walker with no mask on.
--CMT B told him he was supposed to stay in his/her room due to having COVID-19 and gave the resident a mask which he/she put on and walked back to his/her room.
Observation on 12/5/23 showed at 9:58 A.M., the resident was in his/her room and the door was open.
Observation on 12/6/23 showed:
-At 6:56 A.M., the resident was the dining room at a dining room table without a mask on and was watching a movie.
-At 7:00 A.M.,
--There was a red sign on the door frame outside the resident's room to report to the nurses' station before entering the room.
--There was an isolation cart outside the resident's room.
-Continuous observation from 9:28 A.M., to 10:57 A.M. showed:
--The resident was sitting at a dining room table without a mask on and was talking to a staff member who had a KN-95 mask on.
--The resident remained in the dining room watching television with no mask on.
--No staff encouraged the resident to wear a mask or go back to his/her room.
Observation on 12/7/23 showed:
-At 9:57 A.M., the resident was in his/her room and the red sign and isolation cart were still present.
-At 10:12 A.M.:
--The resident walked into the dining room without a mask on.
--A staff member went to the resident and gave him/her a medical mask and asked the resident to put it on.
--The resident put on the mask and walked toward his/her room.
-At 10:43 A.M., the resident walked into the dining room without a mask on.
-At 10:44 A.M.:
--Staff asked the resident to put on a mask.
--Staff gave the resident a medical mask and he/she put it on.
During an interview on 12/8/23 at 2:45 P.M., the DON said the resident had one COVID-19 symptom and that was a runny nose.
During an interview on 12/11/23 at 10:29 A.M., CMT B said:
-The resident stayed in his/her room at times.
-They tried to re-direct the resident when he/she came out of his/her room.
-They tried to keep a mask on him/her and to keep away from other residents.
During an interview on 12/11/23 at 11:23 A.M., the DON said:
-The residents who were on isolation should stay in their room with the door closed except if they were a fall risk.
-Residents who were COVID-19 positive should not be outside of their room without a mask.
-Staff was expected to encourage the residents who were COVID-19 positive to wear masks and go back to their rooms.
-Residents who were COVID-19 positive should be kept six feet apart from others if out of their room.
-The resident did not like to wear a mask.
-He/She was not sure about getting the resident to go back to his/her room.
-The resident would probably just walk back out of his/her room.
-The resident was difficult to separate from other residents.
-All residents who were COVID-19 positive should have a physician's order for 10 days of isolation.
8. Review of Resident #42's care plan dated 1/19/23 (with no updated date) showed:
-The resident had a diagnosis of COVID-19.
-The resident required contact and droplet isolation precautions and other monitoring related to COVID-19 infection.
-Instructions to staff to:
--Encourage the resident to wear a mask if leaving his/her room.
--Encourage the resident to stay in his/her room and away from other people as much as possible.
-The resident was a fall risk related to walking and balance problems with a history of falls.
-The resident was unaware of safety needs.
-The resident had a non-injury fall on 7/29/23.
-The resident had a diagnosis of dementia.
Review of the resident's significant change MDS dated [DATE] showed the following staff assessment of the resident:
-Had short-term and long-term memory impairment.
-Displayed no negative behaviors.
-Did not wander.
-Did not reject care.
-Required supervision when using his/her wheelchair.
-Had one non-injury fall since 7/8/23.
Review of the resident's POS dated November 2023 showed no physician's orders related to COVID-19.
Review of the resident's POS dated December 2023 showed physician's orders dated 11/29/23 for contact precautions due to COVID-19 positive for ten days.
Review of the resident's physician's progress note dated 11/29/23 at 9:57 A.M. showed:
-The resident was sitting in his/her wheelchair in the commons area.
-Nursing staff informed the physician the resident was COVID-19 positive.
-The nursing staff reported the resident had a cough and was non-compliant with isolation related to cognition.
Review of the resident's inter-disciplinary notes dated 11/30/23-12/4/23 showed no notes regarding the res

Based on observation, interview, and record review, the facility failed to retain operable thermometers in all refrigerators/freezers to confirm adequate temperature ranges; to maintain sanitary utensils, beverage dispensers, and food preparation equipment; to maintain plastic cutting boards and utensils in good condition to avoid food safety hazards (cross-contamination); and to record the testing of the dishwasher machine's chemical solution balance for the sanitizing of eating/serving utensils, plates, and cups/mugs, in accordance with professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who ate food from the kitchen. The facility's census was 54 residents with a licensed capacity for 99 residents at the time of the survey.
1. Observations on 12/4/23 between 8:44 A.M. and 9:47 A.M. during the initial kitchen inspection showed the following:
-There was unknown residue on the right side of the manual can opener blade.
-There was no thermometer in the reach-in freezer.
-A brown handled white rubber spatula blade was chipped on one edge.
-The multi-juice soda gun (a soda gun system allows you to stream multiple beverage types through a single hose) and coffee dispensers' nozzles were stained.
-A 4-drawer plastic storage unit had plastic cup lids in one drawer and plastic eating utensils in another, both drawers had lint and crumbs in the bottom.
-The microwave had food splatters on the upper inside.
-A 4-slice toaster had an overabundance of crumbs in the bottom.
-The green and red cutting boards were excessively scored to the point of plastic bits flaking off.
Observations on 12/4/23 between 11:27 A.M. and 12:03 P.M. during the kitchen meal pass inspection showed the following:
-There was still an unknown residue on the right side of the manual can opener blade.
-There was a Dish Machine Sanitizer Log sheet for Dec. '23 in a plastic sleeve on the wall next to the machine for recording the dishwasher's chemical balance that was yet to be filled out.
-A 4-drawer plastic storage unit had plastic cup lids in one drawer and plastic eating utensils in another, both drawers had lint and crumbs in the bottom.
-The microwave had food splatters on the upper inside.
-A 4-slice toaster had an overabundance of crumbs in the bottom.
-The green and red cutting boards were excessively scored to the point of plastic bits flaking off.
During an interview on 12/4/23 at 11:43 A.M. the Day Dishwasher said that he/she checked the chemical balance for the dishwashing machine with test strips during the morning shift and the next dishwasher did it for the evening shift.
Observations on 12/5/23 at 9:47 A.M. during the follow-up kitchen inspection showed the following:
-There was no thermometer in the reach-in freezer with an accumulation of crumbs in the bottom.
-An unknown residue remained on the right side of the manual can opener blade.
-A brown handled white rubber spatula blade was chipped on one edge.
-The microwave had food splatters on the upper inside.
-A 4-slice toaster had an abundant amount of crumbs in the bottom.
-The green and red cutting boards were excessively scored.
During an interview on 12/5/23 at 9:51 A.M. the Dietary Manager (DM) said:
-He/she did not see a thermometer in the reach-in freezer.
-He/she would go get one from his/her office and put it inside.
During an interview on 12/7/23 at 9:27 A.M. the DM said:
-Staff notify him/her verbally if food preparation items are damaged and need replaced.
-Food preparation items are cleaned after each use.
-Food should be free from foreign substances.
-Coffee dispenser nozzles are cleaned and the soda gun is soaked daily.

Based on interview and record review, the facility failed to ensure they completed a check of the Employee Disqualification List (EDL) and/or Criminal Background Check (CBC) and/or the Nurse Aide (NA) Registry to ensure they did not have a Federal Indicator (FI-a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) prior to hire for two sampled staff out of 10 staff sampled. The facility census was 70 residents.
Record review of the facility's abuse prevention policy updated November 2017 showed:
-A request for a CBC would be completed no later than two working days of the date an applicant for a position to have contact with residents is hired.
-An EDL check would also be completed.
-The policy did not address the NA registry.
-The facility would not employ individuals who had been found guilty of abusing, neglecting or mistreating elders by a court of law.
1. Record review of the facility's list of employees hired since their last annual survey showed Employee D was hired on 4/6/22.
Record review of Employee D's employee files showed his/her CBC was requested, the EDL was checked and the NA registry was checked for employee D on 5/17/22 (41 days after date of hire).
2. Record review of the facility's list of employees hired since their last annual survey showed Employee J was hired on 12/6/21.
Record review of employee J's employee files showed the EDL was checked for Employee J on 12/7/21 (one day after date of hire).
3. During an interview on 5/17/22 at 11:03 A.M.:
-The Administrator said they did not know they needed to check the EDL prior to hire if they did not have the results back from the Family Care Safety Registry (FCSR-helps to protect long-term care residents by providing background information on employees or prospective employees) prior to the employee's date of hire.
-The business office manager said:
--They were using the FCSR for EDL checks.
--He/she did not know they should do an EDL check separate from FCSR if they did not have the results from the FCSR prior to the employee's date of hire.
--Employee D's screenings were missed prior to hire so they ran them today.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident # 42) had a diagnosis for Levothyroxine (Synthroid a medication used to replace thyroid hormones) a medication prescribed by the physician; to notify the physician of one sampled resident's (Resident #31) continued refusals to take his/her Levothyroxine; to ensure Levothyroxine was not given with other medications or foods according to the manufacturer's instructions for three sampled residents (Resident #39, #42, and #56) and to administer medications within one hour of the medication administration time for one sampled resident (Resident #56) out of 18 sampled residents. The facility census was 70 residents.
Record review of the facility's policy, Medication Monitoring/Medication Management, dated August 2014 showed:
-In order to optimize the therapeutic benefit of medication therapy and minimize or prevent potential adverse consequences, facility staff, the attending physician prescribes, and the consultant pharmacist perform ongoing monitoring for appropriate, effective, and safe medication use.
-When a resident receives a new medication the order was to have been evaluated for a written diagnosis.
