Valley Center

Based on family interview, record review and staff interview, the facility failed to notify the resident's representative of two (2) significant changes for Resident #123. This was true for one (1) of one (1) residents reviewed during the survey process. Resident identifier: #123. Facility Census: 122.
Findings Include:
a) Resident #123
On 05/14/25 at 10:39 AM, an interview was held with Resident #123's representative. The representative stated, They (the facility) didn't call me when two (2) different incidents happened to (Resident #123). I was very upset and felt someone should have called me.
On 05/14/25 at 11:35 AM, a record review was completed. The review found a physician determination of capacity dated 05/27/23, which indicated the resident lacked capacity due to Alzheimer's disease. The review, also, found the resident representative was not notified about two (2) changes in conditions. The first change in condition was on 02/12/25, when the resident was noted with an elevated pulse/heart rate while resting. The second change in condition was on 02/21/25, when the resident was noted with an altered mental status, weakness, shortness of breath, nausea and vomiting and lethargy. The resident remained in the facility during each event and was treated in-house by the on-call physicians.
On 05/14/25 at 1:30 PM, the facility policy entitled, Change in Condition: Notification of states, A Center must immediately inform the patient, consult with the patient's physician, and notify, consistent with their authority, the patient's representative, where there is: .A significant change in the patient's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) . Under the heading purpose, to provide appropriate and timely information about changes relevant to the patient's condition.
On 05/14/25 at 12:45 PM, the Director of Nursing (DON) and the Administrator were notified and confirmed the resident's representative should have been notified.

Based on record review and staff interview, the facility failed to ensure an accurate MDS assessment in the area of discharge destination. This deficient practice had the potential to affect one (1) of four (4) residents reviewed for the care area of hospitalization. Resident identifier: #117. Facility census: 124.
Findings included:
a) Resident #117
Review of Resident #117's medical records showed the resident was discharged home with home health on 08/21/24.
Resident #117's Discharge Return Not Anticipated Minimum Data Set (MDS) Assessment with Assessment Reference Date (ARD) 08/21/24 stated the resident was discharged to the hospital.
On 10/08/24 at 3:18 PM, the Administrator confirmed the discharge destination on the MDS was incorrect. The Administrator confirmed the resident was discharged home instead of to a hospital. She stated the MDS was corrected.

Based on observation, staff interview and record review, the facility failed to document the refrigerator and room temperatures in the South medication room. This was a random opportunity for discovery. Facility Census: 124.
Findings Include:
a) South Medication Room
On 10/08/24 at 10:05 AM, a tour of the South medication room was completed. During the tour, the medication refrigerator and room temperatures were not documented for the following dates:
--10/01/24 AM room temperature
--10/03/24 PM refrigerator temperature
--10/07/24 PM room temperature
--10/08/24 AM room temperature
On 10/08/24 at 10:22 AM, the Director of Nursing (DON) was notified and confirmed the refrigerator and room temperatures should be documented.

Based on record review and staff interview, the facility failed to maintain accurate and complete medical records for Resident #222. This is true for one (1) of 27 residents reviewed under the care area of advance directives. Resident identifier: #222. Facility Census: 124.
Findings Include:
a) Resident #222
On 10/08/24 at 8:30 AM, a record review was completed for Resident #222. The review found that the Physician's Order for Scope of Treatment (POST) was not complete. The signature of the Medical Power of Attorney (MPOA) was not dated.
On 10/08/24 at 8:58 AM, the Director of Nursing (DON) was notified and confirmed the POST form was missing the date of the MPOA's signature.

Based on record review and staff interview the facility failed to identify Bipolar Disorder on one (1) of three (3) Preadmission Screening and Resident Review (PASARR) reviewed during the Long Term Care Survey Process. Resident identifier: #48. Facility Census: 123.
Findings Include:
a) Resident #48
During record review, on 10/08/24 09:10 AM, a review of Resident #48's medical diagnoses revealed the following:
- UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITH OTHER BEHAVIORAL DISTURBANCE
-DELUSIONAL DISORDERS
-BIPOLAR DISORDER, CURRENT EPISODE MIXED, MODERATE
-ANXIETY DISORDER, UNSPECIFIED
-MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED
-UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITH AGITATION
Further review of Resident #48's medical record showed the PASARR completed on 08/20/24 did not identify Bipolar Disorder.
An interview, on 10/08/24 at 9:20 AM, with the administrator and Director of Nursing (DON) confirmed bipolar disorder was not coded on the PASARR.

Based on record review and staff interview, the facility failed to revise a care plan regarding the discontinuation of an anticoagulant. This was true for one (1) of three (3) residents reviewed under the care area of hospitalizations. Resident Identifier: #74. Facility Census: 124.
Findings Include:
a) Resident #74
On 10/09/24 at 9:30 AM, a record review was completed for Resident #74. The review found a focus area on the care plan noted as Resident is at risk for injury or complications related to the use of anticoagulation therapy lovenox. Upon further review, the anticoagulation medication (Lovenox) was discontinued on 09/29/24. The care plan had not been revised to indicate the Lovenox had been discontinued.
On 10/09/24 at 10:50 AM, the Director of Nursing (DON) confirmed the medication had been discontinued and the care plan had not been revised.

