Accordius Health At Gastonia

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and resident and staff interviews, the facility failed to assess the ability of a resident to self-administer medications kept at bedside for 1 of 1 resident reviewed for self-administration (Resident #39).Findings included:Resident #39 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, coronary heart disease, hypertension, and heart failure. Review of Resident #39's admission Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact.Review of Resident #39's active physician orders included albuterol sulfate (bronchodilator) aerosol 90 micrograms (mcg) inhale 2 puffs every 4 hours as needed for dyspnea (shortness of breath) dated 3/16/26. There was no active order for the oxymetazoline hydrochloride (antihistamine) nasal spray. Review of Resident #39's medical records revealed no documentation Resident #39 was assessed to safely self-administer medications. During an observation and interview with Resident #39 on 03/29/26 at 12:16 PM, two inhalers of albuterol sulfate 90 mcg and two bottles of oxymetazoline hydrochloride nasal spray were observed in a plastic basket on the overbed table beside the bed. Resident #39 was in bed, and both medications were within his reach. Resident #39 stated he used the inhalers probably twice a week when short of breath and took 2 puffs and he used the nasal spray for congestion. An observation on 03/30/26 at 12:57 PM revealed the two inhalers of albuterol and the two bottles of oxymetazoline hydrochloride nasal spray remained in the basket on the overbed table within the reach of Resident #39 while he rested in bed. An interview was conducted on 03/31/26 at 4:07 PM with Nurse #3, the assigned nurse for Resident #39. Nurse #3 revealed she had administered the day shift medications to Resident #39 on 3/31/26 but she did not notice the inhalers or nasal spray bottles in the basket on the bedside table. Nurse #3 stated if she had noticed the medications, she would have removed them from the room and stored them on the medication cart. Nurse #3 stated she was not aware of any resident that self-administered medications.During an interview on 03/31/26 at 3:13 PM, the Director of Nursing (DON) explained if Resident #39 wanted to self-administer his inhaler and nasal spray a self-administer assessment should have been done and the inhaler and nasal spray should be stored securely.An observation on 03/31/26 at 3:16 PM with the DON revealed the two albuterol inhalers and two bottles of oxymetazoline hydrochloride nasal spray remained in the basket placed on the overbed table beside Resident #39. Resident #39 refused to share where he got the inhalers and nasal spray when asked by the DON. The DON explained to Resident #39 if he wanted to self-administer the inhaler and nasal spray she would need to ensure there was a physician's order for the medications and a self-administration assessment was needed to ensure he could safely administer the medication. Resident #39 confirmed he wanted to self-administer his albuterol inhaler and nasal spray. The DON removed both inhalers and nasal spray bottles from the room.During an interview on 04/01/26 at 2:09 PM, the Administrator stated Resident #39's ability to safely administer would need to be assessed if he wanted to self-administer the albuterol inhaler and nasal spray. The Administrator revealed the medications would need to be stored securely and not be left within reach of other residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews with staff and Nurse Practitioner, the facility failed to follow a Nurse Practitioner order for the care of an intravenous (IV) access site for 1 of 1 resident who had a Peripherally Inserted Central Catheter (PICC) (Resident #85).Findings included:Hospital Discharge summary dated [DATE] revealed orders for Resident #85 to continue IV antibiotics for 38 days.A Nurse Practitioner order dated 03/20/26 revealed to change of the PICC line dressing every 7 days on Fridays.The Care Plan dated 03/21/26 revealed Resident #85 had a PICC line with an intervention of dressing change per order.The comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #85 is cognitively intact, received IV medication and had IV access in the form of a PICC.The medication administration record (MAR) revealed to change the PICC line dressing every Friday during dayshift with a start date of 03/27/26; it was left blank and not signed off as completed on 3/27/26.Review of progress notes dated 03/27/26 revealed no documentation as to why the dressing change did not occur.During an interview and observation on 03/29/26 at 2:19 PM of Resident #85 it was revealed that Resident #85 had a PICC line for IV antibiotic therapy. Observation of the IV access site revealed an intact dressing with corners curled up, no redness or drainage at the insertion site and a date of 03/18/26.During an interview conducted on 03/30/26 at 2:09 PM, Nurse #1 stated he had been assigned as the nurse for Resident #85 on 03/27/26. Nurse #1 revealed he was supposed to change the dressing on the PICC line as per the order, but he did not complete the task.During an interview conducted on 03/30/26 at 2:54 PM, the Assistant Director of Nursing (ADON) indicated that she had completed the PICC dressing change on 03/30/26. The ADON revealed the old dressing was dated 03/18/26. The ADON stated she expected the dressing to be changed on 03/27/26 and it was not changed. The ADON stated the dressing change was not completed as ordered.During an interview on 04/01/26 at 10:07 AM the Director of Nursing (DON) stated that dressing changes for IV access sites must be completed at least every seven days, with daily flushes ordered and the site monitored daily for signs of infection. The DON explained she would expect the nurse assigned to Resident #85 to assess the site and recognize that the dressing change was overdue. She emphasized that PICC line dressings must be changed every seven days to prevent infection.During an interview conducted with the Nurse Practitioner on 04/01/2026 at 9:32 AM, she indicated that she expected dressing changes to be performed every seven days. She explained that exceeding this timeframe increases the risk of infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and Consultant Pharmacist interviews, the facility failed to follow the pharmacy recommendation to update a medication order to include indication for use for 1 of 5 residents reviewed for unnecessary medications (Residents #77).
Findings included:
Resident #77 admitted to the facility on [DATE] with diagnoses that included dementia, mood disturbance, anxiety disorder and major depressive disorder.
An active physician's order dated 08/23/24 for Resident #77 read, Lamotrigine (mood stabilizer) 25 milligrams (mg) - give one tablet by mouth two times a day for There was no diagnosis included on the order indicating reason for use.
The significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #77 had severe impairment in cognition.
Review of a Pharmacist's Recommendation to Prescriber form dated 10/31/24 read, Resident #77 has an order for Lamotrigine 25 mg - give one tablet by mouth two times a day for Please update order directions to include indication for use. The bottom of the form where the provider would agree or disagree, provide comments and sign the form was blank.
The Medication Administration Records (MARs) for October 2024, November 2024, December 2024, and January 2025 revealed Resident #77 received Lamotrigine 25 mg twice daily as ordered.
During a phone interview on 01/16/25 at 2:03 PM, the Consultant Pharmacist revealed as part of her monthly medication reviews, she checked to ensure medications had a clinical indication for use and if they did not, she submitted a recommendation to the facility. She confirmed that she submitted a recommendation to the facility on [DATE] to add an indication of use to Resident #77's Lamotrigine medication order. She explained she was out of work November 2024 and December 2024 and the Pharmacists who covered in her absence likely had not known to follow up on the recommendation. The Consultant Pharmacist indicated it was her expectation for the facility to have addressed the recommendation for Resident #77 within 30 days, before the next monthly medication review.
During an interview on 01/16/25 at 11:55 AM, the Director of Nursing (DON) revealed she had started back at the facility in December 2024 and since then, the Unit Manager was the person responsible for reviewing and following-up on pharmacy recommendations and then sending them back to her when completed. The DON stated prior to December 2024, she was not sure who was following-up on pharmacy recommendations. The DON confirmed the pharmacy recommendation dated 10/31/24 for Resident #77 had not been addressed and a diagnosis had not been added to the physician order for Lamotrigine as requested.
During an interview on 01/16/25 at 3:00 PM, the Administrator revealed she thought the former DON would have been the person following-up to make sure pharmacy recommendations were completed. The Administrator stated she expected pharmacy recommendations to be addressed when provided to the facility.

Based on observations and staff interviews the facility failed to maintain a clean floor in 1 of 1 walk-in cooler, 1 of 1 walk-in freezer, and 1 of 1 kitchen; label and date open food items and discard food with signs of spoilage or use-by date in 1 of 1 walk-in cooler; restrain facial hair during food preparation; and label and date food items in 2 of 2 nourishment room refrigerators and freezer (first and second floor nourishment rooms).
Findings included:
1. An initial tour of the walk-in cooler, walk-in freezer, and kitchen on 01/13/25 at 11:10 AM revealed multiple dried white stains and debris scattered on the floor of the walk-in cooler, dried brown stains and scattered debris on the floor of the walk-in freezer, and a dried blue substance to the kitchen floor near the 3 compartment sink, 2 plastic drinking cups on the floor under the dish machine, and a large amount of black debris on the floor under the sink near the dish machine.
An interview with the Dietary Manager on 01/13/25 at 3:04 PM revealed the walk-in cooler, walk-in freezer, and kitchen were mopped daily and she expected the floors to be clean.
An additional observation of the walk-in cooler, walk-in freezer, and kitchen floor on 01/15/25 at 11:10 AM revealed multiple dried white stains and debris scattered on the floor of the walk-in cooler, dried brown stains and scattered debris on the floor of the walk-in freezer, and a dried blue substance to the kitchen floor near the 3 compartment sink, 2 plastic drinking cups on the floor under the dish machine, and a large amount of black debris on the floor under the sink near the dish machine.
An interview with the Administrator on 01/16/25 at 4:05 PM revealed she expected floors of the walk-in cooler, walk-in freezer, and kitchen to be clean and free of debris.