-The resident was not taking other medication, nutritional supplement, including herbal products, or foods that would be incompatible with the prescribed medication.
Record review of the facility's policy, Medication and Treatment Orders, dated July 2016 showed
orders for medications must include the clinical condition or symptoms for which the medication was prescribed.
Record review of the facility's policy, Administering Medications, dated April 2019 showed:
-The Director of Nursing (DON) Services supervises and directs all personnel who administer medications.
-Medications were to be administered in accordance with the prescriber's orders, including any required time frame.
-Medication administration times were determined by the resident's need and benefit.
-Factors that were considered included; enhancing the optimal therapeutic effect of the medication and preventing potential medication or food interactions.
-Medications were to be administered within one hour of their prescribed times unless otherwise specified.
Record review of the manufacturer's undated instruction for Levothyroxine showed:
-The medication should be taken on an empty stomach preferably 30 to 60 minutes before breakfast.
-Products such as Iron, Calcium and Antacids lower the body's ability to absorb Levothyroxine so the medication should be taken four hours before or after taking these products.
1. Record review of Resident #42's Face sheet showed he/she was admitted on [DATE] with no diagnosis of Hypothyroidism.
Record review of the resident's May 2022 Physician's Order Sheet (POS) showed:
-The resident had an order for Levothyroxine 50 micrograms(mcg) to take 1/2 tablet (25 mcg) daily, dated 11/26/21.
-The resident had an order for Ferrous Sulfate (Iron) 325 milligrams (mg) one tablet by mouth twice a day, dated 11/26/21.
-The resident had an order for Calcium 500 mg/Vitamin D3 five mcg, one tablet by mouth twice a day with meals, dated 11/26/21.
Record review the resident's Electronic Medication Administration Record (EMAR) dated 5/13/22 showed:
-Levothyroxine was scheduled to be given at 8:00 A.M.
--The resident was given Levothyroxine at 8:07 A.M.
-Ferrous Sulfate was scheduled to be given at 8:00 A.M.
--The resident was given Ferrous Sulfate at 8:07 A.M.
-Multivitamin was scheduled to be given at 8:00 A.M.
--The resident was given Multivitamin at 8:07 A.M.
Observation on 5/13/22 from 7:30 A.M. to 8:30 A.M. of the morning medication pass with Certified Medication Technician (CMT) B showed:
-The resident was at the table eating at 8:00 A.M.
-The CMT gave the resident Levothyroxine, Ferrous Sulfate, and a multivitamin which contained Calcium while he/she was eating.
During an interview on 5/13/22 at 8:10 A.M. CMT B said he/she would not have done anything different.
During an interview at on 5/13/22 at 9:00 A.M. Licensed Practical Nurse (LPN) C said:
-Levothyroxine should be given an hour before meals.
-It should not be given with any other medications.
-It should have been scheduled at 6:00 A.M. and given by the night shift.
2. Record review of Resident #56's Face sheet showed he/she was admitted on [DATE] with a diagnosis of Hypothyroidism.
Record review of the resident's May 2022 POS showed the resident had an order for Levothyroxine 100 mcg to take by mouth daily before breakfast, dated 4/1/22.
Record review of the resident's May 2022 EMAR showed:
-Levothyroxine was to be given at 6:00 A.M. before breakfast.
-The medication was signed off as given at 6:00 A.M. every day including 5/13/22.
-The EMAR showed the medication was given at 7:39 A.M.
Observation on 5/13/22 at 7:21 A.M. of medication pass showed:
-CMT B gave the resident Levothyroxine at 7:21 A.M.
-Breakfast was served to the resident at 7:35 A.M.
-The resident began to eat breakfast as soon as it was served (less than 30 minutes from the time the medication was administered).
3. Record review of Resident #39's Face sheet showed he/she was admitted on [DATE] with a diagnosis of Hypothyroidism.
Record review of the resident's May 2022 POS showed the resident had an order for Levothyroxine 125 mcg to take by mouth daily at 6:00 A.M., dated 3/5/21.
Record review of the resident's May 2022 EMAR showed:
-Levothyroxine was to be given at 6:00 A.M. before breakfast.
-The medication was signed off as given at 6:00 A.M. every day including 5/13/22.
-The EMAR showed the medication was given at 7:21 A.M. on 5/13/22.
Observation on 5/13/22 at 7:21 A.M. of medication pass showed:
-CMT B gave the resident Levothyroxine at 7:25 A.M.
-Breakfast was served to the resident at 7:30 A.M.
-The resident began to eat breakfast as soon as it was served (less than 30 minutes from the time the medication was administered).
During an interview on 5/13/22 at 12:01 P.M. Acting DON said:
-Levothyroxine should not be given with any medications and before eating.
-Education with the staff would need to be done.
-The staff was expected to sign off the medication as soon as it was given.
During an interview on 5/16/22 at 1:44 P.M. CMT B said:
-Levothyroxine was always given at 6:00 A.M.
-It should be given on an empty stomach.
-It used to be given by the night shift.
During an interview on 5/17/22 at 8:04 A.M. CMT A said:
-There were three residents who were on Levothyroxine.
-The resident had an order for it to be given at 6:00 A.M.
-The night shift should have given it but they do not.
-It flags on his/her shift to be given.
-The resident will not take his/her medications until food is in front of him/her.
Observation on 5/17/22 from 8:00 to 8:45 A.M. showed:
-Breakfast was served at 8:05 A.M
-The resident received his/her medication at the time the food was served.
-The resident had taken two bites before swallowing the medication.
4. Record review of Resident #31's face sheet showed he/she was readmitted on [DATE] with a diagnosis of Hypothyroidism.
Record review of the resident's March 2022 POS showed the resident had an order for Levothyroxine 125 mcg one tablet to be given by mouth daily in the A.M. dated 2/3/22.
Record review of the resident's March 2022 EMAR showed
-The resident only took the medication once on 3/13/22.
-The resident refused the medication the other 30 days.
Record review of the resident's April 2022 POS showed the resident had an order for Levothyroxine 125 mcg one tablet to be given by mouth daily in the A.M. dated 2/3/22.
Record review of the resident's April 2022 EMAR showed the resident refused the medication all 30 days.
Record review of the resident's May 2022 POS showed the resident had an order for Levothyroxine 125 mcg one tablet to be given by mouth daily in the A.M. dated 2/3/22.
Record review of the resident's May 2022 EMAR showed:
-The resident only took the medication once on 5/1/22.
-The resident refused the medication the other 16 days.
During an interview on 5/17/22 at 8:04 A.M. CMT A said:
-The resident had Levothyroxine ordered at 8:00 A.M.
-He/she refused the Levothyroxine every day.
-He/she had told the charge nurse a couple of months ago.
-The nurse had notified the Physician.
-The Physician had changed the prescription.
-The resident still refused the Levothyroxine.
-The resident has refused to take the Levothyroxine for three months.
-The Levothyroxine was destroyed each day.
-The resident was charged for it.
-He/she did not know that you were not supposed to give Levothyroxine with other medications.
-Levothyroxine should be given 30 minutes before meals.
During an interview on 5/17/22 at 8:57 A.M. LPN A said:
-Levothyroxine should be given one hour before eating.
-It was difficult to get the residents on the locked unit to take medications.
-It was best to attempt to give them their medications while they were sitting up or eating.
-The resident refused to take his/her Levothyroxine every day.
-The Physician was notified the resident refused to take his/her Levothyroxine and the Physician changed the order so the pill would look different.
-The resident still refused to take his/her Levothyroxine.
-It has been three months since the Physician had changed the order (2/3/22).
-It should be on the care plan that the resident refused the Levothyroxine.
-The Physician should have been called to discontinue the order.
-He/she should have notified the Physician the Levothyroxine was refused daily.
-The Levothyroxine was destroyed every day.
-The resident was charged for it.
Record review of the resident's undated care plan showed a consistent refusal of medical treatment, including any therapeutic changes to medications.
During an interview on 5/17/22 at 2:25 P.M. the acting DON said:
-Levothyroxine should not be given with any other medications.
-Levothyroxine should be given on an empty stomach before meals.
-There should have been a diagnosis for each medication given.
-The nurse should have notified the Physician when a resident had refused a medication after one week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure diagnoses were listed on the Physician Order Summary (POS) and the Medication Administration Record (MAR) for two psychotropic medications (any drug capable of affecting the mind, emotions, and behavior including stimulants, antidepressants, antipsychotics, mood stabilizers, and antianxiety agents) and to ensure the resident had diagnoses for their medications for one sampled resident (Resident #5) out of 18 sampled residents. The facility census was 70 residents.
Record review of the facility's Medication Monitoring Medication Management policy dated August 2014 showed:
-To optimize the therapeutic benefit of medication therapy and minimize or prevent potential adverse consequences the interdisciplinary team (IDT-facility staff, attending physician/prescriber, and consultant pharmacist) perform ongoing monitoring for appropriate, effective, and safe medication use.
-The IDT reviews the resident's medication regimen for efficacy and actual or potential medication related problems.
-When a resident receives a new medication a written diagnosis, and indication, and/or documented objective findings support each medication.
Record review of the facility's Medication and Treatment Orders policy dated July 2016 showed orders for medications must include clinical condition or symptoms for which the medication is prescribed.
Record review of the facility's Antipsychotic Medication Use policy, dated December 2016, showed:
-Antipsychotic medications (a class of medicines used to treat mental and emotional conditions) may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavior symptoms have been identified and addressed.
-Antipsychotic medications shall generally be used only for the following conditions/diagnoses as documented in the record:
--Schizophrenia (a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others).
--Schizo-affective disorder (a mental health condition including schizophrenia and mood disorder symptoms).