Based on observation, record review and staff interview, the facility failed to maintain an appropriate infection control program for blood glucose monitoring. This was a random opportunity for discovery. Facility Census: 124.
Findings included:
a) Resident #76
On 10/07/24 at 12:06 PM, an observation was made of Registered Nurse (RN) #3 monitoring a blood glucose for Resident #76. RN #3 was not wearing gloves while checking the blood glucose and did not perform hand hygiene prior to or after the blood glucose was obtained. On 10/07/24 at 12:12 PM, an interview was held with RN #3. RN #3 stated, I've been a nurse for a long time, and I never wear gloves when I check blood sugars.
On 10/07/24 at 12:20 PM, the Director of Nursing (DON) and the Administrator were notified. Both the DON and Administrator confirmed RN #3 should be wearing gloves and performing hand hygiene while completing the task of monitoring a blood glucose test.
b) Centers for Disease Control and Prevention (CDC) Guidelines
On 10/07/24 at 12:30 PM, the CDC guidelines were reviewed regarding wearing gloves and blood glucose monitoring. The CDC guidelines state, Wear gloves during blood glucose monitoring and during any other procedure that involves potential exposure to blood or body fluids. Change gloves between patient contacts. Change gloves that have touched potentially blood-contaminated objects or fingerstick wounds before touching clean surfaces. Discard gloves in appropriate receptacles (containers). Perform hand hygiene immediately after removing gloves and before touching other medical supplies intended for use on other persons.
c) Facility Policy
On 10/07/24 at 12:40PM, the facility policy entitled, Personal Protective Equipment was reviewed. Section 6.1 states, Latex-free gloves will be worn when it is reasonably anticipated an employee: 6.1.1 May have hand contact with blood, body fluids, mucus membranes, and/or non intact skin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interview the facility failed to ensure the environment was free of accident hazards. Medicated items were identified to be left out accessible to wandering residents during a complaint survey. This was determined for more than an isolated number of residents identified to be at risk for wandering in the facility. Twenty-five (25) residents were identified to have wandering tendencies. had wandergards. Census: 121.
Findings included:
a) During a tour of the facility on 09/23/24 at approximately 11:45 AM the following rooms were identified to contain items intended for medical use that were readily visible and easily accessible in the residents' rooms as well as numerous personal hygiene items that were not labeled and or stored within reach of wandering residents.
- room [ROOM NUMBER]
Medline Aplicare Hydrogen Peroxide 3% was readily visible and easily accessible on the bed side nightstand. There was not a name marked on the container to identify who it belonged to. Review of the Safety Data Sheet (SDS) provided by the Director of Nursing (DON) revealed under section 2 hazards identification:
Classification of serious eye damage/eye irritation category 2
A Warning. Section f (four) First Aid Measures (typed as written) Eye Contact: Rinse immediately with plenty of water, also under the eyelids, for at least 15 minutes.
Remove contact lenses, if present and easy to do. Continue rinsing. Keep eye wide open while rinsing. Do not rub affected area. Get medical attention if irritation develops and persists. Inhalation: Remove to fresh air. Ingestion: Rinse mouth immediately and drink plenty of water. Never give anything by mouth to an unconscious person. Do NOT induce vomiting. Call a physician.
- room [ROOM NUMBER]
Remedy Anti-fungal Powder was readily visible and easily accessible in a bath basin sitting on the back of the toilet in room [ROOM NUMBER]. There was not a name marked on the bath basin or the bottle to identify who it belonged to. A white powdery substance was identified to be surrounding the area of the container. Review of Material Safety Data Sheet (MSDS) provided by the DON dated 11/08/24 revealed the MSDS identified the health hazards under section 6 (six) as follows (typed as written); Eye contact: Avoid eye contact; Should contact occur, immediately flush eyes with plenty of water for at least 15 minutes. Get medical attention immediately. Inhalation: Could be an inhalation hazard, do not inhale powder. Ingestion: Avoid ingestion; If swallowed, get immediate medical attention or advice. DO NOT INDUCE VOMITING.
Medline Essentials no-rinse foam cleanser (unscented) was readily visible and easily accessible in a pink bath basin sitting on the back of the toilet in room [ROOM NUMBER]. There was not a name marked on the container to identify who it belonged too. A review of the Material Safety Data Sheet provided by the Director of Nursing (DON) identified the first aid measures under section 4 (four) (typed as written): eye contact- rinse immediately with plenty of water. Obtain medical attention if pain, blinking or redness appears; Ingestion- Rinse mouth. Do not induce vomiting. Obtain emergency medical attention if you feel unwell.
- room [ROOM NUMBER]
Orajel mouth sores effective oral pain relief rinse was readily visible and easily accessible on the nightstand. There was not a name marked on the container to identify who it belonged to. A Material Safety Data Sheet was not provided but the following information was listed on the bottle. Warnings: Do not use this product for more than 7 (seven) days unless directed by a dentist or health care provider. When using this product do not swallow- do not exceed recommended dosage. Stop use and see your physician promptly if swelling, rash or fever develops- irritation, pain or redness persist or worsens- sore mouth symptoms do not improve in 7 days. Keep out of reach of children. If more than used for rinsing is accidentally swallowed get medical help or contact a poison control center right away.
- room [ROOM NUMBER]
Medline Essentials no-rinse foam cleanser (unscented) was readily visible and easily accessible in a pink bath basin sitting on the back of the toilet in Rom #103. There was not a name marked on the bottle to identify who it belonged to. During a review of the Material Safety Data Sheet provided by the Director of Nursing (DON) it identified the first aid measures under section 4 (four) (typed as written): eye contact- rinse immediately with plenty of water. Obtain medical attention if pain, blinking or redness appears; Ingestion- Rinse mouth. Do not induce vomiting. Obtain emergency medical attention if you feel unwell.
During an interview with the Corporate Registered Nurse (CRN) #184 on 09/24/24 at approximately 2:30 PM, the CRN stated the medicinal items should not be in the resident's rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure residents received treatemt and care in accordance with professional standards of pratcie, the comprehensive care plan and resident choices.
Resident #49's medication was not available.
Resident #33 did not receive insulin as ordree for elevated blood sugar.
For Resident #125 the facility failed to ensure the residents wishes according to the Physician Orders for Scope of Treatment (POST) forms orders that were followed.
The facility failed to ensure Resident #26's physician orders were followed for skin integrity and fracture stability.
Advanced Directive orders did not match the POST for Resident #71 and Resident #44.
Insulin administration was not documented for Resident #33.
These failed practices had the potential to affect more than a limited number of residents. Resident identifiers: #125, #26, #71, #44, #49 and #33. Facility census: 129.
Findings included:
a) Resident #49
During medication pass observation on [DATE] at 8:53 AM, Licensed Practice Nurse (LPN) #105 could not locate Tizanidine HCl 2 mg tablet. LPN #105 stated, Oh yea that's right [Nurse Practitioner first name] told me I could hold it if it wasn't here from the pharmacy yet.
Review of the Resident's Medication Administration Record (MAR) showed the Tizanidine HCl 2 mg Tablet medication was documented as a missed dose for three (3) consecutive days: [DATE], [DATE], and [DATE].
Record review showed an order for Tizanidine HCl Tablet 2 MG. Give 1 tablet by mouth one time a day for muscle spasms Vaseco 1mg (2 tabs) .
Electronic Medication Administration Record Note dated [DATE] at 8:53 AM stated: Waiting on pharmacy holding Tizandine until arrival. NP notified.
General Note dated [DATE] at 6:08 PM stated: Called pharmacy about resident's tizanidine. Pharmacy stated prescription can be sent out on tomorrow's run to facility on [DATE].
Electronic Medication Administration Record Note[DATE] at 8:58 AM stated: Tizanidine HCl Tablet 2 MG Give 1 tablet by mouth one time a day for muscle spasms waiting on pharmacy. NP notified holding until arrival.
Electronic Medication Administration Record Note dated [DATE] at 10:00 AM stated: TiZANidine HCl Tablet 2 MG Give 1 tablet by mouth one time a day for muscle spasms waiting on pharmacy. NP notified.
On [DATE] at 3:47 PM during an interview with the Director of Nursing (DON) stated not having the medication available for administration was probably a pharmacy issue. The pharmacy was having staffing issues. The DON stated, I call them every day now and check on the orders., We used to get them from [local town] but now they come from [another location] two (2) hours away. We are working on it
b) Resident #33
On [DATE] at 6:03 PM, a record review was completed. There was the following physician order, dated [DATE] at 11:30 AM:
Insulin Lispro MUV
100 Unit/1 ML Vial
Inject as per sliding scale:
141-160 = 1 Unit;
161-180 = 2 Units;
181-200 = 3 Units;
201-220 = 4 Units;
221-240 = 5 Units;
241-260 = 6 Units;
261-280 = 7 Units;
281-300 = 8 Units;
301-320 = 9 Units;
321-340 = 10 Units;
341-360 = 11 Units;
361-380 = 12 Units:
381-400 = 13 Units;
>400 Notify Provider
The [DATE] Medication Administration Record (MAR) revealed Resident #33's blood sugar level was 435 on [DATE] at 5:00 PM. Documentation on the MAR did not reflect that insulin had been administered. Coding on the MAR was NN. The chart code for NN was listed as No/See Nurse Note.
During an interview on [DATE] at 9:45 AM, the interim DON acknowledged the MAR did not reflect that any medication had been given.
Based on observations, record review and staff interview, the facility failed to provide care/treatment services in accordance with professional standards of practice. For Resident #125 the facility failed to ensure the residents wishes according to the Physician Orders for Scope of Treatment (POST) forms orders that were followed. The facility failed to ensure Resident #26's physician orders were followed for skin integrity and fracture stability. Advanced Directive orders did not match the POST for Resident #71 and Resident #44. The facility failure to ensure medication was available for administration for Resident #49. Insulin administration was not documented for Resident #33. These failed practices had the potential to affect more than a limited number of Residents. Resident identifiers: Resident #125, Resident #26, Resident #71, Resident #44, Resident #49 and Resident #33. Facility Census: 129.
Findings Include:
a) Resident #125
During a record review on [DATE] at 2:58 PM, Resident # 125's medical record revealed an admission date [DATE] and the Resident expired on [DATE].
Resident #125's POST form dated and signed by Resident #125 on [DATE]. Section A titled: Cardiopulmonary Resuscitation Orders was coded CPR. Section E titled: Signature was not coded for authorization of changes.
Further record review revealed a Physician Determination of Capacity dated [DATE] coded has capacity by the physician.
Further record review revealed a Nurse Practitioner Encounter Note Date [DATE] typed as written DNR. COMFORT INTERVENTIONS - HD ONLY AS TOLERATED/NO BLOODWORK. NO IVF. NO TF. - Other Directive (Current and Verified) [DATE]
The 2021 POST form guidance titled, Using the POST Form: Guidance for Health Care Professionals, 2021 edition, available on-line, stated The authorization section, when selected by the patient, authorizes the patient ' s Medical Power of Attorney representative to update the patient's POST form (by completing a new form) in accordance with the patient's expressed wishes and health care status in the event the patient becomes incapacitated. This box can only be authorized by the patient whilst they have decision-making capacity. This section is optional.
During an interview on [DATE] at 3:55 PM, the Administrator acknowledged the POST should not have been changed at the end of life.
b) Resident #26
During a record review on [DATE] at 1:32 PM, Resident #26's medical record revealed a physician order dated [DATE] Prevalon Boots to the BLE(bilateral lower extremities), licensed nurse to remove and assess skin integrity every day and night.
Further record review revealed a Physician order dated [DATE] TLSO (Thoracic-Lumbar-Sacral Orthosis) brace to be worn while OOB (out of bed)
Observations of Resident #26's Prevalon Boots and/or TLSO brace made throughout the LTCSP were as follows:
-[DATE] at 2:01 PM, Resident sitting in a geri chair in the lounge not wearing boots or back brace.
-[DATE] at 11:15 AM, Resident sitting a geri chair in the lounge area not wearing boots or back brace
-[DATE] at 11:42 AM, Resident sitting a geri chair in the dining area not wearing boots or back brace
-[DATE] at 1:20 PM, Resident sitting a geri chair in the lounge area not wearing boots or back brace
-[DATE] at 9:20 PM, Resident was lying in bed not wearing boots.
-[DATE] at 12:00 PM,Resident sitting a geri chair in the lounge area not wearing boots or back brace.
During an interview on [DATE] at 3:14 PM, Clinical Operation Lead (COL) #164 was informed of the Resident #26 not wearing the Prevalon boots and/or the TLSO brace.
On [DATE] at 3:17 PM, the COL #164 accompanied this Surveyor to Interview Licensed Practical Nurse (LPN) #127
LPN #127 was asked by the COL #164 clarify the orders: is the TLSO brace when she is out of bed and the Prevalon Boots when she is in bed?
LPN stated The Boots day and night and the TLSO when out of bed.
This surveyor and the COL #164 went Resident #26's room where she was lying in bed. Resident #26 was not wearing the Prevalon Boots. The COL #164 and LPN #127 searched Resident #26's room The Prevalon Boots and the TLSO brace. The COL #164 found one (1) of the Prevalon boots hidden in the bottom of the closet. The COL #164 found the TLSO brace behind the residents' clothing in the closet.
LPN stated (Resident #26 name) had them on yesterday
An immediate interview the COL #164 acknowledged the physician orders were not being followed.
The facility failed to provide care/treatment services in accordance with professional standards of practice.
PS- TB
a) #125 - TB
POST form
b) #26 - TB
Did not follow physician's order
c) #71 - TM
2 Advanced Directive Orders did not match POST form
d) #44 - TM
Advanced Directive Order did not match POST form
e) #49 - BC
Facility did not have medication for three (3) consecutive days.
f) #33 - RG
Did not document insulin was administered on MARS when BS was above 400
Resident #26
Position, Mobility
[DATE] 2:01 Pm No boots Prevalon BOOTS TO BLE LICENSED NURSE TO REMOVE AND ASSESS SKIN INTEGRITY
every day and night shift
Other
Active
[DATE] 19:00
[DATE]
TLSO brace to be worn while OOB.
No directions specified for order.
Other
Active
[DATE]
PUT IN ORdERS
[DATE] at 2:01 no boots or back brace in gerichair. lounge
[DATE] at 11:15Am no boots or back barace gerichair lounge
[DATE] at 11:42 no boots or back brace in dining room
[DATE] at 1:20PM no boots or back brace in gerichair lounge
[DATE] at 9:20PM no boots or brace in bed
[DATE] at 12:00 PM no boots or brace in gerichari lounge area.
[DATE] at 3:14 Pm [NAME] was informed of the no boots and back brace
[DATE] at 3:17 PM [NAME] Brewer was interviewed by the Coroprate RN and this surveyor, Bacj Brace is when she is oob and the boots while she is in beds.
DUring a room visit with the Resident # 26 revealed no boots or brace had on. Coroprate nurse and [NAME] searched room for the brace and the boots. The corprtate RN found one boot hid in the bottom of the closet. the back brace was hid behind the resdients clothing in the closet.
Breweer stated she had it yesterday.
[NAME] acknowledge the physiin orders were not being followed.
Resident #125
Death
Based on record review and staff interview, the facility failed to provide care/treatment services in accordance with professional standards of practice. For Resident #125 the facility failed to ensure the residents wishes according the Physician Orders for Scope of Treatment (POST) forms orders were followed. The facility failed to ensure Resident #26 physician orders were followed for the Prevalon Boots and Thoracic- Lumbar-Sacral Orthosis (TLSO) brace. These failed practices had the potential to affect more than a limited number of Residents. Resident identifiers: Resident #125. Facility Census: 129.
Findings Include:
a) Resident #125
During a record review on [DATE] at 2:58 PM Resident # 125's medical record revealed admission date [DATE] and expiration on [DATE].
Resident #125's POST form dated and signed by the resident on [DATE]. Section A titled: Cardiopulmonary Resuscitation Orders was coded CPR. Section E titled: Signture was not coded for authorization of changes.
Further record review revealed a Physician Determination of Capacity dated [DATE] has capacity by the physician.
Further record review revealed a Nurse Practitioner Encounter Note Date [DATE] read as typed DNR. COMFORT INTERVENTIONS - HD ONLY AS TOLERATED/NO BLOODWORK. NO IVF. NO TF. - Other Directive (Current and Verified) [DATE]
The 2021 POST form guidance titled, Using the POST Form: Guidance for Health Care Professionals, 2021 edition, available on-line, stated The authorization section, when selected by the patient, authorizes the patient's Medical Power of Attorney representative to update the patient's POST form (by completing a new form) in accordance with the patient's expressed wishes and health care status in the event the patient becomes incapacitated. This box can only be authorized by the patient whilst they have decision-making capacity. This section is optional.
[DATE] at 3:55 PM [NAME] acknowledge the POSt should not have been changed
f) Resident #44
-On [DATE] at 1:54 PM a review of Resident # 44's medical record found a active physician's order for cardiopulmonary resuscitation (CPR), full code, full interventions with intravenous fluids (IVF) for two (2) weeks, no tube feeding (TF).
The Physician's Order for Scope of Treatment (POST) form indicating Resident # 44 was to receive CPR, IVF without a stop date and a feeding tube long term.
On [DATE] at 2:50 PM an interview with the facility Administrator was completed. The Administrator acknowledged the physicians order should have been discontinued with a new order entered for CPR, IVF and a feeding tube as needed to match the current POST form.
g) Resident #71
On [DATE] at 2:16 PM, a review of Resident #71's medical record found two (2) active physician orders for advance directives which were conflicting:
-Advanced Care Planning-Goals of Care: Refer to state form CPR (cardiopulmonary resuscitation) Full interventions IVF (intravenous fluids) no TF (tube feeding).
Dated [DATE]
-DO NOT RESUSCITATE (DNR) Comfort interventions, No feeding tube. Dated [DATE]
Further review of Resident #71's medical record on [DATE] at 2:26 PM noted the care plan indicated Resident #71 was a full code with full interventions, intravenous fluids and no tube feeding.
At 02:50 PM on [DATE] the Administrator acknowledged the correct active physician order was for Do Not Resuscitate, and that the previous order should have been discontinued and the care plan updated to reflect the do not resuscitate correct active physician order.

Based on observation, and staff facility failed to ensure the environment was free of accident hazards. Resident #41's medication was left unattended in Resident room. A treatment cart and mediation cart were found unlocked and unattended. This failed practice was a random opportunity for discovery and had the potential affect more than a limited number of residents. Resident identifier: #41. Facility census: 129.
Findings included:
a) Resident #41
On 04/08/24 at 1:11 PM, Surveyor observed a Spiriva inhaler on Resident #41's over the bed table. Resident #41 stated, The nurse left it here this morning. It's probably not supposed to be here, they usually take it with them. Charge Nurse Supervisor Registered Nurse (RN) #9 answered call light and verified the medication in the room belonged to Resident #41 and removed it. RN #9 stated, I wasn't the one the one passed medications this morning and left it here, but I'll take it and put it up. RN #9 verified the Resident did not have an order for the inhaler to be left at bedside.
Record review showed an order for Spiriva Handi-Haler Inhalation Capsule 18 MCG (Tiotropium Bromide Monohydrate). 1 puff inhale orally one time a day for COPD.
Resident had capacity as of 04/16/22.
b) Unlocked Medication Cart
On 04/15/24 at 11:15 AM, Surveyor observed the medication cart on the 300 Hall was unlocked and unattended. Surveyor remained with the unlocked cart until LPN #28 appeared. LPN #28 confirmed the cart was unlocked and stated, I'm sorry. I've had a problem with it locking. Then locked the med cart in front of Surveyor.
The Administrator noted on 04/15/24 at 11:20 AM, He is one of our newer nurses. We will re-educate him promptly.
c) Treatment Cart
On 04/09/24 at 9:30 PM surveyor observed treatment cart by South Nurses Station unlocked. Surveyor remaint by treatment cart till Licensed Practical Nurse (LPN) #106 came and locked it.
At 9:34 PM on 04/09/24 LPN #106 stated oh sorry about that and locked the treatment cart.