2. An initial observation of the walk-in cooler on 01/13/25 at 11:15 AM revealed an undated bowl of salad, 3 opened and undated packs of sliced cheese, a bag of shredded lettuce with brown discoloration with an opened date of 01/02/25, a metal pan of tomato soup with a date of 01/07/25, and an opened and undated 46-ounce box of thickened orange juice sitting on a shelf.
An interview with the Dietary Manager on 01/13/25 at 3:04 PM revealed all food and beverage items should be dated when opened and cooks were responsible for making sure all items were dated on a daily basis. She stated any food with signs of spoilage should be discarded and the tomato soup should have been discarded 3 days after being placed in the cooler.
An interview with the Administrator on 01/16/25 at 4:05 PM revealed she expected all food and beverage items to be dated when opened, food with signs of spoilage should be discarded, and food items should be used or discarded according to use-by policies.
3. An observation of [NAME] #1 on 01/13/25 at 11:35 AM revealed he was preparing food for the lunch meal and did not have a restraint in place to cover his facial hair. [NAME] #1 had a partial beard with varying lengths of hair covering mainly his chin and the surrounding skin.
In an interview with [NAME] #1 on 01/13/25 at 11:35 AM he confirmed he was not wearing a restraint for his facial hair and stated he was not sure if the kitchen stocked restraints for facial hair.
An interview with the Dietary Manager on 01/13/25 at 3:04 PM revealed she had ordered beard guards but had not received them. She stated all employees with facial hair should have a beard guard in place when preparing and serving food.
An interview with the Administrator on 01/16/25 at 4:05 PM revealed she expected all dietary staff with facial hair to have a beard guard in place when preparing and serving food.
4. (a). An observation of the first-floor nourishment room refrigerator on 01/14/25 at 8:39 AM revealed an undated 46-ounce box of thickened apple juice sitting on a shelf.
(b). An observation of the second-floor nourishment room on 01/14/25 at 8:44 AM revealed the following:
(1) an unlabeled and undated bag of meatballs sitting in the door of the refrigerator
(2) an unlabeled and undated bag of pizza slices sitting in the door of the refrigerator
(3) an unlabeled and undated half empty thawed milkshake sitting on a shelf in the refrigerator
(4) an unlabeled and undated pitcher of brown liquid sitting on a shelf in the refrigerator
(5) an undated 12-ounce can of soda sitting on a shelf in the freezer
(6) 2 unlabeled and undated 16.9-ounce bottles of water sitting in the door of the freezer
An interview with the Dietary Manager on 01/15/25 at 11:35 AM revealed the dietary department was responsible for ensuring all items in the nourishment room refrigerators and freezers were labeled and dated on a daily basis. She stated dietary staff would check to ensure all items were labeled and dated but nursing staff would place unlabeled and undated items in the refrigerators or freezers after dietary staff checked for dates and labels.
An interview with the Administrator on 01/16/25 at 4:05 PM revealed she expected all items in nourishment room refrigerators and freezers to be labeled and dated.

Based on observations and staff interviews the facility failed to ensure the area surrounding dumpsters remained free of garbage and debris and failed to close the doors to the dumpsters that contained waste for 3 of 3 dumpsters reviewed. These failures had the potential to attract pests and rodents.
Findings included:
An observation of the dumpster area with [NAME] #1 on 01/13/25 at 11:25 AM revealed the side doors of all 3 dumpsters were open and the door on top of the middle dumpster was open, with multiple cardboard boxes hanging out the top of the dumpster. Further observation of the dumpster area revealed there were 3 gloves, a plastic drinking cup, pieces of tape, a straw, and various condiment packets scattered on the ground around the dumpster area.
An interview with [NAME] #1 on 01/13/25 at 11:25 AM revealed he was not sure who was responsible for cleaning the dumpster area and ensuring dumpster lids were closed.
An interview with the Dietary Manager on 01/13/25 at 3:04 PM revealed the maintenance department was responsible for cleaning the dumpster area.
An interview with the Housekeeping Director on 01/17/25 at 8:26 AM revealed floor technicians and the maintenance department split keeping the dumpster area clean. She stated the dumpster area was supposed to be checked daily for cleanliness and that dumpster lids were closed.
An interview with the Maintenance Director on 01/16/25 at 8:30 AM revealed he and the floor technicians were responsible for ensuring the dumpster area was clean and dumpster lids were closed on a daily basis. He stated he had not had an opportunity to check the dumpster area the morning of 01/13/25.
An interview with Floor Technician #1 on 01/17/25 at 8:33 AM revealed he and the Maintenance Director were responsible for ensuring the dumpster area was clean and dumpster lids were closed on a daily basis. He stated he had not had an opportunity to check the dumpster area the morning of 01/13/25.
An interview with the Administrator on 01/16/25 at 4:05 PM revealed all dumpster lids should be shut and the area around the dumpsters should be clean and free of debris. She stated the housekeeping department was responsible for ensuring the dumpster area was clean.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notices (SNF ABN) prior to discharge from Medicare Part A skilled services for 3 of 3 residents reviewed for beneficiary notification review (Residents #57, #90 and #92).
The Findings Included:
1. Resident #57 was admitted to the facility on [DATE].
Review of a Notice of Medicare Non-Coverage (NOMNC) revealed the notice was discussed with Resident #57's Responsible Party (RP) on 08/20/24 which indicated Resident #57's Medicare Part A coverage for skilled services would end on 08/23/24. Resident #57 remained in the facility.
Review of Resident #57's medical record revealed no evidence a SNF ABN was reviewed with or provided to Resident #57 or Resident #57's RP.
During an interview on 01/16/25 at 11:16 AM, the Business Office Manager (BOM) revealed she issued SNF ABNs for residents covered under Medicare Part B. She stated the Social Worker (SW) issued NOMNC's and SNF ABNs for residents covered under Medicare Part A.
During an interview on 01/16/25 at 11:24 AM, the SW confirmed she was responsible for issuing a NOMNC when a resident's Medicare Part A services were ending. The SW stated she did not know what a SNF ABN was or that she was supposed to issue one when a resident had skilled days left and remained in the facility. The SW confirmed a SNF ABN was not issued to Resident #57 or his RP prior to Medicare Part A skilled services ending on 08/23/24.
During an interview on 01/16/25 at 3:00 PM, the Administrator revealed the SW was responsible for issuing a NOMNC and/or SNF ABN to the resident or their RP when Medicare Part A services were ending. The Administrator expressed she had assumed the SW was aware to issue a SNF ABN in addition to a NOMNC when needed. The Administrator stated she would have expected for the SW to have issued both notices to Resident #57 or his RP as required.
2. Resident #90 was admitted to the facility on [DATE].
Review of a Notice of Medicare Non-Coverage (NOMNC) revealed the notice was discussed with Resident #90's Responsible Party (RP) on 08/26/24 which indicated Resident #90's Medicare Part A coverage for skilled services would end on 08/28/24. Resident #90 remained in the facility until she discharged home on [DATE].
Review of Resident #90's medical record revealed no evidence a SNF ABN was reviewed with or provided to Resident #90 or Resident #90's RP.
During an interview on 01/16/25 at 11:16 AM, the Business Office Manager (BOM) revealed she issued SNF ABNs for residents covered under Medicare Part B. She stated the Social Worker (SW) issued NOMNC's and SNF ABNs for residents covered under Medicare Part A.
During an interview on 01/16/25 at 11:24 AM, the SW confirmed she was responsible for issuing a NOMNC when a resident's Medicare Part A services were ending. The SW stated she did not know what a SNF ABN was or that she was supposed to issue one when a resident had skilled days left and remained in the facility. The SW confirmed a SNF ABN was not issued to Resident #90 or her RP prior to Medicare Part A skilled services ending on 08/28/24.
During an interview on 01/16/25 at 3:00 PM, the Administrator revealed the SW was responsible for issuing a NOMNC and/or SNF-ABN to the resident or their RP when Medicare Part A services were ending. The Administrator expressed she had assumed the SW was aware to issue a SNF ABN in addition to a NOMNC when needed. The Administrator stated she would have expected for the SW to have issued both notices to Resident #90 or her RP as required.
3. Resident #92 admitted to the facility on [DATE].
Review of a Notice of Medicare Non-Coverage (NOMNC) revealed the notice was discussed with Resident #92 on 08/20/24 which indicated Resident #92's Medicare Part A coverage for skilled services would end on 08/22/24. Resident #92 remained in the facility until he discharged home on [DATE].
Review of Resident #92's medical record revealed no evidence a SNF ABN was reviewed with or provided to Resident #92.
During an interview on 01/16/25 at 11:16 AM, the Business Office Manager (BOM) revealed she issued SNF ABNs for residents covered under Medicare Part B. She stated the Social Worker (SW) issued NOMNC's and SNF ABNs for residents covered under Medicare Part A.
During an interview on 01/16/25 at 11:24 AM, the SW confirmed she was responsible for issuing a NOMNC when a resident's Medicare Part A services were ending. The SW stated she did not know what a SNF ABN was or that she was supposed to issue one when a resident had skilled days left and remained in the facility. The SW confirmed a SNF ABN was not issued to Resident #92 prior to Medicare Part A skilled services ending on 08/22/24.
During an interview on 01/16/25 at 3:00 PM, the Administrator revealed the SW was responsible for issuing a NOMNC and/or SNF-ABN to the resident or their RP when Medicare Part A services were ending. The Administrator expressed she had assumed the SW was aware to issue a SNF ABN in addition to a NOMNC when needed. The Administrator stated she would have expected the SW to have issued Resident #92 both notices as required.