--Delusional disorder (Previously called Paranoid Disorder, a type of serious mental illness called a psychosis the person cannot tell what is real from what is imagined).
--Mood disorders (a group of mental health disorders that affect emotional state) including:
---Bipolar disorder (mood disorders characterized usually by alternating episodes of depression and mania [heightened energy [hyper activity], creativity, and euphoria]).
---Depression with psychotic features (depressive illness in which mood disturbance is accompanied by either delusions, hallucinations, or both).
---Refractory major depression (recurrent, long-lasting cycles of severe, often suicidal depressive episodes).
-Diagnoses alone will not warrant the use of antipsychotic medication.
-Antipsychotic medications will generally only be considered if the following conditions are also met:
--The behavioral symptoms present a danger to the resident or others.
--Behavior symptoms identified as being due to mania or psychosis (such as auditory, visual, or other hallucinations; delusions, paranoia or grandiosity).
-Anti-psychotic medications will not used if the only symptoms are one or more of the following:
--Wandering.
--Poor self-control.
--Restlessness.
--Impaired memory.
--Mild anxiety.
--Insomnia.
--Inattention or indifference to surroundings.
--Sadness or crying alone that is not related to depression.
--Fidgeting.
--Nervousness.
--Uncooperativeness.
1. Record review of Resident #5's Face Sheet showed he/she was admitted on [DATE] and readmitted on [DATE] with following diagnoses:
-Primary Hypertension (HTN-abnormally high blood pressure that's not the result of a medical condition).
-Type 2 diabetes Mellitus (condition that affects the way the body processes blood sugar [glucose]).
-Pain.
-Dementia (a general term for a decline in mental ability resulting in memory loss, and other mental abilities severe enough to interfere with daily functioning) without behavioral disturbance.
-Pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) of sacral region (area at base of spinal column and top of pelvic bones), unstageable.
-Chronic kidney disease (CKD- is a condition characterized by a gradual loss of kidney function over time).
-No diagnoses of depression, mood disorders, or bipolar disorders were listed for this resident.
Record review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility staff for care planning) dated 10/28/21 showed he/she:
-Was severely cognitively impaired.
-Had mild depression.
-Did not exhibit signs of psychosis (hallucinations or delusions).
-Active Diagnoses of:
--Hypertension.
--Diabetes Mellitus.
--Hyperlipidemia.
--Dementia.
--Depression (other than bipolar)
-Had pain.
-Medications received in the last seven day lookback:
--Antipsychotic, none.
--Antianxiety, none.
--Antidepressant, seven days.
Record review of the resident's Significant Change MDS dated [DATE] showed he/she:
-Was severely cognitively impaired.
-Had no depression.
-Did not exhibit signs of psychosis (hallucinations or delusions).
-Had active diagnoses of:
--Hypertension.
--Diabetes Mellitus.
--Hyperlipidemia.
--Dementia.
--Depression (other than bipolar).
-Medications received in the last seven day lookback:
--Antipsychotic, none.
--Antianxiety, none.
--Antidepressant, seven days.
Record review of the resident's Pharmacist Drug Regiment Review (DRR- a thorough evaluation of the medication regimen of a resident with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication.) dated 1/11/22 showed:
-Practice guidelines for major depression in primary care recommend continuing the same dose for four to nine months following the acute phase. Whether a patient was to continue therapy in this maintenance phase depends on the established history of previous depressive episodes and the physician assessment. A trial dose reduction may be reasonable at this time.
-This resident had been using Sertraline (Zoloft an antidepressant used for depression, panic attacks, social anxiety disorder) 100 milligram (mg) daily since July 2021.
-Recommend trial reduction of Sertraline from 100 mg daily to 75 mg daily at this time.
-If this therapy was required to prevent future depressive episodes, please document to that effect in your progress notes.
-Physician response:
--Change therapy to Sertraline 75 mg daily.
-- Physician signed the DRR on 1/18/22.
Record review of resident's Electronic Physician Order Sheet (EPOS) dated May 2022 showed:
-Zoloft 50 mg tablet by mouth (PO) Order Date: 4/19/22.
-Depakote (an anticonvulsant and a mood stabilizer used for manic phase of bipolar disorder) delayed-release (DR) 125 mg tablet PO twice a day 4/19/22.
--No diagnosis listed for the use of Zoloft or Depakote.
Record review of resident's Electronic Medication Administration Record (EMAR) dated May 2022 showed no diagnosis for the use of Zoloft or Depakote.
During an interview on 5/17/22 at 1:20 P.M., Licensed Practical Nurse (LPN) C said resident's diagnosis should be listed with the medications on the POS and the MAR.
During an interview on 5/17/22 at 2:25 P.M., the Administrator and the acting Director of Nursing (DON) said:
-Residents should have the appropriate diagnosis for the medication they are prescribed.
-Diagnoses should be listed on the POS and the MAR for each medication, including psychotropic medication, ordered for a resident.

Based on observation and interview, the facility failed to ensure a medication cart on the secured unit was locked while staff went into a resident's room to administer a medication. The facility census was 70 residents.
Record review of the facility's policy, Administering Medications, dated April 2019 showed, during the administration of medications, the medication cart was to be kept closed and locked when out of sight of the medication nurse or aide.
1. During an interview on 5/13/22 at 11:55 A.M. Licensed Practical Nurse (LPN) A said on the secured unit staff have to be very careful because there were two residents who were shoppers and would take belongings that did not belong to them, including off the medication cart.
Observation on 5/13/22 at 12:02 P.M. during the medication pass with LPN A showed:
-The medication cart was left unlocked while he/she went into a resident's room to check the resident's blood sugar.
-The unlocked medication cart was out of site for three minutes while his/her back was turned and he/she checked the resident's blood sugar.
-During the time the nurse was in the resident's room one of the known shoppers was in the hallway within one foot of the unlocked medication cart looking at the items on top of the medication cart.
-The medication cart was left unlocked a second time while he/she went into the resident's room to administer the resident's insulin.
-The unlocked medication cart was out of site for two minutes while his/her back was turned and he/she administered the resident's insulin.
-During the time the nurse was in the resident's room the same shopper was still in the hallway within one foot of the unlocked medication cart looking at the items on top of the medication cart.
-He/she would not have done anything different during the medication administration.
During an interview on 5/17/22 at 8:04 A.M. Certified Medication Technician (CMT) A said:
-The medication cart should be kept locked at all times.
-The residents would take things off of the cart.
-Even when the cart was locked the residents have taken chocolate drinks off of the top of the cart.
-There are a couple of shoppers who had known behaviors of taking things, including off the medication cart.
During an interview on 5/17/22 at 8:57 A.M. LPN A said:
-The medication cart should have always been locked as this was a Memory Care Unit.
-The residents have behaviors where they take things that do not belong to them.
During an interview on 5/17/22 at 2:25 P.M. the acting Director of Nursing (DON) said:
-He/she would expect the medication carts to be kept locked.
-The residents on the locked unit would mess with the cart if it was not locked.

Based on observation, interview and record review, the facility failed to meet sanitary conditions and practice sanitary procedures for food and non-food contact surface areas before, during and after food preparation tasks. This deficient practice of not keeping food and non-food contact surfaces sanitary could, potentially, promote microorganisms and bacterial growth which could adversely affect the health and well-being of the residents and staff who partake of the meals prepared by the dietary staff. The facility census was 70 residents at the time of the survey.
1. Observations on 5/11/22 at 8:34 A.M. during an initial brief tour of the kitchen and on 5/13/22 between 5:07 A.M. and 1:10 P.M. in the kitchen during the facility's kitchen inspection, showed the following:
-A piece of juice dispensing equipment consisting of one hand-held gun with one nozzle connected to six different beverage tubes. All of the beverage tubes were dispensed through the one dispensing gun's nozzle. The flavors of the tubing were beverages of orange juice, fruit punch, cranberry juice, apple juice, and water. These nozzles were sticky with multi-colored debris on the inside and outside of the gun and nozzle.
-The kitchen grill was black with burnt on food preparation debris and food.
-The microwave oven had cooked on debris on the sides, on the top and bottom of the appliance.
-The wooden cabinets located above the food processor were greasy and gritty to the sight and touch.
During an interview on 5/13/22 at 1:08 P.M., the Dietary Supervisor said:
-He/she thought that the beverage gun and nozzle was on the cleaning schedule along with the kitchen cabinets and microwave oven.
-He/she acknowledged that the nozzles of the juice and beverage dispensing equipment was not listed on any cleaning schedules, but would be placed on one.
-The kitchen cabinets were placed on the weekly cleaning schedule but did not know why they were still greasy and gritty.
-He/she had not had time that day to clean the microwave oven.
Review of the 2013 edition of the U.S. Department of Health and Human Services, Food and Drug Administration (FDA) Food Code, Chapter 4-701.10, showed, EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be SANITIZED.
Review of the 2013 edition of the U.S. Department of Health and Human Services, Food and Drug Administration (FDA) Food Code, Chapter 4-702.11, showed, UTENSILS and FOOD-CONTACT SURFACES of EQUIPMENT shall be before use after cleaning.
Review of the 2013 edition of the U.S. Department of Health and Human Services, Food and Drug Administration (FDA) Food Code, Chapter 6-601.11, showed,
(A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch.
(B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations.
(C) Non FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Hospice (end of life care) staff were documenting their visits for two sampled residents (Resident #18 and #25) out of 18 sampled residents and failed to have a designated direct contact who was a member of the Interdisciplinary Team (IDT- facility managers and the physician) for the Hospice companies. The facility census was 70 residents.
Record review of the facility's Policy Hospice Program dated July 2017, showed:
-Hospice providers who contract with this facility; must have a written agreement with the facility outlining in detail the responsibilities of the facility and the hospice agency.