Based on staff interview and record review, the facility failed to ensure monthly Medication Regimen Reviews (MRR) were being reviewed/signed by the attending physician. This was true for one (1) of five (5) residents reviewed in the unnecessary medication review pathway during the Long-Term Care Survey Process. Facility Census: 129. Resident identifier: #6
Findings included:
a) Resident #6
On 04/15/24 at 11:59 AM, a record review revealed the pharmacist had completed a monthly medication regimen review for Resident #6 on 12/26/23 with the following recommendation, Please reassess the existing A1C goal, and if appropriate, initiate Januvia 25 mg PO (by mouth) daily. Close monitoring (e.g., glucose) should accompany any change in diabetic therapy and guide further adjustments. Treatment intensification is recommended for those individuals not meeting therapy goals, to avoid the consequences of prolonged hyperglycemia. There was no evidence the physician had reviewed and acted on the recommendation. The attending physician did not sign the MRR for 12/26/24.
During a staff interview on 04/15/24 at 12:01 PM, the Clinical Operation Lead #164 confirmed the MRR was not signed by the doctor for the MRR done on 12/26/23.

Based on resident interview, staff interview, and record review the facility failed to obtain routine and/or emergency dental services for Resident #75. This failed practice was found true for (1) one of (4) four residents during the Long-Term Care Survey Process. Resident identifier #75. Facility Census 129.
Findings Include:
a) Resident #75
During an interview on 04/08/24 at 2:00 PM, Resident # 75 indicated to the surveyor that she had a loose tooth.
A record review on 04/10/24 at 2:08 PM revealed that Resident # 75 has an active order dated 02/07/24 for a dental referral for loose cap to upper front tooth
Further record review showed no referral to the dentist had been made.
During an interview on 04/10/24 at 9:30 AM, the Interim Director of Nursing (IDON) stated, I'm not going to lie to you, there is not a dental referral in (Resident #75 name's) chart. I will get her an appointment made.

Based on observation, and staff interview the facility failed to maintain appropriate infection control procedures during medication pass for Resident #49. This failed practice was a random opportunity for discovery and had the potential to affect a limited number of residents. Resident identifier: #49. Facility census: 129
Findings included:
a) During medication pass observation, on 04/10/24 at 8:54 AM, Licensed Practice Nurse (LPN) #105 removed the following pills from blister pack with ungloved hand and touched the medication with bare fingers. LPN #105 had been opening medication cart doors and touching over the counter pill bottles with her bare hands prior to removing the pills from blister pack and placing them into a plastic medicine cup to be administered to Resident #49:
Gabapentin 100 mg (milligram) capsule
Lisinopril 2.5 mg tablet
Oyster Shell 500/200 mg tablet
On 04/10/24 at 10:01 AM the administrator was informed of the infection control issue observed by surveyor. The Administrator stated, This surprises me, she [LPN #105] told me med pass went well. So she gave dirty pills? That just common-sense stuff, they know not to handle the pills with soiled bare hands.

Based on record review and staff interview the facility failed to revise the care plans for two (2) of 38 residents when their needs changed. Resident #71's care plan was not revised to reflect pain management. Additionally, the facility failed to include Resident #44's delusional disorder diagnosis in her care plan. Resident identifiers: #71 and #44. Facility census: 129.
Findings included:
a) Resident #44
On 4/08/24 at 1:50 PM a review of Resident #44's medical record noted a diagnosis of delusional disorder added on 04/21/20.
A record review of Resident # 44's care plan revealed the facility failed to revise the interventions when a change occurred.
On 4/10/24 at 11:01 AM an interview with the Social Worker #154 was completed. Social Worker #154 acknowledged Resident #44's PASRR was incorrect and had not been completed prior to readmission to facility from hospitalizations with a diagnosis of delusional disorder and that the care plan had not been revised to reflect changes.
b) Resident #71
-On 4/08/24 at 12:32 PM an interview was conducted with Resident #71. Resident #71 stated, My back hurts sometimes, I take pain pills, sometimes it helps.
-On 4/10/24 at 1:02 PM a follow up interview was conducted with Resident #71. Resident #71 stated, I have been having quite a bit of pain, I tell the certified nursing assistants (CNA'S), they tell me they have to tell someone else and leave, then the nurse never comes back Resident # 71 rated her pain 10/10 at the time of this interview.
-On 4/10/24 at 1:10 PM a review of Resident #71's medical record revealed the care plan focus failed to include and address the resident's goals for pain relief, failed to address a diagnosis of cancer with a chest mass and lymph node involvement that was worsening and a recent code status change from full code to do not resuscitate with comfort measures, no tube feeding. The goal failed to include input from Resident #71 related to her goals for treatment, with the interventions having last been updated or revised on 06/01/22. Resident #71 had a recent change related to her pharmacological pain interventions on 04/10/24. A review of Resident #71's active physician's orders noted an order for Tylenol 350mg two (2) capsules by mouth two times a day for generalized pain.
-On 4/10/2024 at 1:20 PM the Clinical Operations Lead Registered Nurse (RN) #164 accompanied the surveyor and another surveyor to interview Resident #71 . When questioned by RN #164, Resident #71 stated that she was currently in pain, rating her pain a 9/10. RN#164 failed to ask Resident #71 what her goal for pain relief was, which was not addressed on the care plan. The surveyor asked the resident what her pain goal was. Resident #71 stated her pain goal was 0/10. RN #164 asked Resident #71 if she thought repositioning would help with her pain. Resident #71 responded, They have moved me all around this bed, nothing helps. RN#164 responded the nurse practitioner (NP) was in the building and she would have the NP come in and see her.
- On 4/15/24 at 1:07 PM during an interview with the facility Clinical Reimbursement Coordinator (CRC) #3, the CRC acknowledged the care plan has not been updated or revised to reflect Resident #71's goals and recent changes.

Based on record review, resident interview, and staff interview, the facility failed to ensure that all alleged violations involving verbal abuse were reported to the appropriate state agencies. This was true for one (1) of five (5) residents reviewed under the abuse pathway in the Long-Term Care Survey Process. Resident identifier: 95. Facility census: 129.
Findings included:
a) Resident #95
Review of the facility grievance log, completed on 04/09/24 at 9:30 AM, found a grievance dated 01/15/24. Review of the grievance form revealed, Nurse informed resident that she had an odor and that she needed a shower in front of her friends. Actions taken to investigate the grievance were listed as, NHA (Nursing Home Administrator) and DON (Director of Nursing) addressed and interviewed those around and the CNA (Certified Nursing Assistant) that was around. Corrective action taken was to re-educate the nurse with an individual performance improvement plan (IPIP). The description of event on the IPIP was listed as, Resident had complaint that she was addressed in front of other residents in regards to smelling and needing a shower. As part of the re-education the facility's employee handbook Policy Group A #4 was referenced: Treating residents/patients in a disrespectful or unprofessional manner. The IPIP referenced, Re-education by DON (Director of Nursing) or designee in regard to appropriate bedside manner and resident rights. Explaining providing privacy for private conversations including need for shower/hygiene.
During an interview on 04/15/24 at 12:03 PM, Resident #95 stated she recalled a time several months ago when Nurse #9 humiliated her in front of friends in the hallway by discussing her need to take a shower and her poor hygiene. Resident stated she knew that Resident #69 was present when the incident happened because she could remember Resident #69 saying, I don't believe she said that to you! Resident stated the nurse should have never approached her in public. She went on to say she reported the incident to the Administrator who addressed it to her satisfaction and that the nurse had apologized to her.
Resident #69 was interviewed on 04/15/24 at 12:25 PM. Resident #69 reported she also remembered the incident when Nurse #9 spoke to Resident #95 in front of everyone. She stated, It was not nice for the nurse to talk to her like that. It was very derogatory. A bunch of us was sitting there. It was very embarrassing. We are adult human beings. We don't need to be treated like that.
On 04/15/24 at 2:00 PM a record review was completed. Review of the facility's Abuse Prohibition Policy, with a revision date of 10/24/22, revealed the following definition for mental abuse, Mental abuse includes, but is not limited to humiliation, harassment, and threats of punishment or deprivation. Mental abuse may occur through either verbal or nonverbal conduct which causes or has the potential to cause the patient to experience humiliation, intimidation, fear, shame, agitation, or degradation.
Review of the facility's state reportable log, completed on 04/15/24 at 3:03 PM, did not reflect the incident had been reported to the appropriate state agencies as alleged verbal abuse.
During an interview on 04/16/24 at 10:47 AM, the Administrator confirmed the incident had not been identified as an allegation of verbal abuse and had not been reported to appropriate state agencies. The Administrator explained, She never used those words with me.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to complete a new Pre-admission Screening and Resident Review (PASARR) for residents with newly evident or a possible serious mental disorder. This was true for three (3) out of seven (7) residents reviewed under the category of PASARR, during the Long-Term Care Survey Process. Resident identifiers: #49, #44, and #81. Facility census: 129.
Findings included:
a) Resident #49
A record review, completed on 04/10/24 at 10:44 AM, revealed Resident #49 had been admitted to the facility on [DATE]. Review of resident's diagnoses revealed a Bipolar diagnosis with an effective/active date of 09/09/21.
There was only one (1) PASARR, dated 11/20/2018, on file. Section III MI/MR Assessment Question #30 identified Schizophrenia and Major Depression. There was no evidence a new PASARR had been done when the Bipolar diagnosis was given.
During an interview, on 04/10/24 at 11:30 AM, Social Worker #154 reported there was not a new PASARR on file that addressed Resident #49's bipolar diagnosis.
c) Resident #81
On 04/09/24 at 11:14 AM a record review of Resident #81's Preadmission Screening and Resident Review (PASARR) did not have Bipolar disorder or Post Traumatic Stress Disorder (PTSD) marked on the PASRR.
Staff interview conducted on 04/09/24 at 12:00 PM with Administrator, who confirmed the PASARR did not have PTSD or Bipolar Disorder marked.
On 04/09/24 at 12:22 PM Social Worker #154 states she is working on doing all new PASARR's for the facility.
The facility failed to complete a new Pre-admission Screening (PAS). Resident identifiers: #49, #44, #81
PS - RB
a) 49 - RG
b) 44 - TM
c) 81 - BH
Resident #81
PASARR
Facility failed to ensure PASARR was completed after admission with scitzo diagnosis
04/10/24 10:16 AM MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, UNSPECIFIED
Medical Management
10/9/2021
BIPOLAR DISORDER, UNSPECIFIED
Medical Management
10/9/2021
POST-TRAUMATIC STRESS DISORDER, UNSPECIFIED
Medical Management
11/7/2023
Based on record review and staff interview, the facility failed to complete a new Pre-admission Screening and Resident Review (PASARR) for residents with newly evident or a possible serious mental disorder. This was true for three (3) out of seven (7) residents reviewed under the category of PASARR, during the Long-Term Care Survey Process. Resident identifiers: #49, #44, and #81. Facility census: 129.
Findings included:
a) Resident #44
On 4/08/24 at 1:50 PM a review of Resident # 44 medical record revealed a Preadmission Screening and Resident Review form (PASRR) was completed on 08/01/19. A diagnosis of delusional disorder added on 04/21/20. It was noted Resident #44 was hospitalized on two (2) occasions. The facility failed to complete a new PASRR with the diagnosis of delusional disorder upon Resident # 44's readmission to the facility. A record review of Resident # 44's care plan revealed the facility failed to revise the interventions when a change occurred.
On 4/10/24 at 11:01 AM and interview with the Social Worker Employee #154 was completed. Employee # 154 acknowledged Resident # 44 PASRR was incorrect and had not been completed prior to readmission to facility from hospitalizations with a diagnosis of delusional disorder and that the care plan had not been revised to reflect changes.