Based on record review and staff interviews, the facility failed to ensure Registered Nurse (RN) coverage was provided for at least 8 consecutive hours per day for 4 of the 91 days reviewed for RN Coverage (5/04/24, 5/18/24, 5/25/24, and 6/08/24).
Findings included:
The Payroll Based Journal (PBJ) report for third quarter of 2024 (April, May, and June) reported the facility without RN coverage for 8 consecutive hours per day for 5/04/24, 5/18/24, 5/25/24, and 6/08/24.
a. Review of the daily staffing assignment sheet for Saturday, 5/04/24 revealed no RN assigned.
Review of the timecard record for 5/04/24 revealed the former Director of Nursing (DON) had a clock in time of 6:45 AM and a clock out time of 3:15 PM.
An interview on 1/16/25 at 3:54 PM with the Scheduler revealed she was aware of the requirement for RN coverage 8 consecutive hours per day. She stated if there she was unable to schedule an RN, she brought it to the Director of Nursing and Administrator's attention for their assistance to ensure RN coverage.
An interview on 1/14/25 at 5:01 PM with the Administrator revealed that the former DON worked 5/04/24. She stated that since the former DON was a salaried employee and did not clock in and out. However, the Administrator added a clock in and out for the former DON to show the facility had RN coverage for 8 consecutive hours per day.
An interview on 1/15/25 at 1:02 PM with the former DON revealed she was employed at the facility in May 2024. She stated she had never worked at the facility on the weekend and was not at the facility on 5/04/24.
A follow up interview on 1/16/25 at 1:11 PM with the Administrator revealed she felt like the former staff denied being at the facility due to 'disgruntlement'.
b. No daily staffing assignment sheet for Saturday, 5/18/24 was provided by the facility.
Review of the timecard record for 5/18/24 revealed no RN had clocked in or out.
An interview on 1/16/25 at 3:54 PM with the Scheduler revealed she was aware of the requirement for RN coverage 8 consecutive hours per day. She stated if there she was unable to schedule an RN, she brought it to the Director of Nursing and Administrator's attention for their assistance to ensure RN coverage.
An interview on 1/14/25 at 5:01 PM with the Administrator revealed that the former Assistant Director of Nursing (ADON) worked 5/18/24. She stated that since the former ADON was a salaried employee and did not clock in or out. The Administrator stated she should have added a clock in and out for the former ADON to show the facility had RN coverage for 8 consecutive hours per day, but she had not. No documentation was provided regarding the ADON working on 5/18/24.
An interview on 1/15/25 at 4:29 PM with the former ADON revealed that she did not recall ever working a weekend day after she became the ADON on 5/01/24.
During a follow up interview on 1/16/25 at 1:11 PM with the Administrator revealed she felt like the former staff denied being at the facility due to 'disgruntlement'.
c. The facility was unable to provide the daily nurse staffing assignment sheet for Saturday, 5/25/24.
Review of the timecard record for 5/25/24 revealed the former ADON had a clock in time of 6:45 AM and a clock out time of 3:15 PM.
An interview on 1/16/25 at 3:54 PM with the Scheduler revealed she was aware of the requirement for RN coverage 8 consecutive hours per day. She stated if there she was unable to schedule an RN, she brought it to the Director of Nursing and Administrator's attention for their assistance to ensure RN coverage.
An interview on 1/14/25 at 5:01 PM with the Administrator revealed that the former ADON worked 5/25/24. She stated that since the former ADON was a salaried employee and did not clock in and out. However, the Administrator had added a clock in and out for the former ADON to show the facility had RN coverage for 8 consecutive hours per day.
An interview on 1/15/25 at 4:29 PM with the former ADON revealed that she did not recall ever working a weekend day after she became the ADON on 5/01/24.
A follow up interview on 1/16/25 at 1:11 PM with the Administrator revealed she felt like the former staff denied being at the facility due to 'disgruntlement'.
d. No daily staffing assignment sheet for Saturday, 6/08/24 was provided by the facility.
Review of the timecard record for 6/08/24 revealed the former DON had a clock in time of 6:45 AM and a clock out time of 3:15 PM.
An interview on 1/16/25 at 3:54 PM with the Scheduler revealed she was aware of the requirement for RN coverage 8 consecutive hours per day. She stated if there she was unable to schedule an RN, she brought it to the Director of Nursing and Administrator's attention for their assistance to ensure RN coverage.
An interview on 1/14/25 at 5:01 PM with the Administrator revealed that the former DON worked 6/08/24. She stated that since the former DON was a salaried employee and did not clock in and out. However, the Administrator stated she had added a clock in and out for the former DON to show the facility had RN coverage for 8 consecutive hours per day.
An interview on 1/15/25 at 1:02 PM with the former DON revealed she was employed at the facility on 6/08/2024. She stated she had never worked at the facility on the weekend and was not at the facility on 6/08/24.
During a follow up interview on 1/16/25 at 1:11 PM with the Administrator revealed she felt like the former staff denied being at the facility due to 'disgruntlement'.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to maintain residents' wardrobe closets in good repair by not replacing knobs on the drawers which left exposed screws sticking out from the drawer that had the potential to cut residents when entering and exiting their rooms (rooms 202, 208, 215, 223, and 225); failed to ensure a resident's wardrobe closet had functioning drawers (room [ROOM NUMBER]); failed to maintain a clean and sanitary wheelchair (room [ROOM NUMBER]-A); and failed to ensure a call light cover was secured to the wall in a resident's bathroom to prevent it from coming loose when the cord was pulled to engage the call light (room [ROOM NUMBER]) for 8 of 31 rooms on 1 of 2 resident halls (200 hall) reviewed for environment.
The findings included:
1. a. Observations of room [ROOM NUMBER] on 01/14/25 at 8:44 AM, 01/15/24 at 9:02 AM, and 01/16/25 at 11:00 AM revealed a wardrobe closet located just inside the room door. The bottom drawer on the left side of the wardrobe closet was missing a knob and the end of the screw was sticking out approximately one inch. The bottom drawer was approximately 1 foot from the floor.
b. Observations of room [ROOM NUMBER] on 01/15/25 at 9:03 AM and 01/16/25 at 11:01 AM revealed a wardrobe closet located just inside the room door. The bottom drawer on the left side of the wardrobe closet was missing a knob and the end of the screw was sticking out approximately one inch. The bottom drawer was approximately 1 foot from the floor.
c. Observations of room [ROOM NUMBER] on 01/15/25 at 9:05 AM and 01/16/25 at 11:03 AM revealed a wardrobe closet located just inside the room door. The top drawer on the left side of the wardrobe closet was missing a knob and the end of the screw was sticking out approximately one inch. The top drawer was approximately 2 feet from the floor.
d. Observations of room [ROOM NUMBER] on 01/15/25 at 9:07 AM and 01/16/25 at 11:05 AM revealed a wardrobe closet located just inside the room door. Both the bottom and top drawers on the left side of the wardrobe closet were missing knobs and the end of the screws were sticking out approximately one inch. The top drawer was approximately 2 feet from the floor and the bottom drawer was approximately 1 foot from the floor.
e. Observations of room [ROOM NUMBER] on 01/15/25 at 9:08 AM and 01/16/25 at 11:07 AM revealed a wardrobe closet located just inside the room door. The top drawer on the left side of the wardrobe closet was missing a knob and the end of the screw was sticking out approximately one inch. The top drawer was approximately 2 feet from the floor.
f. Observations of room [ROOM NUMBER] on 01/15/25 at 9:04 AM and 01/16/25 at 11:02 AM revealed a wardrobe closet located just inside the room door. The bottom two drawers had no knobs and both drawers were off track preventing them from opening and closing properly.
An environmental tour and interview was conducted on 01/17/25 at 9:39 AM with the Maintenance Director, which revealed the conditions of rooms 202, 208, 212, 215, 223, and 225 remained unchanged. The Maintenance Director acknowledged the exposed screws on the drawers of the wardrobe closets and the drawers not closing properly were safety concerns due to the potential for causing a skin tear or other injury and needed repaired. He explained he had replaced the left 2 knobs on the closet drawers in room [ROOM NUMBER] last week but was not sure why they were missing now and he was not aware of the missing knobs on the closet drawers in rooms 202, 208, 215 and 225. He explained the bottom 2 wardrobe closet drawers in room [ROOM NUMBER] were replacements and he had ordered new tracking for them to fit properly. The Maintenance Director stated he and the Department Managers made daily rounds to identify concerns but he also relied on floor staff to notify him when repairs were needed.
During an interview on 01/17/25 at 11:37 AM, the Administrator stated the Department Managers conducted room rounds twice a day and they should be looking at the wardrobe closet drawers to ensure knobs were in place and were working properly. The Administrator stated the issues with the closet drawers in rooms 202, 208, 212, 215, 223 and 225 should have been identified during daily rounds and staff should have informed the Maintenance Director repairs were needed.
2. Observations of the wheelchair in 227-A on 01/15/24 at 9:04 AM and 01/16/25 at 9:59 AM revealed dried, crusty debris on top and underneath the seat cushion and dried debris on the brake of the wheelchair.