-Hospice providers were held responsible or meeting the same professional standard and timeliness of service as any contracted individual or agency associated with the facility.
Record review of the Hospice Services Agreement showed:
-The contract was signed on 12/29/20.
-Hospice desired to provide hospice services to resident of the facility in cooperation with the management and staff at the facility.
-Hospice would maintain adequate records of each authorization of a hospice admission.
-All contracted service would be coordinated, supervised and evaluated by the IDT.
-Hospice assumes responsibility for supervision of care through observation and communication with the resident and family care-givers documentation in the facility records and participation in the facility conferences.
-The facility must designate an IDT member who would be responsible for working with a hospice representative to coordinate care to the resident provided by the facility staff and the hospice staff.
-The facility and Hospice each shall prepare and maintain complete and detailed clinical records.
-Each clinical record shall completely, promptly and accurately document all services provided.
-Each record shall document that the specified services were furnished in accordance with this agreement and should be readily accessible and systematically organized to facilitate retrieval by either party.
1. Record review of Resident #18's face sheet showed he/she was admitted to the facility on [DATE] with the diagnosis of Cerebrovascular Accident (CVA - damage to the brain from an interruption of it's blood supply).
Record review of the resident's Hospice face sheet dated 4/27/22 showed the resident would receive:
-One visit a week for 12 weeks and 15 as need visits by a Licensed Nurse.
-One visit a week for one week then three visits a week for 12 weeks by a Certified Nursing Assistant (CNA).
Record review of the resident's care plan dated 4/27/22 showed the resident was to receive Hospice care with a primary diagnosis of late affect CVA.
Record review of the resident's May 2022 Physician's Order Sheet showed the resident was admitted to the Hospice service with a primary diagnosis late affect CVA, dated 4/27/22.
Record review of the resident's May 2022 Hospice Nurses' sign in sheet showed:
-It was blank.
-There was no documentation of a Nurses' visit between 5/2/22 and 5/12/22.
--The Nurse was to make one visit per week.
Record review of the resident's May 2022 Hospice CNA's sign in sheet showed:
-The CNA had signed in on 5/2, 5/6, 5/9, and 5/13.
-The week of 5/1 to 5/7 showed two visits on 5/2 and 5/6.
--There was no documentation of what was done on those visits.
-The week of 5/8 to 5/14 showed two visits on 5/9 and 5/13.
--There was no documentation of what was done on those visits.
-The week of 5/15 to 5/17 (end of survey) did not show any visits.
-The CNA was to make three visits per week.
During an interview on 5/16/22 at 9:15 A.M. the Administrator said:
-Hospice staff were expected to sign in when they come into the facility.
-There should have been documentation of each visit.
-The Nurse was to visit once a week and document in the Hospice notebook.
-The CNA was to visit three times a week and document in the Hospice notebook.
-The Charge Nurse should have ensured the Hospice staff had documented what they had done during their visits in the Hospice notebook.
During an interview on 5/16/22 at 9:30 A.M. Charge Nurse/Licensed Practical Nurse (LPN) C said:
-The Hospice staff should sign in on their sign in sheet in the Hospice notebook when they come to the facility.
-There should have been a sheet where the Hospice staff documented what they had done during their visit.
-He/she did not know who was in charge of the Hospice staff to ensure they were documenting their visits.
2. Record review of Resident #25's face sheet showed he/she was re-admitted on [DATE] with the following diagnosis Senile Dementia of the brain (a group of thinking and social symptoms that interfere with daily functioning).
Record review of the resident's Hospice contract dated 1/27/22 showed:
-The Hospice Nurse was to visit the resident two times a week.
-The Hospice CNA was to visit the resident two times a week.
Record review of the resident's February 2022 Physician's order sheet showed:
-The resident was admitted to Hospice services for Senile degeneration of the brain secondary to heart failure (narrowed arteries in the heart or high blood pressure gradually reduce the heart's ability to work properly), dated 1/27/22.
Record review of the resident's February 2022 Hospice CNA's sign in sheet in the Hospice notebook showed:
-The week of 2/13 to 2/19 showed one visit on 2/15.
--Documentation showed a visit on 2/14 not 2/15.
-The week of 2/20 to 2/26 showed no visits.
--Documentation showed one visit on 2/21.
-The Hospice CNA was to visit the resident two times a week.
Record review of the resident's March 2022 Nurses' notes in the Hospice notebook showed:
-The week of 3/6 to 3/8 showed one visit on 3/8.
-The week of 3/9 to 3/15 showed one visit on 3/15.
-The week of 3/20 to 3/26 showed one visit on 3/25.
-The week of 3/27 to 4/2 showed one visit on 3/30.
--The licensed Hospice nurse was to visit the resident two times a week.
Record review of the resident's April 2022 Nurses' notes in the Hospice notebook showed:
-The week of 4/10 to 4/16 showed one visit on 4/15.
-The week of 4/17 to 4/23 showed one visit on 4/22.
-The week of 4/24 to 4/30 showed one visit on 4/29.
--The Licensed Hospice nurse was to visit the resident two times a week.
Record review of the resident's May 2022 Nurses' sign in sheet in the Hospice notebook showed:
-The week of 5/1 to 5/7 showed one visit on 5/6.
-The week of 5/8 to 5/14 showed one visit on 5/10.
-The week of 5/15 to 5/17 showed no visits.
--The licensed Hospice nurse was to visit the resident two times a week.
Record review of the resident's May 2022 CNA's sign in sheet in the Hospice notebook showed:
-There was no documentation 5/15 to 5/17.
-The Hospice CNA was to visit the resident two times a week.
3. During an interview on 5/17/22 at 2:25 P.M. the acting Director of Nursing said:
-The Hospice staff was expected to communicate with the Charge Nurse.
-It was the Hospice staff's responsibility to ensure their documentation was in the Hospice Notebook.
-No one from the facility was checking to ensure Hospice documented their visits in the Hospice notebook.
-There was no one designated as a direct contact from the IDT for the Hospice companies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to use proper infection control practices by blowing on and sticking a finger in one supplemental resident's food (Supplemental Resident #12) and to ensure infection control practices were implemented to prevent cross contamination during Foley Catheter (a tube with retaining balloon passed through the urethra into the bladder to drain urine) care for one sampled resident (Resident #58) who was at risk for urinary tract infections (UTI- an infection in any part of the urinary system-kidneys, ureters, bladder and urethra) out of 18 sampled residents and seven supplemental residents. The facility census was 70 residents.
Record review of the facility Handwashing/Hand Hygiene policy, dated August 2019, showed:
-Handwashing/hand hygiene is the primary means to prevent the spread of infections.
-All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.
-All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.
-Use an ABHR or soap and water for the following situations:
--Before and after coming on duty.
--Before and after direct contact with residents.
--Before and after handling food.
--Before and after assisting a resident with meals.
--Before and after handling an invasive device, e.g., urinary catheters.
--After contact with a resident's intact skin.
--After contact with blood or bodily fluids.
--After contact with objects in the immediate vicinity of the resident.
--After removing gloves.
-The use of gloves does not replace hand washing/hygiene.
-Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.
1. Record review of the facility's assistance with meals policy, revised July 2017, showed all employees who provide resident assistance with meals will be trained and shall demonstrate competency in the prevention of foodborne illness, including personal hygiene practices and safe food handling.
Record review of Resident #12's current face sheet showed he/she was admitted to the facility on [DATE] and one of his/her diagnoses included dementia (a progressive mental disorder characterized by memory problems, impaired reasoning and personality changes).
Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning), dated 1/31/22, showed the following staff assessment of the resident:
-Had short-term and long-term memory impairment.
-Required set up assistance with eating.
-Had a diagnoses of dementia.
Record review of the resident's care plan, updated 5/16/22, showed the resident was placed on hospice (end of life care), had cognitive impairment and required meal assistance of one staff member.
Observation on 5/17/22 at 8:16 A.M., on the Memory Care unit showed:
-Certified Nursing Assistant (CNA) B feeding the resident.
-CNA B took a spoon full of food from the resident's breakfast tray, pulled down his/her KN95 mask below his/her chin and blew on the resident's food.
-CNA B stuck his/her ungloved pointer finger into the food on the spoon.
-CNA B fed the resident the food on the spoon.
-CNA B fed a different resident on his/her right without washing his/her hands.
During an interview on 5/17/22 at 9:07 A.M., CNA B said:
-He/she worked at the facility for about eight months.
-He/she blew on the resident's food, because it seemed hot and he/she didn't know what else to do.
-He/she didn't touch the resident's food with his/her finger.
-He/she held his/her hand over the resident's food to feel how hot it was.
During an interview on 5/17/22 at 8:27 A.M., Licensed Practical Nurse (LPN) A said:
-If staff need to check the temperature of food, they need to go to the kitchen and have the temperature checked.
-He/she would not expect staff to blow on or touch the food to check the temperature of the food.
During an interview on 5/17/22 at 9:14 A.M., Dietary Aide A said they keep a food thermometer on the steam table that they serve from.
During an interview on 5/17/22 at 9:19 A.M., LPN A said there was a thermometer on the buffet table accessible for CNA's to use.
During an interview on 5/17/22 at 2:25 P.M., the Acting Director of Nursing (DON) and Administrator said:
-Staff should not blow on a resident's food or touch it.
-They should learn everything regarding feeding in CNA school.
-Feeding should be one of the skills CNA's already have.
-They don't do a feeding training.
-Staff shouldn't go to a second resident and start feeding them without washing hands.
2. Record review of the facility Catheter Care, Urinary policy, dated September 2014, showed:
-To prevent catheter-associated urinary tract infections.