Based on medical record review and staff interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessments for three (3) of 38 residents reviewed during the Long-Term Care Survey (LTCSP). Resident Identifiers: Resident #126, Resident #124 and Resident #116. Facility Census: 129.
Findings Include:
a) Resident #126
During a record review on 04/10/24 at 10:15 AM, Resident # 126's medical records revealed a discharged date on 02/20/24.
Further record review revealed a general note dated 02/20/24 typed as written D/c (discharge) packet reviewed with resident.
A Social Services (SS) note dated 02/20/24 Typed as written SS referred resident to(local) HH Home health)and ordered her a walker from (a medical supply company). A walker from the center was sent home with the resident and (a medical supply company) will deliver her new walker to her house.
Further medical records review the MDS with an Assessment Reference Date (ARD) 02/20/24 Section A2105 titled Discharge Status: coded 04: Short Term General Hospital.
During an interview on 04/10/24 at 2:57 PM, the Administrator acknowledged the MDS was coded incorrectly, the resident was discharged home.
b) Resident #124
During a record review on 04/10/24 at 10:00 AM, Resident #124's medical record revealed a nurse note dated 01/14/24 Transfer to emergency room due to clinical acuity
Further medical records review the MDS with an Assessment Reference Date (ARD) 01/14/24 Section A2105 titled Discharge Status: coded 01: Home/Community.
During an interview on 04/10/24 at 1:08 PM Administrator acknowledged the MDS was coded incorrectly.
During an interview on 04/10/24 at 2:57 PM, the Administrator acknowledged the MDS was coded incorrectly and the resident was sent to the hospital not discharged home.
c) Resident 116
An observation on 04/08/24 at 1:18 PM, of Resident #116's lunch tray in front of her showed Resident #16 had not taken a bite of her food.
During A record review on 04/08/24 at 3:00 PM, of Resident #116's medical record revealed the following weights:
04/5/24 8:39 AM, 80.6 P pounds (Lbs) with Mechanical Lift (ML)
03/27/24 4:18 PM, 80.8 Lbs with Wheelchair (WC)
03/20/24 5:37 PM, 82.4 Lbs with WC.
03/13/24 5:26 PM, 85.4 Lbs with WC.
03/6/24 9:06 PM, 84.4 Lbs with WC.
02/29/24 9:22 PM, 82.4 Lbs with WC.
02/19/24 3:44 PM, 84.4 Lbs with WC.
02/13/24 9:58 AM, 86.4 Lbs with WC.
01/18/24 8:29 AM, 90.0 Lbs with WC.
01/12/24 8:18 AM, 92.4 Lbs with WC.
01/3/24 9:24 AM, 94.8 Lbs with WC.
12/29/23 7:39 PM, 89.9 Lbs with ML.
12/21/23 10:49 PM, 92.4 Lbs with ML.
12/20/23 6:59 AM 92.4 Lbs admission weight.
The weights equaled a 12.5% weight loss in 3.5 months.
Further record review showed that the last quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/27/24, section K, question K0300, is marked no for weight loss of 5% or more in the last month or loss of 10% or more in last 6 months.
During an interview on 04/15/24 at 12:37 PM the Clinical Reimbursement coordinator (CRC) #3 stated, I do not do that section, it is the Dietician. I agree, It does indicate no weight loss. I will get that fixed.
During an interview on 04/15/24 at 1:18 PM the Registered Dietician (RD) stated, I was told not to do it that way if they have not been here 6 months. According to my people they told me not to mark it as weight loss if the resident had not been here the full 6 months, because we were having too much weight loss doing it that way.

Based on record review and staff interview, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form to two (2) of three (3) residents reviewed for the facility's beneficiary protection notification practice during an annual survey. This failure placed residents at risk of not being informed of their rights prior to the end of Medicare Part A covered services. Resident Identifiers: #28 and #19. Facility census: 129
Findings included:
a) Beneficiary Notice Review
On 04/10/24 at 2:22 PM, a review was completed regarding the beneficiary protection notification liability notices given for the following two (2) residents who remained at the facility following their last covered day of Medicare Part A services:
- Resident #28 began Medicare Part A skilled services on 10/18/23. The last covered day of Part A service was 11/10/23. Notice of Medicare Non-Coverage (NOMNC) was signed and dated on 11/08/23. There was no evidence a SNF ABN form had been provided and signed.
- Resident #19 began Medicare Part A skilled service on 02/20/24. The last covered day of Part A Service was 03/21/24. NOMNC was signed and dated on 03/19/24. There was no evidence a SNF ABN had been provided and signed.
Review of Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice on Non-coverage (SNF ABN) Form CMS-10055 (2018) denoted Medicare requires Skilled Nursing Facilities to issue the SNF ABN to Medicare beneficiaries prior to providing care that Medicare usually covers, but may not pay for because the care is:
- not medically reasonable and necessary; or
- considered custodial.
In an interview on 04/10/24 at approximately 2:33 PM, the Administrator acknowledged the facility failed to provide SNF ABN forms to Resident #28 and Resident #19 prior to their last covered day of Medicare Part A skilled services.

Based on record review and staff, the facility failed to effectively evaluate pain level and effectiveness for pain medication given for two (2) of five (5) residents reviewed for pain. This failed practice had the potential to affect more than a limited number of residents. Facility census: 129 Resident identifiers: #71 and #81.
Findings included:
a) Resident #81
Record review on 04/15/24 at 03:12 PM revealed Licensed Practical Nurse (LPN) #28 signed out an oxycodone 5-325 tablet at 9:56AM on the controlled medication utilization record. The medication was documented on the Resident's Medication Administration Record (MAR) as administered.
Further record review on 04/15/24 at 03:20 PM revealed no documentation showing the effectiveness of the pain medication that was signed out at 9:56 AM given was completed by LPN #29
On 04/15/24 at 3:20PM Clinical Operation Lead (COL) #164 confirmed effectiveness of the pain medication given was not completed by LPN #28.

Based on observation and staff interview, the facility failed to maintain appropriate infection control standards during the medication administration. These were random opportunities for discovery. Facility Census: 119.
Findings Included:
a) Hand Hygiene
On 10/11/23 at 8:09 AM, Licensed Practical Nurse (LPN) #80 was observed during medication administration. LPN #80 was observed touching the trash can lid on the medication cart three times without completing hand hygiene. LPN #80 was notified of the multiple observations. LPN #80 stated I'm sorry.
On 10/11/23 at 9:00 AM, the Director of Nursing (DON) and the Administrator were notified of the observations. The DON stated, thank you for letting me know.
b) Barrier Use
On 10/11/23 at 8:25 AM, LPN #90 was observed during medication administration. Resident #100 was ordered topical Biofreeze to the bilateral knees and a Flovent inhaler. Upon entering the resident room, LPN #90 placed a barrier on the over-the-bed table. After administration of the medication, LPN #90 placed the inhaler box and the roll-on Biofreeze directly on the over-the-bed table. LPN #90 was notified of the observation. LPN #90 stated, I'm sorry I was nervous.
On 10/11/23 at 9:00 AM, the Director of Nursing (DON) and the Administrator were notified of the observations. The Administrator stated, no barrier used
c) Medication Cart
On 10/11/23 at 8:40 AM, the North 300 medication cart was checked. The check found a large personal use styrofoam cup with ice and liquid inside in the bottom drawer of the medication cart. LPN #90 stated, I'll get rid of it.
On 10/11/23 at 9:00 AM, the DON and the Administrator were notified. The Administrator confirmed the large personal use styrofoam cup should not be on the cart. The Administrator stated, thanks for letting me know
No further information was obtained during the survey process.

Based on record review and staff interview the facility failed to ensure the physician to provide an appropriate rationale, for refusing to do a Gradual Dose Reduction (GDR). This was true for one (1) out of five (5) reviewed for unnecessary medications. Resident identifier: #84. Facility census 119.
Findings included:
a) Resident #84
A review of the medical records for Resident #84 found Resident #84 received the following psychotropic medications; Latuda, Fluoxetine, and Trazodone.
A recent GDR for Trazodone on 09/22/23 from the pharmacist, was refused by the facility Nurse Practitioner (NP). The NP wrote as a rationale, due to continued symptoms earlier this month.
However, a review of the MAR (medication administration record) found the order for monitoring for behaviors and depression, were all marked NO by the nursing staff. This was true for the months of September and October.
During an interview with the Director of Nursing (DON) on 10/11/23 at 3:21 PM. The DON was shown the rationale for the GDR for the Trazodone, and the MAR that the nurses marked all NO.
DON was asked if there was any other documentation that indicated continued use of the Trazodone.
On 10/12/23 at 12:23 PM, the DON said there were no assessments or notes stating Resident #84 experienced any worsening symptoms of mood and behaviors of depression.
No other information was provided before the conclusion of this survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure adequate monitoring for efficacy and adverse consequences was provided for the use of psychotropic medications for four (4) of five (5) Residents reviewed for the care area of unnecessary medications. Resident identifiers: #112, #84, #80 and #103. Facility census: 119.
a) Resident #112.
Record review found the resident was admitted to the facility on [DATE]. Active diagnoses included: Schizophrenia, Anxiety, Dementia, and Depression.
Review of the Medication Administration Record (MAR) found the resident was receiving Seroquel an antipsychotic medication, Lorazepam an antianxiety medication, and Prozac an antidepressant medication.
Review of the Medication Administration Record (MAR) found the facility listed Behavior Observations (Beh. O) for the use of Seroquel and Lorazepam by coding a Yes or No answer. The specific behaviors exhibited by the resident to warrant the use of the medications were not listed on the MAR. In addition, the facility did not monitor for any behviors for the use of the antidepressant, Prozac.
On 10/11/23 at 2:44 PM, the Director of Nursing (DON) said she needed to put the targeted behaviors exhibited by the resident to warrant the use of the psychotropic medication somewhere the nurses could look at before answering the question yes or no to note if the Resident had any behaviors. The DON confirmed nursing staff currently have no way to know what behaviors to monitor for.
b) Resident #84
Review of the Medication Administration Record (MAR) found the facility monitored behaviors for the use of Latuda for bipolar disorder, Fluoxetine for depression, and Trazodone for depression by coding a Yes or No answer. The order for monitoring was void documentation of symptoms to continue the need of the medications. No specific types of behaviors were listed for each of the medications mentioned to warrant the continued use of the medications; for that reason, the medication was unable to be evaluated for effectiveness.
On 10/11/23 at 2:55 PM the Director of Nursing (DON) agreed the current way for monitoring for the effectiveness of the psychotropic medications were not specific enough. The DON stated she will add to the MAR a list of mood and behaviors to look for.
Care Plan for Resident #84:
Resident #84 is at risk for complications related to the use of psychotropic drugs: Latuda, fluoxetine, trazodone.
Resident will have the smallest most effective dose without side effects through the next review.
AIMS testing per protocol
Complete behavior monitoring flow sheet
Gradual dose reduction as ordered
Monitor for changes in mental status and functional level and report to MD as indicated
Monitor for continued need of medication as related to behavior and mood.
Monitor for side effects and consult physician and/or pharmacist as needed
Findings included:
d) Resident #103
Resident #103 was admitted on [DATE] with active diagnoses including Alzheimer's disease, dementia with mood disturbances and major depressive disorder.
Review of the current orders and the Medication Administration Record (MAR) found the resident was receiving Trazadone 50 milligrams (mg) every night (HS) for depression, Lexapro 5 mg daily for depression, and Rexulti 0.5 mg every HS for dementia with behaviors.
Review of the MAR found the facility monitored behaviors for the use of Trazadone, Lexapro and Rexulti by coding a Yes or No answer. The specific behaviors exhibited by the resident to warrant the use of the medications were not listed; therefore, the medication was unable to be evaluated for effectiveness of behaviors.
This was confirmed with the Director of Nursing on 10/16/23 at 12:16 PM.
c) Resident #80
On 10/12/23 at 10:00 AM, a record review was completed for Resident #80. The review found the resident was taking an anti-psychotic medication (Seroquel) for schizophrenia. The Medication Administration Record (MAR) was reviewed and found a physician's order for Quetiapine (Seroquel) 25mg (milligram) three (3) tablets by mouth at bedtime for anxiety/depression/schizophrenia. The physician's order included a question regarding behavior, Yes or No. However, the physician's order did not include any specific behaviors to monitor.
On 10/12/23 at 11:17 AM, the Director of Nursing (DON) was notified and confirmed there were no specific behaviors listed to monitor.
No further information was obtained during the survey process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to dispose of expired over-the-counter (OTC) medications stored in the medication room. This was a random opportunity for discovery. Facility Census: 119.
Findings Included:
a) Medication Room
On [DATE] at 8:45 AM, a tour of the North medication room was conducted. Upon completion of the tour, three (3) OTC bottles of medication were found to be expired. The following is a list of the medication:
--Fiber Powder which expired 08/23
--Multivitamins which expired 06/23
--Aspirin 81mg (milligram) which expired 05/23
On [DATE] at 8:48 AM, Licensed Practical Nurse (LPN) #90 confirmed the three (3) bottles of medication were expired.
On [DATE] at 9:00 AM, the Director of Nursing (DON) and the Administrator were notified. The DON stated, we will get rid of those
No further information was obtained during the survey process.