During an interview on 01/17/25 at 10:51 AM, the Environmental Services Director revealed her company was new to the facility as of last week and they were currently in the process of developing a schedule for cleaning and disinfecting resident wheelchairs. She stated that some of the resident wheelchairs were washed on Monday (01/13/25) and Tuesday (01/14/25) but she did not have documentation of the specific wheelchairs that were included.
During an observation and follow-up interview on 01/17/25 at 11:27 AM, the Environmental Services Director confirmed the wheelchair in room [ROOM NUMBER]-A had dried, crusty debris on top and underneath the seat cushion and dried debris on the brake of the wheelchair. She acknowledged the wheelchair needed a good cleaning. The Environmental Services Director stated she was informed by the Administrator during the morning meeting on Monday (01/13/25) that some of the wheelchairs on the 2nd floor, where room [ROOM NUMBER]-A was located, needed to be cleaned but the Administrator had not provided specific room numbers or resident names.
During an interview on 01/17/25 at 11:37 AM, the Administrator revealed she was aware of the issue with resident wheelchairs not being cleaned regularly and explained there had been changes in the environmental services department. She stated she provided the Environmental Services Director with a list of resident wheelchairs that needed cleaned, which included the wheelchair in room [ROOM NUMBER]-A, and had also discussed with the Environmental Services Director to ensure the wheelchair in room [ROOM NUMBER]-A was checked daily and cleaned frequently. The Administrator stated she had been working with the Environmental Services Director on a process to ensure resident wheelchairs were cleaned routinely and a cleaning schedule was recently put into place.
3. Observations of the bathroom in room [ROOM NUMBER] on 01/13/25 at 2:30 PM and 01/16/25 at 8:25 AM revealed when the call light switch was pulled the face plate cover came away from the wall and was not secured in place.
An interview and observation was conducted with the Maintenance Director on 01/17/25 at 9:38 AM. The Maintenance Director observed in room [ROOM NUMBER] the call light in the bathroom did work when the switch was pulled but the face plate cover came away from the wall and was not secure. The Maintenance Director revealed Department Heads did daily rounds to check for environment issues and he tried to check call lights as part of his daily round. He revealed environment concerns identified were discussed with him during the morning meetings and staff could report concerns to him verbally or fill out a work order. The Maintenance Director stated he was not aware the face plate cover was not secured to the wall in the bathroom of room [ROOM NUMBER].
During an interview on 01/17/25 at 5:32 PM the Administrator revealed Department Heads did daily room rounds to check for environment issues. The Administrator stated she was not aware the call light switch in the bathroom of room [ROOM NUMBER] was not secured to the wall.

Based on record review and staff interviews, the facility failed to post complete and accurate daily licensed nurse staffing information for 19 of the 20 days reviewed 5/04/24, 5/18/24, 5/25/24, 6/08/24, and 1/01/25 through 1/16/25 for sufficient staffing and failed to maintain a posted staffing sheets for one day (5/25/24).
Findings included:
Reviews of posted staffing for 5/04/24, 5/18/24, 5/25/24, 6/08/24, and 1/01/25 through 1/16/25 revealed one day, 1/16/25, had been updated to accurately reflect the staffing.
The facility was unable to provide a staffing sheet for 5/25/24.
During an interview on 1/14/25 at 5:01 PM with the Scheduler, she stated she was responsible for the staff posting and that she was unaware of the requirement to adjust the posted staffing information to reflect the actual staff present. She stated that she completed the posted staffing sheets ahead of time based on the staff work schedule. She stated when she was off on the weekend or vacation, she completed the posted staffing sheets ahead of time and they were not adjusted to accurately reflect the actual staffing. The Scheduler was unable to locate the posted staffing sheet for 5/25/24.
During an interview on 1/16/25 at 1:11 PM the Administrator, she stated she was aware of the requirement to adjust the posted staffing to accurately reflect the actual staff present. She also stated she was unaware this was not being done and that the Scheduler did not know that the posted staffing should be updated with the actual staff on each shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff, Consultant Pharmacist, and Medical Director interviews the Consultant Pharmacist failed to provide recommendations for laboratory tests for drug monitoring for 1 of 5 residents reviewed for unnecessary medications (Resident #3).
Findings included:
Resident #3 was admitted to the facility 08/01/19 with diagnoses including hypertension (high blood pressure), atrial fibrillation (irregular heartbeat), thyroid disorder, and vitamin D deficiency.
The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #3 was severely cognitively impaired and received a diuretic 7 out of 7 days during the look back period.
Review of Resident #3's Physician orders included the following medications:
Digoxin (medication for irregular heartbeat and high blood pressure) 125 micrograms (mcg) every other day ordered 08/03/19
Levothyroxine 125 mcg once a day for low thyroid hormone ordered 08/02/19
Magnesium Oxide 400 milligrams (mg) for low magnesium ordered 07/14/22
Vitamin D 2000 units once a day as a supplement ordered 08/02/19
Potassium 20 milliequivalents (mEq) twice a day ordered 08/01/19
Lasix (a diuretic) 20 mg twice a day ordered 08/01/19
Review of Resident #3's Medication Administration Records (MAR) from April 2023 through October 2023 revealed she received Digoxin, Levothyroxine, Magnesium Oxide, Vitamin D, Potassium, and Lasix as ordered with few noted exceptions.
Review of Resident #3's medical record revealed the Consultant Pharmacist had conducted medication regimen reviews (MRRs) monthly from April 2023 through September 2023. No recommendations regarding obtaining a Digoxin level, magnesium level, Vitamin D level, thyroid stimulating hormone (TSH) level (a laboratory test that checks thyroid function), or a potassium level had been made to the Physician.
A telephone interview with the Consultant Pharmacist on 10/04/23 at 3:34 PM revealed she conducted MRRs for Resident #3 from April 2023 through September 2023. She stated laboratory tests for a Digoxin level, magnesium level, Vitamin D level, potassium level, and TSH should be obtained annually unless the resident was having symptoms. The Consultant Pharmacist explained she did not provide a recommendation to the Physician to obtain routine laboratory tests because it was overlooked.
In an interview with the Director of Nursing (DON) on 10/04/23 at 4:45 PM she confirmed the last Digoxin level, magnesium level, TSH level, and comprehensive metabolic panel (a laboratory test for electrolytes including potassium) for Resident #3 were obtained 07/07/22.
An interview with the Medical Director on 10/06/23 at 12:32 PM revealed he expected pharmacy to prompt providers to order laboratory work as indicated by established guidelines.
During a joint interview with the DON and Administrator on 10/06/23 at 4:50 PM they stated they expected pharmacy to make recommendations for laboratory work as appropriate.

Based on record review, observations and staff interviews the facility failed to repair the walk-in refrigerator door seal and remove expired milk stored for use in the walk-in refrigerator. Additionally, the facility failed to maintain a clean and maintain a heating, ventilation, and air conditioning unit (HVAC) located in the kitchen, a vertical pole adjacent to food production, a conduit pipe located above the tray line, and the ceiling area of the dish room free of peeling paint. The practice had the potential to affect the food served to the residents.
Findings Included:
a. On 10/2/23 at 10:42 AM an observation with the Dietary Manager (DM) of the walk-in refrigerator door seal was observed to be peeling away from the bottom right side door jam and sticking out from the closed refrigerator door. Inside the walk-in refrigerator revealed 2 unopened cases (50 count) pint milk on the bottom shelf of food rack with expiration rack 9/28/23.
b. On 10/2/23 at 10:42 AM A heating, ventilation, and air conditioning (HVAC) unit located directly in front of the walk-in refrigerator was observed with a buildup of thick, crumbly to touch debris that spanned the length of the HVAC unit.
On 10/2/23 at 10:45 AM The Dietary Manager stated during the observation that the milk had arrived the previous week and had not been used.
The District Dietary Manager stated on 10/5/23 at 1:55 PM that he had noted the broken door seal on his inspections for the previous 3 months. The inspection report was sent to the Administrator each month.
c. On 10/04/23 at 11:48 AM a vertical pole located directly adjacent to the tray line was observed with brown and sticky to touch debris.
d. On 10/4/23 at 12:03 AM an observation in the kitchen of the ceiling area above the tray line revealed a conduit pipe observed with thick clumpy grayish debris. An air vent was blowing directly onto the conduit pipe with the potential to blow debris onto the tray line. During this observation, the dish machine area was also observed and noted to have peeling paint 2-3 inches in length hanging down from the ceiling.
The DM and stated on 10/05/23 at 1:49 PM that she posted daily cleaning assignments for dietary staff to complete. She stated the pole next to the tray line, HVAC unit and conduit pipe on the ceiling was not assigned to dietary staff.
The Administrator stated on 10/05/23 at 4:15 PM that expired food should have been removed from the walk-in refrigerator and that the peeling paint in the kitchen was an issue and would be repainted. The kitchen should be cleaned as needed and on a cleaning schedule and repairs should be made in the kitchen as soon as possible.