-Use standard precautions, which includes:
--Hand hygiene, washing with soap and water or alcohol based hand rub (ABHR).
-Before putting on gloves and again immediately after removing gloves.
-Maintain clean technique when manipulating the catheter, tubing, or drainage bag, which includes:
--Handwashing.
--Maintaining a clean environment.
--Using clean gloves.
--Preventing direct contamination of materials and supplies.
-Be sure the catheter tubing and drainage bag are kept off the floor.
Record review of Resident #58 electronic face sheet showed he/she was admitted on [DATE] and readmitted on [DATE] with the following diagnoses:
-Urinary Tract infection 4/3/22.
-Dementia (a general term for a decline in mental ability resulting in memory loss, and other mental abilities severe enough to interfere with daily functioning) 5/12/21.
-Retention of urine 4/16/21.
Record review of the resident's electronic nurse's note, dated 1/3/2022 at 1:09 P.M., showed:
-Urine culture called to Nurse Practitioner for Physician.
-Received order for Augmentin (antibiotic for UTI) 500 milligrams (mg) every 12 hours times seven days.
-Resident had been noted to have increased frequency in toileting needs and altered mental status (AMS).
Record review of the resident's electronic nurse's note, dated 2/1/22 at 2:32 P.M., showed new order for Macrodantin (an antibiotic used to treat or prevent certain UTI's) 100 mg PO (by mouth) BID (twice a day) times five days.
Record review of the resident's electronic nurse's note, dated 2/11/22 at 8:19 A.M., showed new order for Doxycycline (an antibiotic used for multi drug resistant UTI's) 100 mg PO daily indefinitely related to reoccurring UTI's.
Record review of the resident's electronic nurse's note, dated 3/10/22 at 7:50 A.M., showed the resident sent to hospital for evaluation related to AMS.
Record review of the resident's electronic nurse's note, dated 3/12/22 at 4:34 P.M., showed the resident returned from hospital with new antibiotic order for UTI.
Record review of the resident's electronic nurse's note, dated 4/3/22 at 11:25 P.M., showed the resident returned from hospital with the diagnosis of a UTI.
Record review of the resident's electronic nurse's note, dated 4/3/22 at 11:43 P.M., showed the resident had orders for Augmentin BID times ten days for UTI.
Record review of the resident's electronic Physician Order Summary (POS), dated May 2022, showed:
-Catheter care every shift dated 4/3/22.
-Change catheter every 30 days dated 4/3/22.
-Foley Catheter 16 French (Fr. - size of catheter) with 20 cubic centimeter (cc) fluid filled bulb for urine retention dated 4/3/22.
Record review of the resident's electronic nurse's note, dated 5/1/22 at 12:44 P.M., showed his/her catheter patent with amber color urine no odor present.
During an interview on 5/11/22 1:08 P.M., the resident's family member said the resident had been in the hospital two times in the last two months for UTI's.
Observation on 5/17/22 at 11:30 A.M., of the resident's catheter care showed:
-CNA C washed hands and donned (applied) gloves.
-Touched door with gloved hands to shut door.
-Picked up bag of wet wipes and a clean brief with same gloves from closing door.
-Hung the clean brief with the inside of brief over the hand rail in the shared bathroom.
-Assisted the resident from his/her wheelchair to stand and hold the handrail.
-Pulled down the resident's pants and assisted him/her to the toilet touching the resident's clothes with the same gloves on.
-Straightened the resident's catheter leg bag strap and did not change gloves.
-Assisted the resident from the toilet to a standing position and cleaned the Foley catheter tubing with a wet wipe with the same gloves on.
-Cleaned the resident's peri area with the same gloves on.
-Cleaned the resident's buttocks with the same gloves on.
-Pulled the resident's pants up and assisted to him/her to his/her wheelchair with the same gloves on.
-Removed gloves and placed in trash.
-Did not wash/sanitize hands after removing gloves.
-Picked up trash bag and carried out of room without washing hands.
During an interview on 5/17/22 at 11:45 A.M., CNA C said he/she would not have done anything differently during the catheter care.
During an interview on 5/17/22 at 2:25 P.M., the Administrator and the Corporate Director of Nursing (DON) said:
-Would not expect staff to hang the inside of an opened clean brief on a bathroom handrail without cleaning the handrail first.
-Would expect staff to wash/sanitize hands and don gloves.
-Would expect staff to change gloves and wash/sanitize hands and re-glove after touching objects such as door or supplies with gloves on before doing resident cares.
-Staff should change gloves, wash/sanitize hands and don new gloves after catheter and peri care and before touching resident clothing or other objects in the room.
-Would expect the staff to change gloves before removing the trash after resident cares.
-Would expect staff to wash/sanitize hands after removing gloves and after taking trash from the resident's room to the dirty utility room.

Based on observation, interview and record review, the facility failed to adequately document the resident's diarrhea, to contact the resident's physician upon receipt of Clostridium Difficile (C. diff-a bacterium that causes diarrhea) lab results, to implement contact isolation precautions timely, to ensure personal protective equipment was available; to keep a red infectious waste trash bin in the resident's room for one sampled resident (Resident #59) and to have a infection prevention and control program designed to help prevent the development and transmission of waterborne pathogens (a bacterium, virus, or other microorganism that can cause disease), and failed to provide documented interventions for such an outbreak as outlined by the Centers for Medicare and Medicaid Services (CMS). This deficient practice had the potential to affect all residents, visitors, and staff who reside in, visit, use, or work in the facility out of 15 sampled residents. The facility census was 58 residents.
Record review of the facility's Clostridium Difficile policy dated July 2014 showed:
-C. diff infection will be considered in residents with an acute onset of diarrhea (three or more unformed stools within 24 hours) or abdominal pain.
-Suspected C. diff infection will be verified by evidence of positive cytotoxin assay (testing to determine toxicity).
-Residents with diarrhea and suspected C. diff infection will be placed on contact precautions while awaiting laboratory results.
-Residents with diarrhea associated with C. diff will be placed on contact precautions including healthcare workers wearing gloves and gowns upon entering the room and removing them prior to exiting the resident's room.
-C. diff is transmitted via the fecal-oral route and
-Any resident-care activity that involves contact with the resident's mouth when hands or instruments are contaminated may provide an opportunity for transmission such as oral care or administration of oral medications.
1. Record review of Resident #59's nurses' notes showed:
-On 5/31/19, the resident returned from the hospital and was incontinent of bowel.
-On 6/1/19, the resident was incontinent of bowel and
-There was no documentation of the resident having diarrhea from 5/31/19-6/3/19.
Record review of the resident's bowel movement details sheet dated 6/3/19 at 10:16 A.M. showed the resident had diarrhea.
Record review of the resident's nurses' notes showed:
-On 6/4/19 at 5:16 A.M.:
--An order was received to obtain a stool specimen to check for C. diff.
--The resident had not had a bowel movement during the night shift.
-On 6/4/19 at 12:36 P.M. the resident was incontinent of bowel.
-On 6/4/19 at 1:22 P.M.:
--A new order was obtained for a stool sample for C. diff.
--The resident had not had a bowel movement during the day shift.
---On 6/4/19 at 2:09 P.M., the resident did not have any diarrhea during the day shift.
-On 6/5/19 at 5:21 A.M.:
--There was an order to obtain a stool specimen for C. diff.
--The order was not completed.
--The resident did not have a bowel movement during the night shift.
-On 6/5/19 at 12:37 P.M., the resident had diarrhea and a stool sampled was collected and was placed in the lab refrigerator and
-On 6/6/19 at 1:55 A.M., the resident had not had any diarrhea during the night shift.
Record review of the resident's bowel movement details sheet dated 6/6/19 at 10:40 A.M. showed the resident had diarrhea.
Record review of the resident's nurses' notes showed:
-On 6/6/19 at 2:08 P.M., the resident had a large bowel movement that morning and
-On 6/7/19 at 5:15 A.M., the stool specimen was obtained by the nurse on the day shift.
Record review of the resident's stool sample results obtained on 6/5/19, delivered on 6/7/19 at 12:27 P.M., results approved on 6/7/19 at 2:28 P.M. and results reported to the facility and the resident's primary care physician on 6/7/19 at 2:25 P.M. showed:
-C. diff toxin was positive (toxins produced by C. diff bacteria can usually be detected in a stool sample).
-C. diff epi 027 (a strain of C. diff known to produce a significantly higher number of C. diff spores and toxins) was presumptive negative (preliminary results) and
-There was nothing hand-written on the lab results.
Record review of the resident's nurse's note dated 6/7/19 at 2:54 P.M., showed the resident did not have any diarrhea.
Record review of a second print out that looked different than the first print out of the resident's stool sample results obtained on 6/5/19, delivered on 6/7/19 at 12:27 P.M., results approved on 6/7/19 at 2:28 P.M. and results reported to the facility and the resident's primary care physician on 6/7/19 at 2:25 P.M. showed:
-C. diff toxin was positive.
-C. diff epi 027 was presumptive negative.
-It was hand-written that the results were re-faxed per request on 6/12/19 and
-It was hand-written that the results were called into the resident's primary care physician's office at 10:40 A.M. and faxed at 10:41 A.M.
Record review of the resident's nurses' notes showed:
-On 6/12/19 at 12:10 P.M., the results of the C. diff sample were called in to the resident's primary care physician by the Director of Nursing (DON).
-On 6/12/19 at 12:36 P.M., the resident was incontinent of bowel several times during the shift with liquid diarrhea.
-On 6/14/19 at 3:35 P.M.,:
--The DON spoke with the resident's nurse practitioner regarding the results of the C. diff sample.