Based on observation, medical record review and staff interview the facility failed to provide a specialized cup, a two (2) handled spouted cup for a resident at meal time. This was a random opportunity for discovery. Resident Identifiers: Resident #25. Facility Census: 119.
Findings Included:
a) Resident #25
During medical record review on 10/12/23 at 9:56 AM Resident #25 medical records revealed a physician ordered dated 06/28/23. Dysphagia Puree texture large portions all meals/ add exception for soft sandwiches & soft cookies to all meals- feed assist due to poor vision Spout cup at meals.
During an North Dining room observation on 10/12/23 at 11:44 AM, Resident #25 was sitting in a wheelchair drinking a red colored drink from a regular plastic cup.
During an observation Resident #25's noon meal ticket stated 2 (two) handled spout cup, which was provided on the noon meal tray.
During an interview on 10/12/23 at 12:12 PM Licensed Practical Nurse (LPN) #91 stated, I just got in the dining room, not sure how she got the regular cup. LPN #91 acknowledged she should have a two handled spout cup for all drinks.
During an interview on 10/12/23 at 12:13 PM, Aide- Non-Certified Nurse #39 stated I was not passing out the drinks not sure where she got the regular cup.
During an interview on 10/23 at 12:23 PM, the Director of Nursing (DON) stated I will go find who gave (Resident #25 name) the regular cup and fix the issue.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure four (4) of twenty-seven (27) residents reviewed had accurate and identifiable medical records. Resident identifiers: #112, #25, #115 and #105. Facility census: 119.
Findings included:
a) Resident #112
Record review found the Resident was admitted to the facility on [DATE]. A Pre admission Screening and Resident Review (PASRR) was completed by the admitting hospital on [DATE]. The Resident triggered a Level II evaluation. On 05/02/23 a Licensed Psychologist completed the Level II screening for the Resident. The psychologist failed to make a determination for the following 3 choices:
Nursing facility services needed-specialized services not needed
Nursing facility services needed - specialized services needed
Nursing facility services not needed.
In addition the recommended placement was not identifier from the following 4 choices:
Nursing Facility Services/Aged/Disabled Waiver
Psychiatric Hospital (21 years or under)
ICF/MR or MR/DD Waiver
Other-identify
Under Notes: typed as written: .Consistent psychiatric follow-up recommenced upon placement.
On 10/11/23 at 12:40 PM, the PASSAR was discussed with the Director of Nursing (DON) and the Administrator. The administrator said the facility did not complete the pre-admission screening. It would have been the psychologist's duty to complete the paperwork properly. The DON said the Resident is seeing a psychologist per tele-med services.
b) Resident #25
During a record review on 10/11/23 at 8:30 AM Resident # 25 medical record reviewed revealed a Physician Orders for Scope of Treatment (POST) form showed that verbal consent was obtained from the resident's representative on 03/21/22. The consent was witnessed by two (2) staff members. However, the resident representative's actual signature was never obtained.
The 2021 POST form guidance titled, Using the POST Form: Guidance for Health Care Professionals, 2021 edition, available on-line, stated, If the incapacitated patient ' s MPOA [medical power of attorney] representative or health care surrogate is unavailable at the time of form completion, this section can be signed by two witnesses for verbal confirmation of agreement from the patient's MPOA representative or health care surrogate. The form should be signed at the earliest available opportunity.
During an interview on 10/11/23 at 9:42 AM, the Social Worker #17 acknowledged Resident #25's representative had not signed the POST form even though verbal consent had been obtained over one (1) year previously.
c) Resident #115
On 10/16/23 at 9:00 AM, a record review was completed for Resident #115. The review found no documentation regarding if a pneumococcal vaccination had been offered to the resident.
On 10/16/23 at 12:10 PM, the Infection Preventionist (IP) #13 provided a copy of the consent, in which the declination by the Medical Power of Attorney (MPOA) was documented and dated as 07/03/23. The IP #13 confirmed there was no documentation in the medical record regarding the refusal of the pneumococcal vaccination. The IP #13 stated, I'll get it in there now.
d) Resident #105
On 10/11/23 at 2:30 PM, a record review was completed for Resident #105. The review found the resident was transferred to an acute care facility on 09/24/23 at 7:00 PM. However, the review of the transfer form indicated the date of the transfer was 07/20/23 at 8:26 AM.
On 10/11/23 at 2:55 PM, the DON was notified and confirmed the information on the transfer form had the incorrect date and time.
No further information was obtained during the survey process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review, and staff interview, the facility failed to ensure two (2) of 28 Residents reviewed were afforded the right to participate in the care planning process. Resident Identifiers: Resident #8 and Resident #57. Facility Census:119.
Findings Included:
a) Resident #8
During an interview on 10/10/23 at 10:14 AM, Resident # 8 stated I have attended a care plan meeting once a year. How often are you supposed to go? This surveyor stated, Quarterly. Resident #8 stated, oh heck they only have them once a year here.
During a record review on 10/11/23 at 10:13 AM, Resident # 8 medical record review revealed a care plan meeting note dated 8/4/2023 typed as written,
1. Attendance (list all in attendance): (Social Worker #17 name) and (an employee name no longer an employee)
2. Family/resident in attendance (Yes/No, who): Resident
3. Summary of meeting (Brief summary. Details are on care plan): Resident is LTC (Long Term Care), on 7/20/23 she weighed 303. She is on a regular diet with intakes at 100% (percent). Resident talked about enjoying working with resident council and how she is now the president of resident council. Resident did express wanting to work with therapy on walking. SS (Social Services) let therapy know this. She also denied sleeping well even though she is on Trazadone, SS sent NP (Nurse Practitioner) an email letting her know this. Resident denied having any other concerns or questions.
4. Advance directive reviewed (yes/no): DNR
Further review of the Medical Record revealed Resident #8 has capacity and Brief Interview Mental Status (BIMS) score of 15 reported on the quarterly Minimum Data Set (MDS) dated [DATE]. The highest score obtainable is 15 and indicates the Resident is cognitively intact.
Record review revealed the Resident should have attended care plan meetings associated with he following MDS's:
A quarterly Minimum Data Set (MDS) with a Reference Assessment Date (ARD) on 05/08/23, a significant change MDS with an ARD on 02/24/23, and a significant change MDS with an ARD of 10/10/22.
During an interview on 10/11/23 at 3:26 PM Social Services Director (SSD) #17 stated she was not invited to any other care plans meetings besides the 08/08/23, because we did not hold any other meetings.
b) Resident #57
On 10/10/23 at 9:04 AM, the Resident said he had never been invited to any care plan meetings.
Record review found the resident was admitted to the facility on [DATE].
Further record review found the resident was deemed to have capacity to make medical decisions on 03/04/23.
The most recent Minimum Data Set (MDS), a quarterly with an Assessment Reference Date (ARD) of 08/04/23 found the residents score on the brief interview for mental status (BIMS) was 15. A score of 15 is the highest score obtainable and indicates the resident is cognitively intact.
Review of the medical record found the following social service notes:
-08/08/2023 at 3:01 PM, Social Service (SS)
Note: SS notified resident that he was scheduled for a care plan meeting on 8/17/23 at 11:30 am.
Further review found the resident's care plan was not held on 08/17/23. It was held on 08/18/23.
-08/18/23 at 8:52 AM, Care Plan Meeting
1. Attendance (list all in attendance):
2. Family/resident in attendance (Yes/No, who): No family in attendance
3. Summary of meeting (Brief summary. Details are on care plan): .Family did not attend meeting. SS contacted family via phone, family expressed no questions or concerns regarding resident's care. Cont (Continue) d/c (discharge) plan of LTC (long Term Care.) SS will cont to follow up for any concerns.
4. Advance directive reviewed (yes/no): No change in code status.
At 3:19 PM on 10/10/23, Social Worker (SW) #20 said if a Resident has capacity then the family member would not be invited to the care plan unless the Resident requested the family be invited.
SW #20 was asked if she could provide evidence Resident #57 was invited to his care plan meeting.
On 10/10/23 at 3:22 PM, the administrator was informed of the resident's comments about not attending his care plan meeting. No further evidence was provided to confirm the Resident was invited and participated in his care plan meeting.

Based on resident interview, medical record review, and staff interview, the facility failed to honor the residents choices for Activities of Daily Living (ADL) and for meals. This failed practice was true for one (1) out of four (4) residents reviewed for the care area choices. Resident identifiers: #72, and #67. Facility census 119.
Findings included:
a) Resident #72
On 10/12/23 at 7:58 AM, Resident # 72 said she was hungry. It was observed the breakfast tray was in front of her. The meal consisted of a bowl of oat meal, one piece of toast, two pieces of bacon and a large portion of scrambled eggs. Resident #72 said she does not like eggs and she has told them many times, but they send her eggs all the time. Nurse Aide #39 was in the room at the above time. NA #39 looked at the meal ticket on the tray and said, well it says right on the ticket her dislikes are eggs.
The dislikes on the meal ticket were as listed:
Chicken Group
Shellfish
Eggs
Pasta
Apple pancakes
Blueberry pancakes
Cholesterol free eggs to order
eggs to order
French toast
French toast casserole
Fresh eggs to order
scrambled eggs
eggs with cheese
seasoned spinach
On 10/12/23 at 8:03 AM, the District Manager (DM) #155 was informed of Resident #72 receiving scrambled eggs for breakfast and eggs are listed on her dislikes. District Manager #155 said she would take her another tray to Resident #72. DM #155 said the kitchen staff must have not read the meal ticket and she will re-educate them about not serving things on the dislike list.
On 10/12/23 at 8:12 AM, Director of Nursing (DON) was informed of the above.
b) Resident #67
On 10/10/23 at 10:58 AM, Resident #67 stated he does not get a shower when he is scheduled and sometimes not at all.
Record review found Resident #67 was scheduled for two (2) showers a week on Wednesdays and Saturdays on day shift.
Activities of Daily Living (ADL) records showed Resident #67 received two (2) showers in the month of September. One (1) on 09/05/23 and one (1) 09/23/23. The September bathing schedule noted the Resident received 22 bed baths. On seven (7) occasions the bathing schedule was coded as Not Applicable (NA).
During the month of October 2023, Resident #67 received a shower on 10/07/23 and 10/08/23 and eight additional bed baths.
A review of the medical records for Resident #67 revealed the Nurse Aide documented this resident received a bed bath on 10/11/23 at 8:52 PM with set-up help only and the Resident also received a bed bath at 12:39 AM on 10/12/23. The Resident was coded as independently completing this bed bath.
On 10/12/23 at 12:17 PM, Resident #67 was asked if he received a shower or bed bath last night? Resident #67 was adamant he did not have a shower or bed bath last night.
On 10/12/23 at 11:46 AM, the Director of Nursing (DON) was informed of the above and said she was going to look at another way the Nurse Aides could document to make sure the information provided lines up with the information in the task tab.
On 10/12/23 at 12:27 PM, the DON said Resident #67 refused a shower yesterday per the Nurse Aide's documentation, however it was also documented he received two (2) bed baths on this same day. There was no nursing note stating the Nurse Aide reported a refusal for a shower on this date.
On 10/12/23 at approximately 1:30 PM, the DON said she will make sure Resident #67 receives a shower today.
Care Plan:
Resident #67 needs assistance for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfers, locomotion, toileting, and ambulation. Residents refuses showers at times.
-Residents ADL care needs will be anticipated and met throughout the next review period.
-Bathing is extensive assist x 1
-(Name of resident) is supervision for bed mobility, transfers, ambulation, dressing and toileting.
-Continue offering showers even after refusal.
-Provide supervision for hygiene.
-Resident prefers showers but will take a bed bath