On 10/06/23 at 1:01 PM the Maintenance Supervisor stated he was made aware of the peeling paint on the ceiling in the kitchen earlier in the day and had replaced the door seal on the walk-in refrigerator. The walk-in refrigerator door seal had been replaced repaired previously but was not aware it was currently needing to be replaced. He stated the HVAC unit could be cleaned by the dietary staff, and that he would clean the conduit pipe above the tray line.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions previously put in place following the recertification and complaint investigation survey that occurred 10/06/23 and the recertification and complaint investigation survey that occurred 05/20/22. This failure was for 3 deficiencies that were originally cited in the areas of Food Procurement, Store/Prepare/Serve-Sanitary (F-812), Accuracy of Assessments (F-641), and Safe/Clean/Comfortable/Homelike Environment (F-584) and were subsequently recited on the current recertification and complaint investigation survey of 10/06/23. The continued failure of the facility during two surveys of record in the same area showed a pattern of the facility's inability to sustain an effective QAA program.
Findings included:
This tag is cross referenced to:
F812: Based on record review, observations and staff interviews the facility failed to repair the walk-in refrigerator door seal and remove expired milk stored for use in the walk-in refrigerator. Additionally, the facility failed to maintain a clean heating, ventilation, and air conditioning unit (HVAC) located in the kitchen, a vertical pole adjacent to food production, a conduit pipe located above the tray line, and the ceiling area of the dish room free of peeling paint. The practice had the potential to affect the food served to the residents.
Based on the recertification and complaint investigation survey conducted 05/20/22 the facility failed to discard spoiled and expired food, date milkshakes to identify their use-by date, and label food and drink items in one nourishment room.
F641: Based on record review and staff interviews, the facility failed to accurately code Minimum Data Set (MDS) assessments in the areas of Preadmission Screening and Resident Review (PASRR), activities of daily living, diagnoses, and skin conditions for 7 of 27 sampled residents reviewed (Residents #8, #55, #72, #3, #15, #18 and #237).
During the recertification and complaint investigation survey conducted 05/20/22 the facility failed to accurately code Minimum Data Set (MDS) assessments in the areas of medications, oral and dental status, and catheter for 3 residents.
F584: Based on observations and staff interviews, the facility failed to maintain residents' wardrobe closets in good repair by not replacing knobs on the drawers which left exposed screws sticking out from the drawer that had the potential to cut residents when entering and exiting their rooms (rooms 107, 204, 206, 208, 209, 212, 217, 232, 234, 236, and 237); failed to maintain the floors, walls and baseboards of residents' rooms clean and in good repair (rooms 104, 230, 231, 232, 233, 234, 236, and 237); failed to ensure resident bathrooms were clean and sanitary that had strong odors resembling urine and/or buildup of debris on the floor (bathrooms 106, 230, 232, 234, and 236); and failed to place a cover over an outlet leaving the cutout in the wall exposed through the adjoining room (room [ROOM NUMBER]) for 17 of 60 rooms on 2 of 2 resident halls reviewed for environment.
During the recertification and complaint investigation survey conducted 05/20/22 the facility failed to ensure a denture cup was stored properly, ensure a raised toilet seat was clean, clean an interior bathroom door, and maintain clean walls in 5 resident rooms.
An interview with the Administrator on 10/06/23 at 6:00 PM revealed the quality assurance team met monthly since she began employment and included the Medical Director, administrative staff, unit managers, Social Worker, MDS Coordinator, therapy, and pharmacy staff. She stated part of the root cause of repeat citations was due to a lack of consistent staff, lack of training, and not having QAA meetings monthly. The Administrator stated she felt she had currently assembled a strong team of employees and once everyone was trained the facility could move forward to achieve and maintain compliance long term.

Based on record review and staff interviews the facility failed to ensure Nurse Aides (NA) received at least 12 hours of in-service training yearly and maintain documentation of the in-service training hours provided for 4 of 4 NA employee records reviewed for staffing (NA #1, NA #2, NA #3, and NA #4).
The findings included:
1. a. On 10/06/23 at 10:59 AM, a review of NA #1's employee file revealed the NA had been employed at the facility for at least 12 months and there was no evidence of educational hours being completed in 2022 or 2023.
b. On 10/06/23 at 10:59 AM, a review of NA #2's employee file revealed the NA had been employed at the facility for at least 12 months and there no evidence of educational hours being completed in 2022 or 2023.
c. On 10/06/23 at 10:59 AM, a review of NA #3's employee file revealed the NA had been employed at the facility for at least 12 months and there was no evidence of educational hours being completed in 2022 or 2023.
d. On 10/06/23 at 10:59 AM, a review of NA #4's employee file revealed the NA had been employed at the facility for at least 12 months and no evidence of educational hours being completed in 2022 or 2023.
An interview on 10/6/23 at 2:48 PM with the Director of Nursing (DON) revealed she was also the Staffing Development Coordinator (SDC) since 6/12/23. The DON explained she was unable to locate documentation of individual NA training hours. In addition, the DON stated she was unaware that NA were still required to receive 12-hours of annual in-service training. She stated going forward they planned to utilize a computer training program to track educational training requirements for staff.
A follow-up interview on 10/6/23 at 3:46 PM with the DON revealed there should be 12 hours per year of documented education provided to NAs that included dementia training. She explained the documentation from the previous corporation was very disorganized and she was unable to locate all the training that was provided to NAs by the previous corporation. The DON explained she was used to using a computer training program that tracked the hours of employee education; however, the previous corporation did not utilize a computer training program and the required NA training hours were overlooked.
An interview on 10/6/23 at 4:50 PM with the Administrator revealed she expected staff to have the required 12 hours or more of in-service education that included dementia and resident abuse training.

Based on record review, resident and staff interviews, the facility failed to resolve and communicate the facility's efforts to address repeated dietary concerns voiced by residents during Resident Council meetings for 4 of 9 months reviewed (January 2023, April 2023, May 2023, and July 2023).
Findings included:
The Resident Council minutes for the period January 2023 through September 2023 were reviewed and revealed the following:
•
Resident Council minutes dated 01/23/23 noted in part, residents voiced dietary concerns that food portions were small, not fully cooked, food was cold, bread was hard, and juice was served hot.
•
Resident Council minutes dated 02/16/23 noted the dietary concerns voiced during the previous month's meeting were reviewed and reported as resolved. There were no new dietary concerns voiced during the meeting.
•
Resident Council minutes dated 04/20/23 noted residents voiced concerns about call light response timing, laundry and food but did not specify what the concerns were.
•
Resident Council minutes dated 05/18/23 revealed no documentation that resolution was provided or discussed regarding the concerns voiced during the previous month's meeting. New dietary concerns were voiced regarding cold food and meal trays not being delivered in a timely manner.
•
Resident Council minutes dated 07/20/23 revealed no documentation that resolution was provided to the residents regarding the dietary concerns voiced during the previous month's meeting. New concerns were voiced regarding the food was too spicy, served late, and staff would not warm up the cold food when requested.
•
Resident Council minutes dated 08/17/23 revealed the dietary concerns addressed during the previous month's meeting were discussed but did not indicate if the issues were resolved or ongoing.
The facility's grievance logs for the period January 2023 through September 2023 were reviewed. The only grievances filed on behalf of the members of the Resident Council regarding dietary concerns were dated 01/25/23, 05/18/23 and 07/20/23. The concerns were all noted as resolved.
A Resident Council group interview was conducted on 10/04/23 at 3:04 PM with Resident #1, Resident #7, Resident #35, Resident #40, Resident #51, and Resident #77 in attendance. The residents all reported ongoing dietary concerns, specifically with meals being served cold. The residents voiced it took staff a long time to deliver their meal trays once the meal cart arrived on the hall. When the meal tray was served to them, the food was cold and if ice cream was on the tray, it was usually defrosted. The residents all stated they had voiced these concerns during previous meetings and the only follow-up they received regarding administrative efforts to address their dietary concerns was they are trying and still working on it.
During an interview on 10/05/23 at 2:11 PM, the Dietary Manager (DM) revealed she was aware of the repeated dietary concerns voiced at the Resident Council meetings such as food being cold when served to the residents. The DM explained in an effort to address the concerns, they had received a quote on a new pellet warmer system (keeps hot foods at safe temperatures for a longer period of time), completed test tray audits one to two times a week to check the temperature and taste of the food, and provided in-service training to staff on delivering the meal trays more quickly as well as keeping the doors shut on the meal carts in-between delivering meal trays. The DM stated she felt the reason cold food was still a concern for the residents was due to new agency staff that might not have received the in-service training.
During an interview on 10/06/23 at 11:21 AM, the Activity Director revealed when concerns were brought up during Resident Council meetings, she wrote them on a concern form for the appropriate Department Manager to address. The Activity Director stated for at least half of this year, residents had brought up repeated dietary concerns, such as cold food, and felt the majority of the time their concerns were addressed. The Activity Director explained once the resolution to the concern was provided to her, she reviewed it with the Resident Council at the next scheduled meeting but did not always document in the Resident Council minutes if the concerns were resolved or improving.
During an interview on 10/06/23 at 5:02 PM, the Administrator stated she was aware there had been repeated dietary concerns voiced during Resident Council meetings. She explained they have requested new menus, an increase in the PPD (per patient day) food cost and more training and support for dietary staff in an effort to address the residents' food concerns. The Administrator stated instead of just informing the residents they were working on addressing the issue, she realized they could do better at explaining the process of what they were actually doing to try and resolve their food concerns.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. An in-room observation conducted on 10/03/23 at 10:00 AM of room [ROOM NUMBER] revealed an outlet cover was missing leaving the cutout in the wall exposed through the adjoining room (room [ROOM NUMBER]) with male resident.