--The DON clarified the fax number of where the results were being sent and
--No orders were received at that time.
Record review of the resident's nurse practitioner's note dated 6/14/19 showed it was noted that the resident had no change in bowel habits.
Record review of the resident's significant change Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff for care planning) dated 6/14/19 showed the following staff assessment of the resident:
-Was cognitively intact.
-Was frequently incontinent of bowel and
-Required extensive assistance of one person with toileting.
Record review of the resident's bowel movement details sheet dated 6/20/19 at 2:14 P.M. showed the resident had diarrhea.
Record review of the resident's nurse's note dated 6/21/19 at 10:38 A.M. showed a verbal order was received from the resident's nurse practitioner to start Vancomycin (an antibiotic) 125 milligrams (mg) four times a day for 14 days for positive C. diff results.
Record review of the resident's June 2019 Medication Administration Record (MAR) showed:
-A physician's order dated 6/21/19 for Vancomycin 125 mg capsule, give one four times a day for 14 days.
-Vancomycin was administered 6/22/19-6/30/19 except:
--The noon dose on 6/25/19 was sent with the resident's family when the resident went out of the building and
--The resident was not available on 6/28/19 at 4:00 P.M.
Record review of the resident's June 2019 Physician's Order Sheet (POS) showed an order dated 6/21/19 for contact isolation.
Record review of the resident's care plan updated on 6/21/19 showed the resident required contact isolation due to C. diff infection.
Record review of the resident's nurses' notes showed:
-6/22/19 at 2:18 A.M. the resident will start antibiotic treatment for C. diff at 8:00 A.M.
-On 6/23/19 on the day shift, the resident continued on isolation for C. diff and had no loose stools.
-On 6/24/19 at 9:01 A.M.,:
--The DON spoke with the resident's nurse practitioner to clarify C. diff results.
--The resident's nurse practitioner said they were treating the resident prophylactically (preventative treatment).
--The resident had no loose stools at the time.
-On 6/24/19 at 12:52 P.M., the resident continued on antibiotic for C. diff and remained on contact isolation precautions.
-On 6/25/19 at 1:23 A.M.,:
--The resident continued on antibiotic for C. diff prophylaxis.
--The resident did not have diarrhea and
-On 6/25/19 at 12:45 P.M., the resident had diarrhea twice during the day shift.
Record review of the resident's bowel movement details sheet dated 6/25/19 at 2:28 P.M. showed the resident had diarrhea.
Record review of the resident's nurse practitioner's note dated 6/26/19 showed:
-The resident had some diarrhea and was under treatment for C. diff and
-Had no change in bowel habits.
Record review of the resident's nurses' notes dated 6/27/19 at 3:25 A.M. and on 6/28/19 at 2:20 A.M. showed the resident had no diarrhea.
Record review of the resident's July 2019 POS showed an order dated 6/21/19 for contact isolation.
Record review of the resident's July 2019 MAR showed a physician's order dated 6/21/19 for Vancomycin 125 mg capsule, give one four times a day for 14 days with a stop date of 7/5/19 was administered four times a day through 7/4/19 at 4:00 PM.
Record review of the resident's nurses' notes showed:
-On 7/2/19 at 1:34 A.M., on 7/3/19 at 1:19 A.M., on 7/3/19 at 12:51 P.M., on 7/3/19 at 10:21 P.M., and on 7/4/19 at 2:10 A.M., the resident had no diarrhea and
-On 7/4/19 at 1:02 P.M., the resident remained on an antibiotic for C. diff and remains to have diarrhea.
Record review of the resident's bowel movement details sheet showed:
-The resident had diarrhea on 7/4/19 at 8:07 P.M and
-There was no documentation of any more diarrhea through 7/11/19 at 2:50 A.M.
Record review of the resident's nurse's note dated 7/5/19 at 2:20 A.M., showed the resident had no diarrhea.
Observation during initial tour beginning on 7/8/19 at 9:09 A.M. showed:
-There was a sign on the outside of the resident's room that said to report to the nurses' station before entering his/her room.
-A red trash bin was outside the resident's room and
-There was no cart with personal protective equipment such as gowns and masks outside the resident's room or anywhere else on the hall.
During an interview on 7/8/19 9:35 A.M., Licensed Practical Nurse (LPN) A said the resident was on contact isolation precautions due to C. diff but he/she thought the resident was no longer on contact isolation precautions.
Observation on 7/8/19 at 9:49 A.M. showed:
-There was a red trash bin outside the resident's room.
-There was no cart with personal protective equipment such as gowns and masks outside the resident's room or anywhere else on the hall.
-The maintenance supervisor put on gloves, picked up the red trash bin in the hall and placed it in the resident's room and
-The maintenance supervisor asked the resident who moved the red trash can and the resident said he/she did not know.
Record review of the resident's nurse's note on 7/8/19 at 2:22 P.M. showed the resident remained on contact precautions for C. diff and had no diarrhea on the day shift.
Observation on 7/9/19 at 9:39 A.M. showed there was a personal protective equipment cart outside the resident's room.
Record review of the resident's nurses' notes showed:
-On 7/9/19 at 12:49 P.M., the resident was having some diarrhea and remained on contact precautions for C. diff and
-On 7/9/19 at 2:38 P.M., the resident was seen by his/her nurse practitioner and received new orders to start Vancomycin 250 mg four times a day for 14 days, then 250 mg three times a day for seven days and then 250 mg twice a day for seven days for C. diff.
During an interview on 7/11/19 at 9:31 A.M., the DON said:
-The resident was having loose stools at the time of the stool sample.
-Staff should notify the nurse of the presence of diarrhea.
-Nursing staff should document the presence of diarrhea.
-He/she doesn't know what happened when the lab results came in on the 6/7/19.
-He/she called the resident's primary care physician's office on 6/12/19 and spoke with the nurse practitioner regarding the resident's lab results.
-The nurse practitioner told him/her that anyone can have C. diff toxins present and they should treat the resident prophylactically.
-The nurse practitioner provided no further details about the lab results.
-He/she doesn't know why there was no contact isolation order until 6/21/19
-They normally would do contact isolation immediately.
-Staff should be gowning and gloving when entering rooms at all times.
-The personal protective equipment cart should always be right outside the resident's room and
-The red trash bins should be in the resident's room.
During the infection control review interview on 7/11/19 at 12:17 P.M., the Assistant DON said:
-The resident has loose stools.
-Staff tested the resident's stool.
-The nursing staff should be able to get a stool sample that day or the next.
-The lab comes every Monday, Wednesday and Friday.
-Staff should receive lab results within 24-48 hours.
-The resident's stool sample came back positive for C. diff.
-Nursing staff should then call the resident's physician for orders.
-Antibiotic treatment should be started right away.
-The resident had C. diff before so he/she was started on Vancomycin.
-Contact isolation was put in place when they received the positive sample results.
-The pharmacist reviews antibiotic use to make sure the antibiotic was appropriate and effective.
-The communication between the facility and the resident's physician was poor.
-Staff had to fax the lab results to the resident's physician's office a couple of times and
-It took too long to get the resident started on an antibiotic.
2. Record review on 7/11/19 at 9:49 A.M., of the facility's emergency preparedness plan obtained from the front common area, under the tab marked Legionella Bacteria, showed the following:
-A three page document entitled Facility's Policy and Procedure For Monitoring Water Supply to minimize outbreaks of Legionella Bacteria Contamination,
-There was no facility-specific risk assessment that considers the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) industry standard,
-Though referenced twice, there was no completed Centers for Disease Control (CDC) toolkit including control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens,
-There was no facility specific infection prevention program or plan to deal with outbreaks of Legionella and/or other water borne pathogens, and
-There were no facility specific interventions or action plans for when parameter control limits outlined are not met.
During an interview on 7/11/19 at 11:05 A.M., the Administrator said they were unaware of the requirements for using the CDC toolkit and an ASHRAE risk assessment.
During an interview on 7/11/19 at 12:31 A.M., the Maintenance Supervisor said the following:
-He/she tested the facility's water for chloramine levels monthly.
-Maintenance staff periodically flushed toilets and ran faucets.
-The whirlpool was routinely cleaned.
-Water temperatures were monitored weekly, and
-They were not aware that any risk assessment or toolkit completion was required.

Based on observation, interview, and record review, the facility failed to educate all regular staff as to the existence, whereabouts, and contents of a written, on-site policy regarding the acceptance, usage, and storage of foods brought into the facility for residents by family and other visitors, to ensure the food's safe and sanitary handling and consumption. This deficient practice had the potential to affect all residents who ate food brought in by visitors. The facility census was 58 residents with a licensed capacity of 99 residents.
Record review on 7/9/19 at 10:07 A.M., of the policy entitled Foods Brought by Family/Visitors, provided by the Dietary Manager showed a generic document obtained online, with no facility specific information added, and 11 separate points for safe implementation of the policy including, but not limited to:
-If necessary, the nursing staff will discuss with the physician whether a diet can be liberalized.
-A dietician would counsel residents or families if diet conflicts with foods and document as needed,
-Non-perishable foods retained in the residents' rooms must be stored in re-sealable containers with tight fitting lids.
-Containers will be labeled with the resident's name and the use by date.
-Foods that present a potential choking hazard for residents with impaired cognitive function or swallowing difficulty will be taken from the resident, and
-Potentially hazardous foods that are left out for the resident without a source of heat or refrigeration longer than two hours will be discarded.
1. Observations on 7/10/19 between 9:55 A.M., and 11:51 A.M., showed there were refrigerators for storing residents' foods located in each of two nurse's stations' Medication Rooms.