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, and staff interview, the facility failed to ensure the residents environment was safe, comfortable, and homelike. This was true for 14 of 71 resident bedrooms observed at the facility. In addition, Resident #117's wheelchair was littered with dust and debris. Rooms 116, 117, 118, 319, 100, 101, 102, 103, 104, 107, 108, 110, 113, and 114. Resident identifier: #117. Facility census: 119.
Findings included:
a) room [ROOM NUMBER]
On 10/11/23 at 4:16 PM, observation of the bathroom in room [ROOM NUMBER] with the senior director of maintenance (SDM) #5 found a bedside commode setting over the toilet in the bathroom. The 4 legs of the bedside commode were rusted as well as the bar across the back holding the toilet seat. The drywall was peeling from the wall behind the toilet. A dark stain was present around the toilet. A rusted rack for storing plastic gloves was hanging on the wall. The light bar above the sink was rusted. Under the sink were 6 gray basins stacked together with stagnant water in the top basin. Employee #5 said maybe the sink was leaking and someone had placed a basin under the sink to catch the water. E #5 also said he believed the stain around the toilet was from the rust on the legs of the bedside commode.
b) room [ROOM NUMBER]
Observation of room [ROOM NUMBER] on 10/11/23 at 4:20 PM, with SDM #5 found the bathroom had black spots on the ceiling above the toilet. The floors of the bathroom were sticky causing the surveyors shoes to stick to the floor.
c) room [ROOM NUMBER]
Observation of room [ROOM NUMBER] on 10/11/23 at approximately 4:22 PM, with SDM #5 found the plaster on the ceiling was handing down in strips. The cove molding under the sink was stained with a reddish/brown substance. The paint was scratched and missing on the door frames and the door leading into the bathroom.
On 10/12/23 at 1:36 PM, the administrator toured rooms [ROOM NUMBER] with the surveyor. The bedside commode had been replaced but the stains remained on the floor of room [ROOM NUMBER]. The rusted glove rack and the basins had also been removed.
In room [ROOM NUMBER] the black spots remained on the ceiling and the floor remained sticky.
In room [ROOM NUMBER] the plaster on the ceiling was still peeling. The cove molding had been cleaned. The paint was still missing on the door and door frame leading into the bathroom.
d) Resident #117
Observation on 10/10/23 at 9:31 AM, found the Resident was seated in her wheelchair in the resident lounge beside the nurses station on the North hallway. Foam was protruding from a cushion in the Resident's wheelchair. On the front metal frame around the wheels and handbrakes was a dried heavy build up of debris.
On 10/11/23 at 1:30 PM, the resident was again seated in her wheelchair in the lounge. The Administrator and the Director of Nursing (DON) observed the Resident's wheelchair. The dried debris remained on the wheelchair, and the foam on the cushion was still protruding from the cushion on the seat of the wheelchair. The DON said the cushion wasn't torn, it just needed to have the cover zipped up. The Administrator said the resident constantly drops food on the wheelchair.
e) room [ROOM NUMBER]
During a interview on 10/10/23 at 10:28 AM, Resident # 54 stated the wall in the bathroom looks awful. It's been like that for a couple months. The maintenance guys put new drywall up while it was still wet. It looks like its mold is growing under the spackling.
During an observation on 10/10/23 at 10:29 AM, room [ROOM NUMBER]'s bathroom, revealed half way up the wall, from the sink going around the wall toward the toilet a brownish stain, where the newer drywall was installed.
During an interview on 10/11/23 12:47 PM, Maintenance Tech #2 stated we had a leak from another room that flooded that bathroom also. We fix the leak,and then put the drywall up . It didn't dry properly, it needs to be cleaned up and replaced. Maintenance Tech #2 acknowledged the wall was not in good repair.
During an interview on 10/11/23 at 2:14 PM Maintenance Supervisor a sister facility #169 stated we have to cut the wall completely out, put up the drywall, sand and paint it. We will bring in a team tomorrow to do that.
During an interview on 10/12/23 at 3:19 PM, a Maintenance Supervisor from a sister facility #169 stated we completed the first stage of hanging the drywall in the bathroom in room [ROOM NUMBER]. We have to let it dry, and we finish the last steps of sanding and painting. It will be finished by the weekend.
f) room [ROOM NUMBER]
At approximately 9:54 am on 10/10/2023, a thick brown layer of dirt and grime was observed around the base of the toilet in room [ROOM NUMBER].
At approximately 11:00 am on 10/11/23, a walk through was completed with Registered Nurse (RN) #6, who witnessed the condition of the bathroom.
g) room [ROOM NUMBER]
At approximately 10:03 am on 10/10/2023, a thick brown layer of dirt and grime was observed around the base of the toilet in room [ROOM NUMBER].
At approximately 10:03 am on 10/10/2023, Director of Nursing (DON) and Maintenance Tech #2 were present in the room and both witnessed the condition of the bathroom.
h) room [ROOM NUMBER]
At approximately 10:13 am on 10/10/2023, a thick brown layer of dirt and grime was observed around the base of the toilet in room [ROOM NUMBER].
At approximately 11:00 am on 10/11/2023 a walk through was completed with RN #6, who witnessed the condition of the bathroom.
i) room [ROOM NUMBER]
At approximately 10:24 am on 10/10/2023, a thick brown layer of dirt and grime was observed around the base of the toilet in room [ROOM NUMBER].
At approximately 11:01 am on 10/11/2023, a walk through was completed with RN #6, who witnessed the condition of the bathroom.
j) room [ROOM NUMBER]
At approximately 10:30 am on 10/10/2023, a thick brown layer of dirt and grime was observed around the base of the toilet in room [ROOM NUMBER].
At approximately 11:03 am on 10/11/2023, a walk through was completed with RN #6, who witnessed the condition of the bathroom.
k) room [ROOM NUMBER]
At approximately 10:34 am on 10/10/2023, a thick brown layer of dirt and grime was observed around the base of the toilet in room [ROOM NUMBER].
At approximately 11:05 am on 10/11/2023, a walk through was completed with RN #6, who witnessed the condition of the bathroom.
l) room [ROOM NUMBER]
At approximately 10:45 am on 10/10/2023, a thick black and brown ring of dirt and grime was observed around the base of the toilet in room [ROOM NUMBER]. There was a musty smell in the bathroom. An interview with Resident #31 revealed that the toilet in the bathroom had been leaking for quite some time, had been reported, and had not been fixed.
At approximately 10:45 am on 10/10/2023, Environmental Services Manager (EVSM) #25 was present outside room [ROOM NUMBER]. EVSM #25 entered the bathroom, and confirmed the toilet had been leaking. EVSM #25 ran his finger through the black and brown grime and stated it needed some caulk put on it. EVSM #25 was not wearing gloves when he ran his finger through the brown and black grime, and did not perform any hand hygiene after doing so.
m) room [ROOM NUMBER]
At approximately 10:50 am on 10/10/2023, room [ROOM NUMBER] was observed with empty soda bottles scattered about the floor in the room, a sticky, light brown substance covering the majority of the floor in the room, causing shoes to stick to the floor. An empty cup sat on top of the mini refrigerator on the night stand and a thick dark brown substance appeared to be dripping down the wall above the mini refrigerator. The toilet in room [ROOM NUMBER] had a thick ring of brown grime around the base.
At approximately 10:50 am on 10/10/2023, Nurse Aide (NA #99) entered room [ROOM NUMBER] to confirm the condition of the room.
n) room [ROOM NUMBER]
At approximately 11:00 am on 10/10/2023, the bathroom in room [ROOM NUMBER] was observed. There was a soiled towel laying on the floor in front of the toilet with a yellow substance on it. There was a strong odor of urine in the bathroom upon entering, and flies were flying around the towel at the base of the toilet. The toilet was observed to have had a thick brown and yellow ring around the base.
At approximately 11:00 am on 10/10/2023, RN #170 entered the bathroom of room [ROOM NUMBER] to confirm its condition. RN #170 stated it is hard for housekeeping to keep the bathroom in room [ROOM NUMBER] cleaned because the resident would urinate on the floor frequently.
o) room [ROOM NUMBER]
At approximately 11:04 am on 10/10/2023, the bathroom in room [ROOM NUMBER] was observed as having a thick brown layer of grime around the base of the toilet.
At approximately 11:08 am on 10/11/2023, a walk through was completed with RN #6, who witnessed the condition of the bathroom.

Based on record review, policy review and staff interview the facility failed to ensure all falls which resulted in serious bodily injury were reported to the appropriate state agencies within the required time frame. This is true for one (1) of three (3) residents reviewed for the care area of falls. Resident Identifier: Resident #25. Facility Census:119
Findings Included:
A review of a facility policy titled Abuse Prohibition with a revision date 10/24/22 read as follows:
.Other Definitions:
Serious Bodily Injury is a injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; or requiring medical intervention such as surgery, hospitalization, or physical rehabilitation.
.7. Immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the Administrator or designee will perform the following . (Refer to the External Abuse Reporting Requirements table).
.7.3 Report allegations to the appropriate state and local authority(s) involving neglect, exploitation or mistreatment (including injuries of unknown source), suspected criminal activity, and misappropriate of patient property not later than two (2) hours after the allegation is made if the event results in serious bodily injury
The facility External Abuse Reporting Requirement table reads as follows:
Type: Serious Bodily Injury
Person Responsible for Reporting to State Agency(ies): Administrator or Director of Nursing
When to Report: Immediately but not later than two (2) hours after forming the suspicion
To Whom to Report: State Survey Agency (SA), Law Enforcement, Adult Protective Services where state law provides for jurisdiction in long term care facilities.
a) Resident #25
During a record review on 10/10/23 at 11:00 AM, Resident # 25's medical record review revealed a general note dated 06/25/23 typed as written This nurse entered Resident's room after being alerted that (Room Number) had leaned forward and fallen out of chair while CNA(Certified Nurse Aide) was making her bed. This nurse observed resident laying on her back yelling out in pain and a skin tear on the left hand. This nurse stopped the bleeding with gauze and pressure while evaluating Resident. Resident was extremely sensitive to touch around the left hip. Resident stated multiple times 'Don't move me.' CNA reported head contact during fall. Resident sent to hospital due to pain.
During a review on 10/11/23 at 9:53 AM, the facility's reportable log indicated Resident #25's fall was reported to the appropriate agencies.
Further review of the medical records revealed the fall on 06/25/23, with serious bodily injury had not been reported to the appropriate state agencies within two (2) hours of acknowledgement of the hip fracture.
During an interview on 10/11/23 at 3:26 PM, SW #17 acknowledged the fall with major injury was not reported in a timely manner. The log indicating the fall was reported was incorrect.

Based on medical record review and staff interview, the facility failed to provide evidence that a copy of the Notice of Transfer was sent to the Office of the State Long-Term Care Ombudsman. This was true for one (1) of two (2) Residents reviewed for the care area of hospitalization during the Long-term care process. Resident Identifiers: Resident #124. Facility Census: 119.
Findings Included:
a) Resident #124
During a record review on 10/11/23 at 12:00 PM, Resident #124's medical record review revealed a general note dated 7/13/2023 typed as written. Nurse in room at this time to initiate 02 (oxygen) therapy EOL (End of Life) comfort care. Nurse observed no breaths and no heartbeat was auscultated or palpated. NP's name notified. (NP's name) in room to verify no signs of life. (Son's name) notified of situation with wishes to send to (a local funeral home) CNA (Certified Nurse Aide) in room at this time to provide postmortem care.
During an interview on 10/11/23 at 2:14 PM, Medical Records #37 stated I email the Ombudsman every Friday and attach the Notice of Transfer or Discharge form to the email.
A review of the email provided by the Medical Records #37 dated 07/14/23 read as follows typed as written Please see attached notice of transfer/discharge from Valley Center.
Further review of the medical records revealed no evidence the documentation was sent to the Ombudsman.
On 10/12/23 at 10:10 AM, Medical Records #37 she could not find evidence the above documents were sent to the Ombudsman regarding Resident #124's death.
During the interview on 10/12/23 at 10:25 AM, the Administrator acknowledged the notice of transfer/discharge was not sent to the Ombudsman regarding Resident #124's death.

Based on record review and staff interview, the facility failed to ensure the Minimum Data Set (MDS)was correct regarding a dental assessment for Resident #57 and a discharge destination for Resident #125. Resident identifiers: #57 and #125. Facility census: 119.
Findings included:
a) Resident #57
On 10/10/23 at 8:58 AM, the Resident #57 said I need to see a dentist. He said, I told some lady I needed to go. I signed a paper but nothing ever happened. I have missing teeth and it's hard to chew.
Review of the current care plan found dental needs had been addressed and an intervention noted in the care plan was: (Name of Resident) said he broke part of his right upper tooth on 08/03/23.
A quarterly MDS with an ARD of 08/04/23 found the resident was again coded as having no dental issues. The dental section of the MDS was completed on 08/08/23.
On 10/11/23 at 12:31 PM, the Clinical Reimbursement Coordinator (CRC) #22 observed the resident's oral cavity. The resident showed CRC #22 he was unable to wear his partial because he had a broken tooth.
On 10/16/23 at 2:15 PM, CRC #22 said she had completed a corrected MDS. She stated the dental section should have been coded as broken or loosely fitting full or partial denture. CRC #22 said the partial had to be poorly fitting as one of the teeth the partial hooked to was broken.
b) Resident #125
During a record review on 10/11/23 at 10:56 AM, Resident # 125's medical record review revealed a nurses note dated 09 /12/2023 typed as written:
This RN received report from (LPN name) . This resident arrived at approximately 2120 (9:20 PM) at the facility via EMS from acute care hospital. Per LPN(Licensed Nurse) name and CNAs(Certified Nurse Aide), the resident was immediately displeased with the facility and was requesting to leave Against Medical Advice (AMA) Vital signs were taken and found to be stable. The resident was found to be alert and oriented x 4.
(LPN name) , and (two CNA names) all made reasonable attempts to satisfy patient. They offered the resident a bath; they stripped the bed,cleaned bed and put clean sheets on bed. The resident was offered to be moved to B bed but refused. The room was too warm for this resident so they turned the air conditioner on. The resident was concerned about air flow, so they offered to pull the curtain back part of the way to improve air flow but maintain privacy and the resident refused. The resident requested to go back to hospital.
(Nurse Manager on duty name) as notified by previous shift of desire to leave facility. Manager on duty was able to speak with the resident and (nephew name). They continued to express the desire to leave the facility. Nephew signed AMA paperwork. The resident and (nephew name) refused to sign the bed hold policy paperwork. The resident had appropriate medical equipment prior to leaving the facility. Nephew had brought the resident home oxygen tank, nasal cannula, and wheelchair from home.
The resident and nephew left at approximately 2317 (11:17 PM) when she was wheeled off of the unit by nephew in her personal wheelchair. The resident and nephew had her personal belongings with them when they left the facility.
Further review of the medical record revealed a MDS with ARD date of 09/12/23 Section A titled Identification Information, section A2100 titled discharged Status was coded 03 Acute Hospital.
During an interview on 10/11/23 at 12:10 PM Clinical Reimbursement Coordinator (CRC) #22 stated Resident # 125's name was discharged AMA on 09/12/23. CRC #22 acknowledged the MDS was coded incorrectly. She stated I will transmit a updated assessment.