On 10/5/23 at 9:56 AM an observation of room [ROOM NUMBER] revealed the cutout in the wall to be unchanged. Resident #73 was interviewed during the observation. She stated the cutout in the wall had been there since she moved into the room.
On 10/05/23 at 4:15 PM the Maintenance Manager and the Administrator reported they were not aware of the missing outlet cover for room [ROOM NUMBER], and it would be repaired.
2. a. Observations of room [ROOM NUMBER] on 10/02/23 at 3:31 PM, 10/03/23 at 9:22 AM, 10/04/23 at 9:13 AM, 10/05/23 at 8:52 AM, and 10/06/23 at 12:04 PM revealed a wardrobe closet located just inside the room door. Three of the four drawers of the wardrobe closet were missing a knob leaving the end of the screws sticking out approximately one-half inch.
b. Observations of room [ROOM NUMBER] on 10/02/23 at 3:45 PM, 10/03/23 at 9:37 AM, 10/04/23 at 9:20 AM, 10/05/23 at 9:10 AM, and 10/06/23 at 12:05 PM revealed a wardrobe closet located just inside the room door. One of the four drawers of the wardrobe closet was missing a knob leaving the end of the screw sticking out approximately one-half inch.
c. Observations of room [ROOM NUMBER] on 10/02/23 at 3:52 PM, 10/03/23 at 9:41 AM, 10/04/23 at 9:24 AM, 10/05/23 at 9:13 AM and 10/06/23 at 12:06 PM revealed a wardrobe closet located just inside the room door. Two of the four drawers of the wardrobe closet were missing a knob leaving the end of the screws sticking out approximately one-half inch.
d. Observations of room [ROOM NUMBER] on 10/03/23 at 9:02 AM, 10/03/23 at 9:06 AM, 10/05/23 at 8:36 AM, and 10/06/23 at 12:06 PM revealed a wardrobe closet located just inside the room door. One of the four knobs of the wardrobe closet was missing a knob leaving the end of a screw sticking out approximately one-half inch.
e. Observations of room [ROOM NUMBER] on 10/03/23 at 9:31 AM, 10/05/23 at 9:08 AM, and 10/06/23 at 12:08 PM revealed a wardrobe closet located just inside the room door. One of the four knobs of the wardrobe closet was missing a knob leaving the end of a screw sticking out approximately one-half inch.
3. a. Observations of room [ROOM NUMBER] on 10/02/23 at 2:32 PM, 10/04/23 at 9:55 AM, 10/05/23 at 8:33 AM, 10/06/23 at 12:03 PM revealed linear scrapes with exposed sheetrock behind the headboards of A and B beds and a dried black substance on the floor between A and B bed.
b. Observations of room [ROOM NUMBER] on 10/02/23 at 3:30 PM, 10/03/23 at 9:15 AM, 10/04/23 at 8:27 AM, 10/05/23 at 8:46 AM, 10/06/23 at 12:04 PM revealed food particles and other debris scattered throughout the floor of both sides of the room.
c. Observations of room [ROOM NUMBER] on 10/03/23 at 9:13 AM, 10/04/23 at 8:27 AM, 10/05/23 at 8:46 AM, and 10/06/23 at 12:04 PM revealed an approximately 4-inch by 4-inch area of exposed sheetrock to the wall beside B bed and food particles and other debris scattered throughout the floor of both sides of the room.
d. Observations of room [ROOM NUMBER] on 10/02/23 at 3:31 PM, 10/03/23 at 9:22 AM, 10/04/23 at 9:13 AM, 10/05/23 at 8:52 AM, and 10/06/23 at 12:04 PM revealed food particles and other debris scattered throughout the floor on both sides of the room.
e. Observations of room [ROOM NUMBER] on 10/02/23 at 3:46 PM, 10/03/23 at 9:37 AM, 10/04/23 at 9:20 AM, 10/05/23 at 9:10 AM, and 10/06/23 at 12:05 PM revealed the baseboard along the wall behind both beds was peeling away from the wall and food particles and other debris were scattered throughout the floor of both sides of the room.
f. Observations of room [ROOM NUMBER] on 10/02/23 at 3:36 PM, 10/04/23 at 9:17 AM, 10/05/23 at 8:59 AM, and 10/06/23 at 12:07 PM revealed multiple linear scratches with exposed sheetrock behind B bed, the baseboard peeling away from the wall behind the room entrance door, and food particles and other debris scattered throughout the floor on both sides of the room.
g. Observations of room [ROOM NUMBER] on 10/03/23 at 9:18 AM, 10/05/23 at 8:50 AM, and 10/06/23 at 12:07 PM revealed a missing baseboard to the wall beside A bed and the corner of the wall beside A bed had exposed sheetrock.
h. Observations of room [ROOM NUMBER] on 10/03/23 at 9:31 AM, 10/05/23 at 9:08 AM, and 10/06/23 at 12:08 PM revealed the corner of the wall beside A bed had exposed sheetrock and food particles and debris scattered throughout the floor on both sides of the room.
i. Observations of room [ROOM NUMBER] on 10/02/23 at 3:52 PM, 10/04/23 at 9:24 AM, 10/05/23 at 9:13 AM, and 10/06/23 at 12:06 PM revealed food particles and other debris scattered throughout the floor on both sides of the room.
4. a. Observations of room [ROOM NUMBER]'s shared bathroom on 10/02/23 at 2:37 PM, 10/04/23 at 9:57 AM, 10/05/23 at 8:35 AM, and 10/06/23 at 12:03 PM revealed multiple circular areas of a dried brown substance on the floor beside the toilet.
b. Observations of room [ROOM NUMBER]'s shared bathroom on 10/03/23 at 9:31 AM, 10/03/23 at 9:15 AM, 10/04/23 at 8:27 AM, 10/05/23 at 8:46 AM, and 10/06/23 at 12:04 AM revealed scattered debris throughout the floor and a strong odor of urine was noted.
c. Observations of room [ROOM NUMBER]'s shared bathroom on 10/02/23 at 3:39 PM, 10/03/23 at 9:29 AM, and 10/04/23 at 9:18 AM, 10/05/23 at 9:08 AM, and 10/06/23 at 12:08 PM revealed circular dried brown stains on the floor beside the toilet and scattered debris throughout the floor.
d. Observations of room [ROOM NUMBER]'s shared bathroom on 10/02/23 at 3:31 PM, 10/03/23 at 9:22 AM, 10/04/23 at 9:13 AM, 10/05/23 at 8:52 AM, and 10/06/23 at 12:04 PM revealed scattered debris throughout the floor.
e. Observations of room [ROOM NUMBER]'s shared bathroom on 10/02/23 at 3:46 PM, 10/03/23 at 9:37 AM, 10/04/23 at 9:20 AM, and 10/06/23 at 12:05 PM revealed scattered debris throughout the floor.
An environmental tour and interview was conducted on 10/06/23 at 3:36 PM with the Administrator, Maintenance Director, and Environmental Services Director which revealed the conditions of rooms 104, 107, 230, 231,232, 234, 236, and 237. The Maintenance Director stated he was unaware of the issues identified with the walls, missing baseboard and exposed screws on the wardrobe closets in residents' rooms. He explained since starting his position in July 2023, he had been trying to train staff to enter work orders into the TELS system instead of on paper so there would be a record of the work order. Both the Maintenance Director and Administrator voiced the exposed screws on the wardrobe closets were potential safety hazards and needed to be repaired. The Administrator explained it was an older building and the Maintenance Director's primary focus had been addressing the plumbing issues within the facility. She stated it was her expectation that residents would have clean rooms that were well-taken care of to live in and the issues identified with the walls, baseboards and wardrobe closets would be addressed. The Environmental Services Director stated housekeeping staff were not mopping or sweeping rooms daily. She further stated resident rooms should be clean and free of odors and she was going to provide education to staff regarding her expectations. The Administrator stated she expected resident rooms to be clean and free of odors.
Based on observations and staff interviews, the facility failed to maintain residents' wardrobe closets in good repair by not replacing knobs on the drawers which left exposed screws sticking out from the drawer that had the potential to cut residents when entering and exiting their rooms (rooms 107, 204, 206, 208, 209, 212, 217, 232, 234, 236, and 237); failed to maintain the floors, walls and baseboards of residents' rooms clean and in good repair (rooms 104, 230, 231, 232, 233, 234, 236, and 237); failed to ensure resident bathrooms were clean and sanitary that had strong odors resembling urine and/or buildup of debris on the floor (bathrooms 106, 230, 232, 234, and 236); and failed to place a cover over an outlet leaving the cutout in the wall exposed through the adjoining room (room [ROOM NUMBER]) for 17 of 60 rooms on 2 of 2 resident halls reviewed for environment.