During an interview on 7/9/19 at 2:08 P.M., at the front nurse's station, Licensed Practical Nurse (LPN) A said that if food was brought in for a resident:
-Staff would date it.
-Put it in the refrigerator in the Medication Room.
-If it was not eaten within 24 hours, it would be thrown out.
-As a department head for five years previously he/she just knew how to handle it, and
-If there was a written policy it would most likely be in their Policy and Procedure binder.
During an interview on 7/9/19 at 2:15 P.M. at the Special Care Unit nurse's station, LPN B said that if food was brought in for a resident:
-Staff would put a sticker on it with the date.
-Staff would put it in a sealed container if it wasn't already.
-Staff would place it on the resident's dresser or in a refrigerator if needed.
-He/she learned the procedure by word of mouth, and
-He/she has not seen a procedure written down anywhere.
During an interview on 7/10/19 at 9:37 A.M., the Dietary Manager said:
-Direct care staff should be familiar with the outside food policy's contents and location.
-He/She believed there had been in-services on the subject, and
-He/She also thought it was included in new employees' orientation packets.

Based on observation and interview, the facility failed to keep the kitchen perimeter floors clean; to maintain sanitary food preparation equipment and utensils; to ensure spatulas were in good condition to avoid food safety hazards; to adequately clean coffee machine nozzles; and to make sure proper hair hygiene practices were followed to prevent foodborne illness. These deficient practices potentially affected residents who ate food from the kitchen. The skilled nursing facility census was 58 residents with a licensed capacity for 99.
1. Observation during the kitchen inspection on 7/9/19 between 9:50 A.M. and 12:33 P.M., showed the following:
-The manual can opener had paper debris on the blade and the day cook subsequently used it without cleaning the blade before or after.
-The coffee machine nozzles had crust at the tips.
-Two spatulas hanging on a rack near the stove had chipped edges.
-The day cook's and the Dietary Manager's hairnets did not completely cover their back bottom few inches of hair.
-There was one used dessert bowl and one used small plastic cup under the disposal sinks by the wall,
-A two-slice toaster had an abundance of crumbs in the bottom.
-A white handled scoop set on the steam table for meal service had food residue on the bowl and scraper, which the Dietary Manager acknowledged and replaced when pointed out.
-A white handled serrated knife in a drawer had a broken tip and rust on the edge, which the day cook later used to cut an onion and
-An oven mitt by the stove had a large dried splotch of food on the fingertip.
During an interview on 7/9/19 at 10:10 A.M., the day cook said they would replace the spatulas with chipped edges because even a little ding can make plastic come off.
During an interview on 7/10/19 at 9:37 A.M., the Dietary Manager said the following:
-The coffee machine nozzles were to be cleaned by the night dietary staff once a week.
-The cooks were responsible for cleaning cutlery and equipment after use and check them beforehand as well.
-The staff are told about hair hygiene and protection upon hire and reminded every other month at in-services.
-The dishwasher is supposed to clean the kitchen floor perimeter each day upon arrival and before leaving and
-The day cook should clean the toaster once a week.

Based on observation, interview, and record review, the facility failed to ensure residents' medications were stored at the proper temperature to preserve their integrity by not monitoring the temperature of the refrigerators that the medications and vaccines were stored in potentially affecting all of the residents in the facility. The facility census was 58 residents.
Record review of the facility's Storage of Medications policy dated 5/12 showed:
-Medications requiring refrigeration are kept in a refrigerator at temperatures between 36 degrees Fahrenheit and 46 degrees Fahrenheit with a thermometer to allow temperature monitoring.
-The Facility should maintain a temperature log in the storage area to record temperatures at least once a day and
-The Facility should check the refrigerator in which vaccines are stored, at least two times a day, per CDC (Centers for Disease Control) guidelines.
Record review of the CDC's Resources on Proper Vaccine Storage and Handling, policy dated 4/18 showed:
-Vaccines are to be stored in a refrigerator.
-The temperature in the refrigerator should be between 36 degrees Fahrenheit and 46 degrees Fahrenheit.
-The temperature in the refrigerator should be checked daily at the start of each day.
-The temperature in the refrigerator should be checked when the vaccines are accessed and
-The temperature in the refrigerator should be recorded.
1. During an observation and interview of the front medication room on 7/10/19 at 9:06 A.M. with Licensed Practical Nurse (LPN) A showed:
-The medication refrigerator's temperature log was missing signatures verifying that the temperature had been checked.
-From 6/1/19 to 7/9/19, 11 signatures were missing out of 39 opportunities.
-The residents' medications were stored in the medication refrigerator which included insulin (a medication used to treat high blood sugars).
-LPN A said the medication refrigerator should be checked daily by the night nurse and
-LPN A said the temperature should be recorded on the temperature log.
During an interview on 7/12/19 at 12:55 P.M., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) said:
-They would expect the medication refrigerator's temperature to be checked daily.
-The medication refrigerator's temperature should be checked by the night nurse.
-The vaccines for the residents are kept in a refrigerator in the DON/ADON's office.
-All residents are given or offered the Pneumococcal (vaccine that protects against 23 types of Pneumococcal bacteria) vaccine or the Influenza (a vaccine that protects against the flu virus) vaccine).
-The temperature in the vaccine refrigerator was not checked.
-The temperature should be checked daily and
-The temperature should be recorded on the temperature log.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish or maintain a system of medication records that enables periodic accurate reconciliation and accounting for all controlled medications by not having a log showing that two nurses verified the destruction of a used narcotic pain patch for one sampled resident (Resident #40) out of 15 sampled residents. The facility census was 58 residents.
Record review of the facility's policy, Discarding and Destroying Medications, dated 10/14 showed:
-Scheduled II controlled substances (Fentanyl is a Scheduled II drug), will be disposed of in accordance with state and federal guidelines.
-The medication should be disposed of in the presence of two witnesses.
-The nurse should document the disposal on the medication disposition record.
-The record should include the signature of two witnesses (two nurses).
-The medication disposition record will contain the following information:
-The resident's name.
-The date the medication was disposed.
-The name and the strength of the medication.
-The name of the dispensing pharmacy.
-The quantity disposed.
-The method of disposition.
-The reason for disposition and
-The signature of the witnesses.
1. Record review of Resident #40's face sheet showed he/she was readmitted on [DATE] with the following diagnoses:
-Polyosteoarthritis (joint pain and stiffness).
-Contracture of muscle, right hand (permanent shortening of muscle or joint).
-Pain in ankles and joints.
-Polyeuropathy in diseases (damage affecting the nerves).
-Muscle spasm in calf and
-Pain.
Record review of the resident's care plan dated 5/18/19 showed:
-The resident experiences the presence of frequent pain in his/her right foot and
-The resident has a history of drug seeking for pain medication.
Record review of the resident's Physician Order Sheet (POS) dated 6/04/19 showed:
-The resident had an order for Fentanyl (Narcotic pain medication) 25 mcg/hr (micrograms per hour) patch.
-The nurse was to apply one patch topically (on the skin).
-The nurse was to change the patch every 72 hours and
-The nurse was to rotate the site where the patch was placed.
Record review of the resident's July 2019 Electronic Medication Administration Record (EMAR) showed:
-The Fentanyl patch had been applied on 7/1, 7/4, 7/7, and 7/10 and
-Licensed Practical Nurse (LPN) A had applied the pain patch on all the above dates.
Observation on 7/10/19 at 8:23 A.M. of the medication pass on Cherry Lane with LPN A showed:
-Resident #40 had a Fentanyl patch.
-The patch was to be changed every three days.
-LPN A took off the old used patch.
-LPN A applied a new patch in a different place than where the old patch had been located (rotated the location).
-LPN A and the Director of Nursing (DON) together put the patch in the Drug Buster (a chemical drug disposal system) container to destroy it and
-There was no sheet to sign verifying that two nurses had destroyed it.
During an interview on 7/10/19 at 8:30 A.M. LPN A said:
-Two nurses were to destroy the used patch together. and
-There was not a sheet to sign verifying that two nurses had destroyed the patch.
During an interview on 7/10/19 at 9:00 A.M. LPN B said;
-A medication patch like Fentanyl should be cut up.
-The patch should be put in the Drug Buster.
-It should be written on a log that two nurses destroyed it and
-He/she thought there was a log in the front but he/she was not sure.
During an interview on 7/12/19 at 12:25 P.M. the DON and Assistant Director of Nursing (ADON) said:
-He/she would expect the facility to have a log to verify the destruction of a Fentanyl patch to show that two nurses have destroyed it.
-The two nurses would sign it and
-The patch should be put in the Drug Buster to be destroyed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents with a mental disorder and/or individuals with intellectual disability had a DA-124 C level I screen (used to evaluate for the presence of psychiatric conditions to determine if a preadmission screening/resident review (PASRR) level II screen is required) as required for one sampled resident (Resident #40) out of 15 sampled residents. The facility census was 58 residents.
Record review of the Missouri Department of Health and Senior Services (DHSS) guide titled, PASRR Desk Reference, dated 3/3/08, showed:
- The PASRR is a federally mandated screening process for any person for whom placement in a Medicaid Title (XIX) certified bed is being sought. This is a Level I screening (completion of the DA 124 C form). (In this facility, all beds are Medicaid certified).
- A Level II assessment is completed on those persons identified at Level I who are known or suspected to have a serious mental illness, Intellectual Delay, Developmental Delay or related condition to determine the need for specialized service (completion of the DA 124 A/B form). The facility responsible for completing the DA 124 A/B and/or DA 124 C forms is also responsible for submitting completed form(s) to DHSS, Division of Regulation and Licensure, Section for Long Term Care Regulation, Central Office Medical Review Unit (COMRU).