Based on observation, record review, family interview, and staff interview the facility failed to provide Activities of Daily Living (ADL) care for a dependent resident. This was true for two (2) out of four (4) Residents reviewed for ADL care. Resident identifiers: #72, and #67. Facility census 119.
Findings included:
a) Resident #72
On 10/10/23 at 11:53 AM, Resident #72 said she has not had a bed bath in two weeks her hair appeared to be oily. She said her hair has not washed in 2 weeks. Resident #72 was noted to be wearing a white top with flowers on it and ruffled short shelves.
There was a handwritten sign above her bed that said, wash hair when giving bed bath per daughter.
A phone interview with Resident # 72's daughter on 10/11/23 at 1:46 PM, found she did put the sign behind her mother's bed to remind her mom and the staff to wash her mother's hair when they give her a bed bath. She said the staff tells her that her mom refuses to have her hair washed. However, she was surprised to see her hair was not washed yesterday (10/10/23) because it was her mother's birthday, and she would normally want her hair washed if she knew she was going to have visitors.
On 10/11/23 at 11:06 AM, it was noted Resident #72 was still wearing the same top she had on yesterday, 10/10/23. Resident # 72 said she is supposed to be bathed on Tuesdays and Thursdays. Yesterday was a Tuesday and bathing did not occur.
On 10/12/23 at approximately 8:00 AM, it was observed Resident #72 was wearing the same shirt as she wore on 10/10/23 and 10/11/23.
On 10/12/23 at approximately 11:30 AM, the Director of Nursing (DON) was shown that Resident #72 had been wearing the same top for the past three days, and her hair was stuck to her head. The DON asked Resident #72 if she wanted a bed bath and her hair washed. Resident #72 was agreeable.
Care Plan:
Resident requires assistance for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfers, locomotion, and toileting related to: Limited mobility, history of malignant cancer of uterus, spinal stenosis with pain.
-Resident will maintain the highest capable level of ADL ability throughout the next review period.
-Prefers bed baths; Resident will refuse at times. Notify the nurse if Resident refuses showers.
-Provide extensive assistance with bed mobility, dressing, grooming, and hygiene.
-Provide total assistance with bathing/showers.
-Provide total assistance with transfers utilizing a mechanical lift & 2 staff members.
b) Resident #67
On 10/10/23 at 10:58 AM, Resident #67 stated he does not get a shower when he is scheduled and sometimes not at all.
Record review found Resident #67 was scheduled for two (2) showers a week on Wednesdays and Saturdays on day shift.
Activities of Daily Living (ADL) records showed Resident #67 received two (2) showers in the month of September. One (1) on 09/05/23 and one (1) 09/23/23. The September bathing schedule noted the Resident received 22 bed baths. On seven (7) occasions the bathing schedule was coded as Not Applicable (NA).
During the month of October 2023, Resident #67 received a shower on 10/07/23 and 10/08/23 and eight additional bed baths.
A review of the medical records for Resident #67 revealed the Nurse Aide documented that this resident received a bed bath on 10/11/23 at 8:52 PM with set-up help only and the Resident also received a bed bath at 12:39 AM on 10/12/23. The Resident was coded as independently completing the bed bath.
On 10/12/23 at 12:17 PM, Resident #67 was asked if he received a shower or bed bath last night? Resident #67 was adamant he did not have a shower or bed bath last night.
On 10/12/23 at 11:46 AM, the Director of Nursing (DON) was informed of the above and said she was going to look at another way the Nurse Aides could document to make sure the information provided lines up with the information in the task tab.
On 10/12/23 at 12:27 PM, the DON said Resident #67 refused a shower yesterday per the Nurse Aide's documentation, however it was also documented he received two (2) bed baths on this same day. There was no nursing note stating the Nurse Aide reported a refusal for a shower on this date.
On 10/12/23 at approximately 1:30 PM, the DON said she will make sure Resident #67 receives a shower today.
Review of the Resident's current Care Plan found:
Resident #67 needs assistance for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfers, locomotion, toileting, and ambulation. Residents refuses showers at times.
-Residents ADL care needs will be anticipated and met throughout the next review period.
-Bathing is extensive assist x 1
-(Name of resident) is supervision for bed mobility, transfers, ambulation, dressing and toileting.
-Continue offering showers even after refusal.
-Provide supervision for hygiene.
-Resident prefers showers but will take a bed bath

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to obtain an order for urinary catheter care, follow physicians orders for applying range of motion (ROM) splints, obtain labs, neurological checks after a fall and obtain an Magnetic Resonance Imaging (MRI) as ordered. Resident Identifiers: #24, #35, #112, #28 and #8. Facility Census: # 119
Findings include:
a) Resident #24
On 10/10/23 at 9:30 AM, observation found Resident #24 to have a covered urinary catheter bag at bedside. On 10/12/23 at 11:43 AM, upon review of his medical records, it was found there was no order for the care of his urinary catheter. This was confirmed with the Director of Nursing on 10/12/23 at 12:45 PM.
b) Resident #35
1) On 10/12/23 at 11:00 AM medical record shows a change of condition on 09/10/23 at 6:40 PM when there was an Physicians order to administer 15 units of Novolog insulin and recheck the blood glucose in 2 hours for a critical blood glucose of 525.
Based on the Medication Administration Record, the Resident received the 15 units of Novolog, however, there was no recheck of the blood glucose after 2 hours.
This was confirmed with the Director of Nursing on 10/12/23 at 1:45 PM. No further information was provided prior to exiting the survey process.
2) On 10/10/23 at 11:00 AM observations of Resident #35 found him to have contractures to his bilateral upper extremities.
On 10/10/23 at 11:40 AM record review shows the following Physician orders:
Resident to wear left elbow splint to be worn for 2 hours between the hours of 7a-7p, Nurse to assess skin integrity prior to application and upon removal every day shift.
Resident to wear right hand splint for 2 hours between the hours of 7a-7p, Nurse to assess skin integrity prior to and after removal of splint every day shift.
Review of the Treatment Administration Record (TAR) shows the Licensed Practical Nurse (LPN) #62 applied the above splints. During an interview with the LPN on 10/11/23 at 3:40 PM, he stated he was going back to apply the splints but got involved with something else.
Nine (9) observations on the following dates and times found none of the above range of motion splints were on the resident at any time.
10/10/23 1 PM and 3 PM
10/11/23 8 AM, 12 noon, 2 PM, 3:30 PM
10/12/23 8:30 AM, 10 AM and 12:32 PM
The above information was confirmed with the Director of Nursing and Administrator on 10/12/23 at 12:45 PM.
.
c) Resident #112
Record review found the resident was admitted to the facility on [DATE].
The Resident was receiving the antipsychotic medication Seroquel for Schizophrenia.
On 05/02/23 the physician ordered:
Obtain HGA1C ( a blood test that measures your average blood sugar levels over the past 3 months) every 4 months (May/September/ and January for Seroquel use.
At 10:25 AM on 10/16/23, the DON confirmed the facility failed to obtain the HGA1C for September 2023, as ordered by the physician.
At 3:11 PM on 10/16/23, the administrator was notified of the findings. No further information was provided by the close of the survey.
d) Resident #28
Review of the facility policy Falls Management, revised 8/7/23 directs:
.5.3 Any patient who sustains an injury to the head from a fall and/or has an unwitnessed fall will be observed for neurological abnormalities by performing neurological check, per policy
Record review found the Resident fell on 5/21/23 out of her wheelchair while trying to get a teddy bear from another resident. The fall was unwitnessed, and the Resident was assisted from the floor via a mechanical lift and 2 staff members.
The Resident fell again on 08/17/23, while trying to walk from the toilet to her wheelchair. She was found sitting on her bottom on the bathroom floor.
At 10:56 AM on 10/12/23, the Director of Nursing (DON) confirmed neuro checks were not completed for the falls on 05/21/23 or 08/17/23, but should have been because both falls were unwitnessed.
e) Resident #8
During a record review on 10/12/23 at 10:30 AM, Resident # 8 medical records review revealed a physician order dated 07/07/23. Please schedule for MRI (Magnetic Resonance Imaging) cervical and thoracic spine ASAP (As soon as possible) due to chronic neck pain and back pain with h/o (history of) frequent falls.
Further record review revealed a nurse note dated 07/26/23 typed as written Pre authorization request sent for the MRI faxed on 07/26/23.
Further review of the medical records revealed no evidence of documentation of imaging reports for the MRI ordered by physician.
During an interview on 10/12/23 at 10:00 AM, the DON stated I am sure we have that MRI report, it just has not been scanned in, I will look and get back with you.
During an interview on 10/12/23 at 1:54 PM, the DON stated we never followed through with the prior authorization to get Resident #8's MRI.

Based on observations, record review and staff interview the facility failed to provide the appropriate services to prevent worsening or further contractions/range of motion (ROM) by failing to follow physicians orders for placing ROM splints as ordered. This was true for one (1) of five (5) residents reviewed for ROM. Resident identifier: #35 Facility Census: 119
Findings include:
a) Resident #35
On 10/10/23 at 11:00 AM, observation of Resident #35 found him to have contractures to his bilateral upper extremities.
On 10/12/23 at 9:15 AM, record review shows the following Physician orders:
Resident to wear left elbow splint to be worn for 2 hours between the hours of 7 am-7 pm, Nurse to assess skin integrity prior to application and upon removal every day shift.
Resident to wear right hand splint for 2 hours between the hours of 7 am-7 pm, Nurse to assess skin integrity prior to and after removal of splint every day shift.
Nine (9) observations on the following dates and times found none of the above ROM splints were on the resident at any time.
10/10/23 1 PM and 3 PM
10/11/23 8 AM, 12 noon, 2 PM, 3:30 PM
10/12/23 8:30 AM, 10 AM and 12:32 PM
The above information was confirmed with the Director of Nursing and the Administrator on 10/12/23 at 12:45 PM.
.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to ensure the residents environment remains as free of accident hazards as possible. This was a random opportunity for discovery which included leaving medications on the bedside table, failure to dispose of a controlled medication properly, failure to dispose of a razor, and failure to ensure an intervention for fall prevention was in place as directed by the physician. The above failed practices had the potential to affect a limited number of residents. Resident identifier: # 55, and 112. Facility census 119.
Findings included:
a) Resident #55
On 10/10/23 at 9:45 AM, observation found Inzo (antifungal cream), Remedy Skin times two (2) tubes, and nasal spray were on the Resident's bedside table. Nurse Aide #55 (NA) verified the medications were on the bedside table and removed them.
On 10/101/23 at 11:06 AM, the Director of Nursing (DON) said NA #55 told her about the medications and they were removed.
b) Resident #177
On 10/10/23 at 11:24 AM, a box with the name of Resident #177 was in the trash can in the conference room. The box contained Morphine 20mg/1 ml. The bottle still had a small amount of morphine in the bottle. The conference room was not locked, and anyone had the potential to have access to the medication.
Review of the medical records found Resident #177 passed away in the facility on 08/12/23.
On 10/10/23 at 11:28 AM, the Director of Nursing (DON) was asked about this medication being in the conference room in the trash can with a small amount of medication left in the bottle and with identifying information of Resident #177. The DON stated it was there from when she destroyed the medications with the Pharmacy.
On 10/17/23 at 2:48 PM, the DON said the medication was put in the trash can on 10/09/23, and the conference room remains unlocked from 8 AM to about 4 PM, with multiple people going in and out of the room during the day.
c) Resident #112
Record review found in the resident had 2 falls in the past six months:
On 08/06/23 at 6:21 PM the Resident was found lying on her back on the floor. The cushion from the wheelchair slid out with the Resident.
On 05/12/23 at 11:56 AM, the Resident was found lying on the floor on the fall mats beside her bed.
Review of the current orders found the Resident had an active order, dated 07/23/23, for a dump wheelchair when out of bed.
On 10/11/23 at 3:40 PM, the North unit manager Registered Nurse (RN) #8 and Nurse Aide #100 observed the Resident in her wheelchair setting in the lounge area. Both staff members said the Resident was not in a dump wheelchair.
On 10/12/23 at 11:17 AM, the Physical Therapy Assistant (PTA) #153 confirmed the Resident was seated in a regular wheelchair, not a dump wheelchair. (A dump wheelchair is described as the seat of the wheelchair is lower in the back than in the front.) The Director of Nursing (DON) and Administrator observed the Resident in her wheelchair at approximately 11:20 AM on 10/12/23. Both staff members were informed of the findings by the PTA.
No further information was provided by the close of the survey.
d) room [ROOM NUMBER]
Observation of room [ROOM NUMBER] with the Administrator at 1:36 PM on 10/12/23, found a razor with blades was laying on the sink of the bathroom. The Administrator immediately removed the razor.