The findings included:
1. a. Observations of room [ROOM NUMBER] on 10/03/23 at 9:45 AM, 10/04/23 at 12:33 PM, and 10/05/23 at 9:00 AM revealed the corner of the wall next to the shared bathroom had a section of missing baseboard exposing the sheetrock. The left side of the of door to the wardrobe closet was missing a doorknob.
b. Observations of room [ROOM NUMBER] on 10/03/23 at 9:48 AM, 10/04/23 at 12:34 PM, and 10/05/23 at 9:01 AM revealed a wardrobe closet located just inside the room door. The top drawer on the left side of the wardrobe closet was missing a knob and the end of the screw was sticking out approximately one inch. The top drawer was approximately 2 feet from the floor. There was an open, square shaped hole, approximately 2 inches by 2 inches, in the middle of the wooden bathroom door.
c. Observations of room [ROOM NUMBER] on 10/03/23 at 9:52 AM, 10/04/23 at 12:35 PM, and 10/05/23 at 9:02 AM revealed on the wall behind the headboard of the A bed were linear and circular scrapes with exposed sheetrock from the top of the headboard and halfway to the floor.
d. Observations of room [ROOM NUMBER] on 10/03/23 at 9:55 AM, 10/04/23 at 12:36 PM, and 10/05/23 at 9:03 AM revealed a wardrobe closet located just inside the room door. The bottom drawer on the right side of the wardrobe closet was missing a knob and the end of the screw was sticking out approximately one inch. The bottom drawer was approximately 1 foot from the floor.
e. Observations of room [ROOM NUMBER] on 10/03/23 at 10:00 AM, 10/04/23 at 12:37 PM, and 10/05/23 at 9:04 AM revealed on the wall behind the headboard of the B bed were linear and circular scrapes with exposed sheetrock from the top of the headboard and halfway to the floor.
f. Observations of room [ROOM NUMBER] on 10/03/23 at 10:04 AM, 10/04/23 at 12:38 PM, and 10/05/23 at 9:05 AM revealed a wardrobe closet located just inside the room door. The top drawer on the left side of the wardrobe closet was missing a knob and the end of the screw was sticking out approximately one inch. The top drawer was approximately 2 feet from the floor.
g. Observations of room [ROOM NUMBER] on 10/03/23 at 10:07 AM, 10/04/23 at 12:39 PM, and 10/05/23 at 9:06 AM revealed a wardrobe closet located just inside the room door. The bottom drawer on the left side of the wardrobe closet was missing a knob and the end of the screw was sticking out approximately one inch. The bottom drawer was approximately 1 foot from the floor.
h. Observations of room [ROOM NUMBER] on 10/03/23 at 10:23 AM, 10/04/23 at 12:40 PM, and 10/05/23 at 9:07 AM revealed a wardrobe closet located just inside the room door. The top drawers on both the left and right sides of the wardrobe closet were missing knobs and the end of the screws were sticking out approximately one inch. The top drawers were approximately 2 feet from the floor.
i. Observations of room [ROOM NUMBER] on 10/03/23 at 10:27 AM, 10/04/23 at 12:41 PM, and 10/05/23 at 9:08 AM revealed a wardrobe closet located just inside the room door. The bottom drawer on the left side of the wardrobe closet was missing a knob and the end of the screw was sticking out approximately one inch. The bottom drawer was approximately 1 foot from the floor.
An environmental tour and interview was conducted on 10/06/23 at 3:36 PM with the Administrator, Maintenance Director, and Environmental Services Director which revealed the conditions of rooms 203, 204, 205, 206, 207, 208, 209, 212, and 217 remained unchanged. The Maintenance Director stated he was unaware of the issues identified with the walls, missing baseboard and exposed screws on the wardrobe closets in residents' rooms. He explained since starting his position in July 2023, he had been trying to train staff to enter work orders into the TELS system instead of on paper so there would be a record of the work order. Both the Maintenance Director and Administrator voiced the exposed screws on the wardrobe closets were potential safety hazards and needed to be repaired. The Administrator explained it was an older building and the Maintenance Director's primary focus had been addressing the plumbing issues within the facility. She stated it was her expectation that residents would have clean rooms that were well-taken care of to live in and the issues identified with the walls, baseboards and wardrobe closets would be addressed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to accurately code Minimum Data Set (MDS) assessments in the areas of Preadmission Screening and Resident Review (PASRR), activities of daily living, diagnoses, and skin conditions for 7 of 27 sampled residents reviewed (Residents #8, #55, #72, #3, #15, #18 and #237).
Findings included:
1. Resident #8 was admitted to the facility on [DATE]. Her diagnoses included Parkinson's disease, anxiety, depression, and bipolar disorder.
A care plan initiated on 12/04/18 revealed Resident #8 had a mood problem related to disease process and had a [NAME] II PASRR. Interventions included: administer medications as ordered, behavioral health consults as needed, and has a Level II PASRR.
The annual MDS assessment dated [DATE] indicated Resident #8 was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or other related conditions.
Review of a North Carolina Medicaid Uniform Screening Tool (NC MUST) inquiry document dated 10/05/23 revealed Resident #8 had a Level II PASSR with no expiration date. There was no effective date listed on the NC MUST inquiry.
During an interview 10/06/23 at 9:30 AM, the MDS Coordinator explained Resident #8's MDS assessment dated [DATE] was completed by another MDS Coordinator who was no longer employed at the facility. The MDS Coordinator confirmed Resident #8 had a Level II PASRR that should have been reflected on the MDS assessment and it was likely an oversight.
During an interview on 10/06/23 at 5:02 PM, the Administrator stated it was her expectation for MDS assessments to be completed accurately.
2. Resident #55 was admitted to the facility on [DATE]. Her diagnoses included depression and bipolar disorder.
A PASRR Level II Determination Notification letter dated 08/19/22 revealed Resident #55 had a Level II PASRR with no expiration date.
The annual MDS assessment dated [DATE] indicated Resident #55 was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or other related conditions.
During an interview on 10/06/23 at 9:30 AM, the MDS Coordinator revealed she was not always informed when a resident had a Level II PASRR and due to changes in staff, she was not sure who was responsible for keeping track to let her know. The MDS Coordinator explained she was not informed Resident #55 had a Level II PASRR which is why the MDS assessment dated [DATE] did not accurately reflect her PASRR status.
During an interview on 10/06/23 at 5:02 PM, the Administrator stated it was her expectation for MDS assessments to be completed accurately.
3. Resident #72 was admitted to the facility on [DATE]. Her diagnoses included anxiety and depression.
The annual MDS assessment dated [DATE] indicated Resident #72 was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or other related conditions.
Review of a North Carolina Medicaid Uniform Screening Tool (NC MUST) inquiry document dated 10/06/23 revealed Resident #72 had a 30-day Level II PASSR effective 07/31/23 with an expiration date of 08/30/23.
During an interview on 10/06/23 at 9:30 AM, the MDS Coordinator revealed she was not always informed when a resident had a Level II PASRR and due to changes in staff, she was not sure who was responsible for keeping track to let her know. The MDS Coordinator stated she was not informed Resident #72 had a Level II PASRR which is why the MDS assessment dated [DATE] did not accurately reflect her PASRR status.
During an interview on 10/06/23 at 5:02 PM, the Administrator stated it was her expectation for MDS assessments to be completed accurately.
4. Resident #40 was admitted to the facility 08/08/20 with diagnoses including anemia and muscle weakness.
The quarterly Minimum Data Set (MDS) dated [DATE] reflected Resident #40 was cognitively intact, required extensive assistance with bed mobility, and was on a turning and repositioning program.
An interview with the MDS Coordinator on 10/06/23 at 9:35 AM revealed she received assistance with coding some parts of the MDS from a staff member who worked remotely. She explained the staff member who worked remotely coded the quarterly MDS incorrectly because the facility did not have a turning and repositioning program and the coding error was an oversight.
An interview with the Director of Nursing (DON) on 10/06/23 at 4:50 PM revealed she expected the MDS to be coded correctly.
5. Resident #237 was admitted to the facility 12/05/22 with diagnoses including anemia and diabetes.
The nutrition care plan initiated 04/26/23 revealed Resident #237 had significant weight loss due to refusing meals and was at risk for malnutrition. Interventions included monitoring Resident #237 for signs or symptoms of malnutrition and providing his diet as ordered.
The significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #237 was cognitively intact and did not eat or drink during the look back period.
An interview with the MDS Coordinator on 10/06/23 at 9:46 AM revealed she received assistance with coding some parts of the MDS from a staff member who worked remotely. She explained the staff member who worked remotely coded the quarterly MDS incorrectly because even though Resident #237 had a poor appetite, he did eat and drink during the look back and the coding error was an oversight.
An interview with the Director of Nursing (DON) on 10/06/23 at 4:50 PM revealed she expected the MDS to be coded correctly.
6. Resident #18 was admitted to the facility 05/04/20 with diagnoses including non-Alzheimer's dementia and diabetes.
Review of Resident #18's Physician orders revealed an order dated 02/22/22 for valproic acid (used to treat seizures) oral solution 250 milligrams per 5 milliliters(ml) give 2.5 ml twice a day for seizures.
Review of Resident #18's Medication Administration Record (MAR) from June 2022 through October 2023 revealed she received valproic acid as ordered.
The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #18 was severely cognitively impaired and did not list seizures as a diagnosis.
An interview with the MDS Coordinator on 10/06/23 at 9:44 AM revealed the quarterly MDS should have reflected Resident #18 had a diagnosis of seizures and it was an oversight that it was not coded correctly.
An interview with the Director of Nursing (DON) on 10/06/23 at 4:50 PM revealed she expected the MDS to be coded correctly.
7. Resident #3 was admitted to the facility 08/01/19 with diagnoses including Alzheimer's disease and hypertension (high blood pressure).
Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #3 was severely cognitively impaired, required extensive assistance with bed mobility, and was on a turn and reposition program.