- PASRR screening is required:
--To assure appropriate placement of persons known or suspected of having a mental impairment,
--To assure that the individual needs of mentally impaired persons can be and are being met in the appropriate placement environment.
--To be compliant with the Omnibus Budget Reconciliation Act (OBRA)/PASRR federal requirements, see 42 CFR 483.Subpart C.
--To assure Title XIX funds are expended appropriately and in accordance with Legislative intent.
-To comply with PASRR requirements, the facility must maintain a legible copy on file of the DA124C and Level II Screening Report for each resident until the resident is transferred. If a legible copy is not maintained, the facility must complete and submit a new set of DA 124 A/B and C forms to COMRU,
- If a resident is discharged to a new nursing home, the receiving facility is responsible for assuring the DA124C and Level II screening results are included in the transfer packet and
- Should the DA124C not be included in the packet, the admission should not be completed. The DA124C and Level II screening results should be requested from the prior facility by the receiving facility.
1. Record review of Resident #40's quarterly Minimum Data Set (a federally mandated assessment tool completed by facility staff for care planning) dated 6/4/19 showed the following staff assessment of the resident:
-Was severely cognitively impaired.
-Some of his/her diagnoses included anxiety disorder (a psychiatric disorder that involve extreme fear, worry and nervousness), depression (a mental disorder in which the individual has intense sadness or despair that affects their daily life), bipolar disorder (a disorder characterized by extreme mood swings from depression to mania) and psychotic disorder (a mental disorder in which there is a severe loss of contact with reality).
-He/she showed minimal depressive mood indicators and
-He/she had no behaviors.
Record review on 7/08/19 at 2:51 P.M. showed no DA-124 C level I screen in the resident's medical records.
During an interview on 7/09/19 at 11:08 A.M., the bookkeeper said he/she could did not find the resident's DA-124 C.
During an interview on 7/11/19 at 9:27 A.M., the bookkeeper said:
-He/she called COMRU and the DA-124 C was over [AGE] years old so COMRU no longer had a copy of it and
-COMRU instructed him/her to do another DA-124 C and write replacement on it and they would process it.
During an interview on 7/12/19 at 12:25 P.M., the Assistant Director of Nursing (with the Director of Nursing present) said Social Services was responsible for the DA-124 C.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide in writing the facility's bed-hold information and agreement prior to being transferred/discharged to the hospital for two sampled residents (Residents #59 and #16) out of 15 sampled residents. The facility census was 58 residents.
Record review of the facility's Bed Hold Policy & Agreement Form dated February 2014 showed:
-The facility is to execute an acknowledgement stating whether or not the resident desires to exercise his/her right to a bed hold.
-The bed hold agreement is to be obtained for each occurrence of hospital leave.
-When hospital leave is reported on the midnight census, the business office will notify the resident/responsible party to sign the bed hold agreement.
-The business office will address weekend or holiday transfers to the hospital on the next business day and
-A telephone call may be documented as notification of the bed hold agreement.
1. Record review of Resident #59's assessments and tracking forms showed he/she:
-discharged from the facility with his/her return anticipated on 5/27/19.
-Re-entered the facility on 5/31/19. and
-Cognitively intact.
Record review of the resident's medical records showed a bed hold policy would accompany the transfer/discharge form for the resident's discharge on [DATE] but there was no documentation that the resident and his/her representative was provided with the information.
Record review of the resident's nurses' notes and Social Services notes showed no documentation regarding providing the resident and his/her representative with a bed hold policy.
During an interview on 7/10/19 at 12:47 P.M., the resident said he/she and his/her family members were not given a bed hold policy when he/she went to the hospital.
2. Record review of Resident #16's assessments and tracking forms showed he/she:
-discharged from the facility with his/her return anticipated on 1/15/2019.
-Re-entered the facility on 1/18/2019.
-discharged from the facility with his/her return anticipated on 4/18/2019 and
-Re-entered the facility on 4/23/2019.
Record review of the resident's medical records showed a bed hold policy would accompany the transfer/discharge form for the resident's discharges on 1/15/19 and 4/18/19 but there was no documentation that the resident and his/her representative was provided with the information.
Record review of the resident's nurses' notes and Social Services notes showed no documentation regarding providing the resident and his/her representative with a bed hold policy.
3. During an interview on 7/12/19 at 12:25 P.M., the Assistant Director of Nursing said (with the Director of Nursing present) that Social Services was responsible for providing the resident and the resident's representative with the bed hold policy when transferred/discharged to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to send the discharge or transfer letters to the residents and their representative when they were transferred/discharged for two sampled residents (Residents #59 and #16) out of 15 sampled residents. The facility census was 58 residents.
The facility did not have a policy on transfers and discharges.
1. Record review of Resident #59's assessments and tracking forms showed he/she:
-discharged from the facility with his/her return anticipated on 5/27/2019.
-Re-entered the facility on 5/31/2019 and
- Cognitively intact.
Record review of the resident's medical records showed a transfer/discharge form for the resident's discharge on [DATE] but there was no documentation that the resident and his/her representative was provided with the information.
Record review of the resident's nurses' notes and Social Services notes showed no documentation regarding providing the resident and his/her representative with a transfer/discharge letter.
During an interview on 7/10/19 at 12:47 P.M., the resident said he/she and his/her family members were not given a transfer/discharge notice when he/she went to the hospital.
2. Record review of Resident #16's assessments and tracking forms showed he/she:
-discharged from the facility with his/her return anticipated on 1/15/2019.
-Re-entered the facility on 1/18/2019.
-discharged from the facility with his/her return anticipated on 4/18/2019 and
-Re-entered the facility on 4/23/2019.
Record review of the resident's medical records showed a transfer/discharge form for the resident's discharges on 1/15/19 and 4/18/19 but there was no documentation that the resident and his/her representative was provided with the information.
Record review of the resident's nurses' notes and Social Services notes showed no documentation regarding providing the resident and his/her representative with a transfer/discharge letter.
3. During an interview on 7/12/19 at 12:25 P.M., the Assistant Director of Nursing said (with the Director of Nursing present) that Social Services was responsible for providing the resident and the resident's representative with discharge/transfer notices.

Based on interview and record review, the facility failed to complete the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN-form CMS-10055) for one sampled resident (Resident #39) out of three sampled residents who were discharged from Medicare part A services and remained in the facility. The facility census was 58 residents.
The facility did not have a policy on SNFABNs.
Record review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C-09-20), dated 1/9/09, showed the following:
-The Notice of Medicare Provider Non-Coverage (NOMNC-form CMS-10123) is issued when all covered Medicare services end for coverage reasons;
-If the SNF believes on admission or during a resident's stay that Medicare will not pay for skilled nursing or specialized rehabilitative services and the provider believes that an otherwise covered item or service may be denied as not reasonable or necessary, the facility must inform the resident or his/her legal representative in writing why these specific services may not be covered and the beneficiary's potential liability for payment for the non-covered services. The SNF's responsibility to provide notice to the resident can be fulfilled by the use of either the SNFABN (form CMS-10055) or one of the five uniform denial letters;
-The SNFABN provides an estimated cost of items or services in case the beneficiary had to pay for them him/herself or through other insurance they may have; and
-If the SNF provides the beneficiary with either the SNFABN or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits, the provider has met is obligation to inform the beneficiary of his/her potential liability for payment and related standard claim appeal rights. Issuing the NOMNC to a beneficiary only conveys notice to the beneficiary of his/her right to an expedited review of a service termination.
1. Record review of Resident #39's SNF Beneficiary Protection Notification Review showed the resident's last Medicare Part A was 5/25/19.
Record review of the Beneficiary Notice-Residents discharged within the Last Six Months showed the resident was discharged from Medicare Part A services on 5/25/19 and remained in the facility.
Record review of the resident's NOMNC showed the resident's responsible party signed the notice on 5/21/19.
Record review of the resident's undated SNFABN-CMS 10055 form showed the form was left blank.
During an interview on 7/10/19 at 6:30 A.M., the Social Services Director said he/she attached the ABN to the NOMNC but did not fill it out unless the resident wanted to continue services.
During an interview on 7/12/19 at 12:25 P.M., Assistant Director of Nursing said (with the Director of Nursing present) that Social Services was responsible for the ABNs.

Based on interview and record review, the facility failed to ensure incoming mail received from the postal service for residents on Saturdays was delivered to the residents within 24 hours. The facility census was 58 residents.
Record review of facility's policy titled Policy and Procedures for Mail dated March 2013, showed mail will be delivered to the resident(s) within 24 hours of delivery on the premises or to the facility's post office box (including Saturday deliveries) and the resident's out-going mail will be delivered to the postal service within 24 hours, except on holidays.
1. During the Resident Council/Group Interview (an interview held as a part of the survey process) on 7/9/19 at 2:00 P.M., residents attending the Group Interview said:
-Mail comes to the facility on Saturday but is not delivered to the residents until Monday.
-There is no one here to deliver the mail on Saturday and
-The activities staff delivers the mail on Monday that comes in on Saturday.
During an interview on 7/9/19 at 3:15 P.M., the Activities Worker said:
-The mail that comes on Saturday is sorted by the secretary.
-He/she puts the mail for the residents in our (Activities) mailbox and
-The mail is delivered to the resident on the following Monday.
During an interview on 7/12/19 at 12:25 P.M., the Director of Nursing (DON) said:
-He/She would expect residents to receive their mail on Saturday if it is delivered to the facility on Saturday.
-There is activity staff at the facility on weekends.
-If activity staff does not deliver the mail that comes in on Saturday to the residents on Saturday, the nursing staff could do it and
-He/She will look into who is responsible for making sure the residents' incoming mail is delivered on Saturday.