Based on observation, medical record review, and staff interview the facility failed to provide necessary respiratory care consistent with professional standards of practice. Nebulizer masks and a Resident's CPAP (Continuous positive airway pressure) mask were on the bedside table with no protective covering. This observation was a random opportunity for discovery. Resident identifier: Resident #96 and Resident #8. Facility Census: 119.
Findings Included:
A review of the facility policy titled Procedure: Oxygen Simple Mask with a revision date of 08/07/23 read as follows:
.19. Replace and date entire set up every seven days. Date and store in treatment bag when not in use.
a) Resident #96
During the initial tour of the facility on 10/10/23 at 10:05 AM, Resident # 96's nebulizer mask was on the bedside table without a protective covering.
During a record review on 10/11/23 at 1:00 PM, Resident # 96's medical records revealed a physician order dated 08/24/23 Ipratropium-Albuterol Solution 0.5-2.5 (3) mg/ml ( milligrams/milliliters) 3 (three) ml orally two(2) times a day for Shortness of Breath (SOB), wheezing.
During an observation on 10/11/ 23 at 8:26 AM, Resident # 96's nebulizer mask was on the bedside table without a protective covering.
During an observation on 10/11/23 at 12:58 PM Resident # 96's nebulizer mask was on the bedside table without a protective covering.
During an observation on 10/12/23 at 8:26 AM ,Resident # 96's nebulizer mask was on the bedside table without a protective covering.
Another observation on 10/16/23 at 9:56 AM, Resident # 96's nebulizer mask was on the bedside table without a protective covering.
During an interview on 10/16/23 at 9:58 AM, Licensed Practical Nurse (LPN) #80 acknowledged the masks were not stored appropriately.
During an interview on 10/16/23 at 10:03 AM, the DON stated it is probably care planned Resident #92 is independent and removes it themselves when they are finished.
During a medical record review on 10/16/23 at 10:15 AM Resident #92's care plan revealed no evidence of documentation of being independent to remove the masks.
During an interview on 10/16/23 at 10:24 AM the DON stated there was no evidence in the care plan about the nebulizer mask being removed by the Resident independently.
The DON acknowledged the mask should have been stored appropriately.
b) Resident #8
During the initial tour of the facility on 10/10/23 at 10:14 AM, Resident #8's nebulizer mask and Resident #8's CPAP mask was on the bedside table without a protective covering.
During a record review on 10/11/23 at 1:53 PM Resident #8 medical records revealed a physician order dated 08/28/23 Ipratropium-Albuterol Solution 0.5-2.5 (3) mg/ml ( milligrams/milliliters) 3 (three) ml orally two(2) times a day for COPD (Chronic Obstructive Pulmonary Disease).
Further review of the medical records revealed a physician order dated 10/18/22 CPAP MODE: CPAP Pressure Settings: 6/20. Hours of usage qhs (at night) and PRN (as needed) at bedtime for sleep apnea.
During an observation on 10/11/ 23 at 8:26 Resident # 8 nebulizer mask and Resident #8's CPAP mask was on the bedside table without a protective covering.
During an observation on 10/11/23 at 12:58 PM Resident #8 nebulizer mask and Resident #8's CPAP mask was on the bedside table without a protective covering.
During an observation on 10/12/23 at 8:26 AM Resident #8 nebulizer mask and Resident #8's CPAP mask was on the bedside table without a protective covering.
Another observation on 10/16/23 at 9:56 AM Resident #8 nebulizer mask and Resident #8's CPAP mask was on the bedside table without a protective covering.
During an interview on 10/16/23 at 9:58 AM, Licensed Practical Nurse (LPN) #80 acknowledged the the nebulizer mask and/or the CPAP mask was not stored appropriately
During an interview on 10/16/23 at 10:03 AM, the Director of Nursing (DON) stated it is probably care planned that they are independent and remove it themselves when they are finished.
During a medical record review on 10/16/23 at 10:15 AM Resident #8's care plan revealed no evidence of documentation of being independent to remove the masks.
During an interview on 10/16/23 at 10:24 AM the DON stated there was no evidence in the care plan about the nebulizer and/or CPAP mask being removed by the Resident independently.
The DON acknowledged both of the masks should have been stored appropriately.

Based on record review and staff interview, the facility failed to provide dialysis services consistent with professional standards of care. This was true for one (1) of one (1) residents reviewed under the care area of dialysis. Resident Identifier: #39. Facility Census: 119.
Findings Included:
a) Resident #39
On 10/12/23 at 9:05 AM, a record review was completed for Resident #39. The resident receives hemodialysis on Monday, Wednesday and Friday with a chair time of 11:15 AM. The Dialysis Communication Book was reviewed at this time as well. The Dialysis Communication Book was noted with incomplete information on the following dates:
--08/19/23 missing post dialysis facility nurse's signature.
--08/25/23 missing pre-dialysis time of last meal, type of diet and resident's general condition, the pre-dialysis facility nurse's signature and date as well as the pre-dialysis weight.
--08/28/23 missing post dialysis facility nurse's signature and date, with no indication if new orders were received from the dialysis center.
--09/06/23 missing post dialysis facility nurse's signature and date with no indication if new orders were received from the dialysis center and post dialysis vital signs.
--09/15/23 pre-dialysis vital signs, pre-dialysis facility nurse's signature and date; post dialysis vital signs, with no indication of new orders from the dialysis center and facility nurse's signature and date.
--09/22/23 missing post dialysis vital signs, post dialysis facility nurse's signature and date with no indication if new orders were received from the dialysis center.
--09/25/23 missing post dialysis vital signs, post facility nurse's signature and date with no indication if new orders were received from the dialysis center.
--09/27/23 missing the resident's name, patient's room number, facility physician, center name, pre-dialysis vitals, time of last meal, type of diet, patient's general condition, pre-dialysis facility nurse's signature and post dialysis vitals signs, with no indication if new orders were received from the dialysis center, post dialysis facility nurse's signature and date.
--10/03/23 missing post dialysis vital signs, with no indication if new orders were received from the dialysis center, and post dialysis facility nurse's signature and date.
--10/09/23 missing pre-dialysis vital signs, time of last meal, type of diet, patient's general condition, facility nurse signature and date
--10/11/23 missing post dialysis vital signs, no indication if new orders were received from the dialysis center, and post dialysis facility nurse's signature and date.
On 10/12/23 at approximately 11:00 AM, the Director of Nursing (DON) was notified and confirmed the Dialysis Communication Book was incomplete.
No further information was obtained during the survey process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain an accurate and complete record for Resident #126's smoking status and 15 minute observations for Resident #86. This was true for two (2) of six (6) residents reviewed during the survey process. Resident Identifiers: #126 and #86. Facility Census: 125.
Findings Included:
a) Resident #126
On 09/26/23 at 1:45 PM, a record review was completed for Resident #126. The review found a smoking evaluation dated 08/31/23. The smoking evaluation indicated the resident was not allowed to smoke. Upon reviewing the hospital records prior to the admission to the facility, the documentation stated the resident had never smoked. The admission Minimum Data Set (MDS) dated [DATE] section J, indicated the resident did not use tobacco.
On 09/26/23 2:57 PM, the Director of Nursing (DON) confirmed the smoking assessment was completed in error upon admission.
b) Resident #86
On 09/27/23 at 12:45 PM, a record review was completed for Resident #86. The review found the resident was placed on 15 minute observations for inappropriate sexual/physical seeking behaviors which was initiated on 05/13/23. The 15 minute observations were discontinued on 06/24/23. The 15 minutes observation sheet has the time printed from 7:00 AM to 7:00 AM for each day; also, there is an area entitled location/activity and an area for the staff's initials and/or signature.
The 15 minute observation sheets were reviewed for 05/13/23 through 05/31/23. The 15 minute observation sheets were undated, unsigned by staff and timeframes which had no documentation of the location or activity of the resident. The review found three (3) days throughout this timeframe which did not have a 15 minute observation sheet completed.
In addition, the 15 minute observation sheets were reviewed for 06/01/23 through 06/24//23. The 15 minute observation sheets were undated, unsigned by staff and timeframes which had no documentation of the location or activity of the resident. The review found eight (8) days throughout this timeframe which did not have a 15 minute observation sheet completed.
On 09/27/23 at 2:00PM, the Director of Nursing (DON) was notified and confirmed the 15 minute observation sheets were incomplete, unsigned by the staff member and some were not completed at all.

Based on medical record review and staff interview the facility failed to ensure they developed an ongoing program to support residents in their choice of individual activities for (1) resident. Resident #87 was reviewed at random for activities. Resident identifier: #87. Facility census: 125.
Findings included:
a) Resident #87
The medical record review for Resident #87 revealed the resident received MediTelecare. MediTelecare provides behavioral telemedicine services to residents of skilled nursing and assisted living facilities. A therapy note dated 07/09/23 stated the resident felt bored at times. He stated he liked attending physical therapy and he enjoyed listening to country music and watching television. A therapy note dated 08/07/23 revealed the resident had a primary symptom of depression and sadness. The note also stated the resident enjoyed reading but was unable to due to problems with his vision.
During an interview with the Administrator and Director of Nursing on 09/27/23 at 2:11 PM they both stated the resident had been sexually inappropriate with female residents in the past and was currently out of the facility for an in patient psychiatric evaluation.
The resident's care plan did not mention the resident would enjoy reading, and listening to country music.
During an interview with the recreation director on 09/27/23 at 2:14 PM he stated he was unaware of this too. The Administrator then stated she does not always receive the MediTelecare notes from the provider but did not provide any further information regarding when the notes dated 07/09/23 and 08/07/23 were reviewed/received by the facility.

Based on medical record review and staff interview the facility failed to ensure one (1) of five (5) residents had a care plan revised when a resident's advanced directive had changed. Resident identifier: #28. Facility census: 125.
Findings included:
a) Resident #28
Medical record review revealed Resident #28 had an advanced directive care planned as comfort care. A progress note dated 08/17/23 stated the resident's medical power of attorney had changed the resident's advance directives from Do Not Resuscitate (DNR)/Selective Measures to DNR Comfort Care. A Physician Orders for Scope of Treatment (POST) form dated 08/17/23 also reflected the MPOA's signature and the box was checked for Comfort Focused Treatments.
A progress note dated 09/02/23 stated the resident was now DNR/Comfort and would no longer be having labs obtained or following up with specialists.
A care plan provided by the Director of Nursing (DoN) dated 09/26/23 under the focus Activities of Daily Living (ADL) the resident would at times refuse care and lab draws.
Another care plan focus area stated the resident was resistive to care related to cognitive loss/dementia as evidence by refusal of insulin, finger sticks, labs, medications and showers at times as well as meals. An intervention stated to monitor laboratory rest results and report abnormal results to physician/mid-level provider.
A care plan focus stated the resident had a diagnosis hypo Thyroid Disease. She had an intervention that stated to do a CBC annually and as needed.
On 09/26/23 at 5:25 PM the Director of Nursing (DoN) was interviewed and the information in the care plan that conflicted with the residents Comfort Care Advanced Directive was discussed. No further information was was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop and/or implement a comprehensive care plan for Resident #126. This is true for one (1) of six (6) residents reviewed during the survey process. Resident Identifier: #126. Facility Census: 125.
Finding Included:
a) Resident #126
On 09/26/23 at 11:30 AM, a record review was completed for Resident #126. The record review found the care plan had not been developed and implemented for Resident #126. Resident #126 was admitted on [DATE] and had been sent to the emergency department on 09/07/23.
The care plan had incomplete focus areas, interventions and goals in the areas of at risk for decreased ability to perform ADL(s), risk for falls, may not smoke per smoking evaluation and exhibits or is at risk for alterations in comfort. The care plan was void of any information. The sections listed were all blanks .nothing was added to the above focus areas.
On 09/26/23 at 1:50 PM, the Director of Nursing (DON) was notified and confirmed the care plan was not developed or implemented for Resident #126

Based on observation and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Proper infection control practices were not followed during medication administration. This deficient practice had the potential to affect one (1) of three (3) residents reviewed for medication administration. Resident identifier: #54. Facility census: 122.
Findings included:
a) Resident #54
On 07/03/23 at 9:23 AM, medication pass to Resident #54 by Licensed Practical Nurse (LPN) #126 was observed.
Among the oral medications Resident #54 received was paroxetine (antidepressant). When LPN #126 popped the paroxetine tablet out of the medication packaging, it did not fall into the medication cup. The tablet landed on a tissue LPN #126 was using as a barrier on the top of the medication cart. LPN #126 used her bare hands to put the tablet into the medication cup before taking the medications into the resident's room and administering them to the resident.
Additionally, Resident #54 was ordered Fluticasone nasal spray, artificial tears, Spiriva inhaler, Symbicort inhaler, and insulin which was supplied in an insulin pen. LPN #126 placed the resident's Spiriva inhaler, insulin pen, Fluticasone nasal spray, artificial tears, and Symbicort inhaler directly on the resident's overbed table without using a barrier between the overbed table and the medication.
Following the medication pass, LPN #126 was informed that she had touched the resident's pill with her bare hands after touching other items in the medication cart and even picking up a piece of cardboard that had fallen on the floor. She was also informed that because a barrier was not used between the inhalers, medication bottles, and insulin pen, infectious agents could have been transferred from the resident's overbed table to the medication carts when the items were returned to the cart. LPN #126 said she understood.