An interview with the MDS Coordinator on 10/06/23 at 9:32 AM revealed she received assistance with coding some parts of the MDS from a staff member who worked remotely. She explained the staff member who worked remotely coded the quarterly MDS incorrectly because the facility did not have a turning and repositioning program and the coding error was an oversight.
An interview with the Director of Nursing (DON) on 10/06/23 at 4:50 PM revealed she expected the MDS to be coded correctly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to request a Preadmission Screening and Resident Review (PASRR) Level II evaluation for a resident with a history of mental health diagnoses for 1 of 5 sampled residents reviewed for PASRR (Resident #53).
Findings included:
Review of hospital records dated 12/28/22 noted Resident #53 had a diagnosis of bipolar disorder with an effective date of 04/09/21.
Resident #53 was admitted to the facility on [DATE] with diagnoses that included manic depression (bipolar disease).
The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #53 was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability.
Review of Resident #53's list of cumulative diagnoses contained in her medical record revealed the following diagnoses: bipolar disorder with a date of 01/02/23, anxiety disorder with a date of 04/05/23, persistent mood disorder with a date of 04/13/23, and schizophrenia with a date of 04/13/23.
A hospital psychiatric consult progress note dated 03/29/23 revealed Resident #53 had a psychiatric history of bipolar disorder and anxiety. It further noted a diagnosis of schizoaffective disorder.
A psychiatric progress note dated 04/21/23 revealed in part, Resident #53 was seen to evaluate severe mood swings and behaviors. It was also noted Resident #53 had informed a previous provider she was diagnosed with schizophrenia and has had auditory hallucinations.
A physician's order dated 04/26/23 for Resident #53 read, Venlafaxine (antidepressant medication) 75 mg one time a day for bipolar depression related to persistent mood disorder.
A physician's order dated 06/21/23 for Resident #53 read, Risperidone (antipsychotic medication) 1 mg/milliliter (ml) mouth two times a day for delusions related to schizophrenia.
Review of a North Carolina Medicaid Uniform Screening Tool (NC MUST) document dated 10/03/23 revealed Resident #53 had a Level 1 PASRR effective 03/09/21. There were no requests for reevaluation after 03/09/21.
During interviews on 10/05/23 at 9:02 AM and 10/06/23 at 10:52 AM the Admissions Director revealed when she started her position in August 2023, no one was keeping up with Level II PASRR's so she started submitting the PASRR requests for reevaluations of time-limited PASRR via NC MUST. The Admissions Director explained as part of the admission process, she checked NC MUST to ensure resident's had a PASRR number prior to their admission but she did not submit requests for PASRR reevaluations if they had mental health diagnoses. The Admissions Director stated going forward the SW would be responsible for managing Level II PASRRs.
During an interview on 10/06/23 at 3:30 PM the SW revealed she started her position at the facility in June 2023 and had not yet been trained on the process for requesting Level II PASRR reevaluations.
During an interview on 10/06/23 at 5:02 PM, the Administrator stated she expected Level II PASRR requests to be requested per regulatory guidelines. She explained the SW would be the staff member responsible for requesting PASRR reevaluations going forward and corporate would be coming next week to train the SW on the process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to provide supporting documentation for a resident with a new diagnosis of schizophrenia for 1 of 5 residents reviewed for unnecessary medications (Resident #18).
Findings included:
Resident #18 was admitted to the facility 05/04/20 with diagnoses including non-Alzheimer's dementia, depression, and anxiety.
Review of the care plan for psychotropic medication use (medication that affects mental functions and behaviors) last updated 07/04/23 revealed Resident #18 received medications related to dementia, depression, and anxiety. Interventions included administering Resident #18's medications as ordered and monitoring her for any adverse reaction.
Resident #18 had a Physician order dated 12/20/22 for Seroquel (an antipsychotic) 25 milligrams (mg) twice a day for psychosis related to schizophrenia. On 05/05/23 the Physician order for Seroquel 25 mg twice a day was changed to Seroquel 50 mg at bedtime for sleep related to schizophrenia.
A summary of Physician #1's progress note dated 02/27/23 is as follows: Resident #13 was seen at the request of staff to evaluate whether she had a diagnosis to justify the use of Seroquel. The note stated Resident #18 was doing reasonably well with some underlying confusion but was not floridly (severely) delusional (beliefs not based in reality). The note further stated Resident #18 had a diagnosis of schizophrenia and dementia, but the delusional disorder predated the onset of her dementia and attempts to wean Seroquel were not successful due to florid psychosis.
The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #18 was severely cognitively impaired, had no behaviors during the look back period, had a diagnosis of schizophrenia, and received antipsychotic medications 7 out of 7 days during the look back period.
Review of Resident #18's medical record revealed there was no further documentation of what specific behaviors she exhibited that resulted in a new diagnosis of schizophrenia on 02/27/23. No orders for a psychiatry consult were observed in Resident #18's medical record.
An interview with the Director of Nursing (DON) on 10/06/23 at 8:22 AM revealed she was unable to locate any further documentation for why Resident #18 was given a diagnosis of schizophrenia on 02/27/23. She stated psychiatric services had been offered to Resident #18's family in the past and they declined those services.
Physician #1 was unavailable for interview during the investigation.
A telephone interview with the Medical Director on 10/06/23 at 12:32 PM revealed any resident with a new diagnosis of schizophrenia should have documentation to support the diagnosis.
A joint interview with the DON and Administrator on 10/06/23 at 4:50 PM revealed any resident with a new diagnosis of schizophrenia should have a Physician assessment and documentation to support the diagnosis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, the facility failed to have a discharge planning process in place that incorporated the resident in the development of a discharge care plan that addressed the resident's discharge goals and post-discharge needs for a resident who wished to discharge to the community for 1 of 2 sampled residents (Resident #236).
Findings included:
Resident #236 was admitted to the facility on [DATE] with diagnoses that included cellulitis of left lower limb, obsessive-compulsive personality disorder, major depressive disorder, and anxiety.
The baseline care plan initiated on 02/01/23 noted Resident #236's discharge goal was to return to the community.
The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #236 had intact cognition. The MDS noted an active discharge plan was in place for Resident #236 to discharge to the community.
A physician progress note dated 03/06/23 read in part, Resident #236 was seen for coordination of care in preparation for discharge. Resident #236's level of function improved while at the facility and received maximum inpatient therapy benefit. Decision was made for her to discharge to home with supervision and assistance, therapy and ongoing medical treatment. After review of the discharge plan with the social worker, the Director of Nursing (DON), and Administrator it was uncovered Resident #236 did not have a safe place in which to go to and decision was made to suspend her discharge to try and arrange a safe location.
Review of Resident #236's comprehensive care plan, last reviewed/revised 08/24/23, revealed no discharge care plan.
A physician's order dated 09/08/23 for Resident #236 read in part, discharge home with home health services. A walker will be needed.
Resident #236 discharged to the community on 09/08/23.
During an interview on 10/05/23 at 11:09 AM, the Social Worker (SW) revealed she did not develop a discharge care plan for Resident #236 as she was admitted to the facility prior to the SW starting her employment in June 2023. The SW stated prior to Resident #236 discharging from the facility, they had a care plan meeting with Resident #236 and her family member. The SW recalled Resident #236 voicing she wanted to return home and was agreeable to a discharge date of 09/08/23.
During an interview on 10/06/23 at 9:55 AM, the MDS Coordinator revealed it depended on the SW as to whether or not a discharge care plan was developed. The MDS Coordinator stated she was not sure of the reason why the previous SW did not develop a discharge care plan for Resident #236 as they had multiple meetings throughout Resident #236's stay regarding her discharge plans.
The previous SW was no longer employed at the facility and unable to be interviewed.
During an interview on 10/06/23 at 5:02 PM, the Administrator stated it was her expectation for care plans to be developed that reflected a resident's discharge goals and needs. The Administrator explained the discharge planning process initially started during the 72-hour care plan meeting conducted after the resident's admission. The discharge plan was then reviewed and discussed during discharge plan of care meetings and updated accordingly as the discharge plans progressed.

Based on record review and staff interviews the facility failed to ensure performance reviews were completed every 12 months for 4 of 4 Nurse Aides (NAs) reviewed to ensure in-service education was designed to address the outcome of the performance reviews (NA #1, NA #2, NA #3, and NA #4).
The findings included:
1. a. On 10/06/23 at 10:59 AM, a review of NA #1's employee file revealed NA #1 had been employed at the facility for at least 12 months and there was no evidence a performance review was completed in 2022 or 2023.
b. On 10/06/23 at 10:59 AM, a review of NA #2's employee file revealed the NA had been employed at the facility for at least 12 months and there was no evidence a performance review was completed in 2022 or 2023.
c. On 10/06/23 at 10:59 AM, a review of NA #3's employee file revealed the NA had been employed at the facility for at least 12 months and there was no evidence a performance review was completed in 2022 or 2023.
d. On 10/06/23 at 10:59 AM, a review of NA #4's employee file revealed the NA had been employed at the facility for at least 12 months and there was no evidence a performance review was completed in 2022 or 2023.
A joint interview on 10/6/23 at 5:21 PM with the Director of Nursing (DON) and the Administrator revealed they were unable to locate any documentation that performance reviews had been completed and stated they were overlooked. They both stated their expectation was for performance reviews to be completed annually with the staff's weaknesses incorporated into the required staff training. The DON stated she was responsible for completing performance reviews.