Beatitudes Campus

Based on interviews, review of clinical record, and facility records, policy, and procedures, the facility failed to protect the rights of one resident (#60) to be free from verbal abuse by a staff member. The deficient practice could result in psychosocial harm.

Based on interviews, review of clinical record, and facility policy, the facility failed to ensure a thorough investigation was conducted and recorded, and that a resident (#66) was assessed for injury regarding an allegation of abuse. The deficient practice could lead to continued physical and psychosocial harm of a resident, and/or a missed injury and delay of care.

The facility failed to ensure resident assessments for two residents were encoded and transmitted according to regulatory requirements.  The deficient practice can impact the facility's ability to monitor changes to residents' health data over time.   

Based on observations, staff interviews, United States Food and Drug Administration (FDA) recommendations and policy review, the facility failed to ensure food and drinks were palatable and maintained at an appetizing temperature. The deficient practice could result in the potential of bacterial growth in susceptible conditions, also known as the ‘danger zone’.

Based on observations, staff interviews, United States Food and Drug Administration (FDA) recommendations, and policy review, the facility failed to ensure that prepared food was stored in accordance with professional standards for food safety. The deficient practice could result in the potential of bacterial growth in susceptible conditions, also known as the 'danger zone'. 

Based on interviews, review of clinical record, and facility records, policy, and procedures, the facility failed to protect the rights of one resident (#60) to be free from verbal abuse by a staff member. The deficient practice could result in psychosocial harm.

Based on observations, staff interviews, United States Food and Drug Administration (FDA) recommendations, and policy review, the facility failed to ensure that prepared food was stored in accordance with professional standards for food safety. The deficient practice could result in the potential of bacterial growth in susceptible conditions, also known as the 'danger zone'. 

Based on observations, staff interviews, United States Food and Drug Administration (FDA) recommendations and policy review, the facility failed to ensure food and drinks were palatable and maintained at an appetizing temperature. The deficient practice could result in the potential of bacterial growth in susceptible conditions, also known as the ‘danger zone’.

Based on document review and staff interview the facility failed to maintain, review, and update the Emergency Preparedness (EP) Plan annually. Failure to ensure the EP plan was reviewed annually poses a potential risk that all required revisions to the plan will not be recognized and residents and staff.

Findings include:

Based on document review and staff interview on September 04, 2024, revealed outdated information contained in the Emergency Plan (EP) indicating that the EP had not been reviewed within the last year.

Facility management confirmed during the exit conference on September 04, 2024, that some of the documentation regarding facility staff and residents was not accurate and had not been updated.

Based on record review and staff interview, the facility failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State, and local laws and must include contact information related to staff, entities providing services under arrangement, next of kin, guardian or custodian, other facilities and volunteers be reviewed and updated at least annually. Failure to have an emergency preparedness communication plan that includes specific information could lead to harm to both patients and staff.

Findings include:

Based on record review and staff interview on September 04, 2024, revealed the communication plan that included contact information related to staff, residents, and physicians was outdated. Several administrative staff listed are no longer with the facility and the resident census was from 2021.

Management staff confirmed during the records review and exit conference on September 04, 2024, the Emergency Plan contained outdated information.

Based on observation the facility failed to have the appropriate arrangements to provide emergency egress through a designated exit. Failing to provide the appropriate arrangements for emergency egress during an emergency could cause harm to the patients or staff.

NFPA 101 2012 Life Safety Code Chapter 19.2.2.2.5.1 "Door-locking arrangements shall be permitted where the clinical needs of patients require specialized security measures or where patients pose a security threat, provided that staff can readily unlock doors at all times in accordance with 19.2.2.2.6." NFPA 101 2012 Life Safety Code Chapter 19.2.2.2.6 "Doors that are located in the means of egress and are permitted to be locked under other provisions of 19.2.2.2.5 shall comply with all of the following: (1) Provisions shall be made for the rapid removal of occupants by means of one of the following: (a) Remote control of locks, (b) Keying of all locks to keys carried by staff at all times, (c) Other such reliable means available to the staff at all times. (2) Only one locking device shall be permitted on each door. (3) More than one lock shall be permitted on each door, subject to the approval of the authority having jurisdiction."

Observations made while on tour on September 04, 2024, accompanied by the facility management team, an illuminated exit sign over a locked door was observed. The door labeled "Exit" had a key-activated locking cylinder that was locked. The door led into a storage room which then led to another exit door to the outside of the facility.

During the exit conference on September 04, 2024, the above findings were again acknowledged by the management team.

Based on observation the facility failed to assure that all parts of the facility were provided sprinkler system coverage. Failing to provide sprinkler coverage in all areas of the facility by blocking the sprinkler heads could result in the sprinkler not controlling the fire which could cause harm to the patients.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.3 Where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.." Chapter 9, Section 9.7.1.1, " Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems." NFPA 13, 2010 Edition. Chapter 8, Section 8.6.6.1 "The clearance between the deflector and the top of storage shall be 18 in. or greater." 19.3.5 Extinguishment Requirements. 18.3.5.1 * Buildings containing health care occupancies shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.

NFPA 13: Standard for the Installation of Sprinkler Systems, 2010 Edition - Chapter 8 Installation Requirements 8.15.7 * Exterior Roofs, Canopies, Porte-Cocheres, Balconies, Decks, or Similar Projections. 8.15.7.1 Unless the requirements of 8.15.7.2, 8.15.7.3, or 8.15.7.4 are met, sprinklers shall be installed under exterior roofs, canopies, porte-cocheres, balconies, decks, or similar projections exceeding 4 ft (1.2 m) in width. 8.15.7.2 * Sprinklers shall be permitted to be omitted where the canopies, roofs, porte-cocheres, balconies, decks, or similar projections are constructed with materials that are noncombustible, limited-combustible, or fire retardant-treated wood as defined in NFPA 703, Standard for Fire Retardant-Treated Wood and Fire-Retardant Coatings for Building Materials. 8.15.7.3

Findings include:

Observations made while on tour on September 04, 2024, revealed that storage in many areas where within eighteen (18) inches of the sprinkler heads. The facility's policy requires all areas to maintain a minimum of eighteen (18) inches of clearance from the sprinkler heads. Observations also revealed an area on the southeast exterior of the facility that contained electrical boxes covered by weathered combustible material attached to the building that was not sprinklered.

The following areas revealed storage within eighteen (18) inches of the sprinkler heads:

1) Storage room off of the maintenance room.
2) Chapel closets. (Three different closets).
3) Buckwalds dining area closets. (Two different closets).
4) Kitchen coolers

The following area was not sprinklered:

The southeast side of the facility where condenser units are ground mounted as well as electrical boxes mounted to the facility at the north end of this area. A weathered frame cover consisting of combustible materials greater than four (4) feet is attached to the facility and is not sprinklered.

The management team acknowledged during the facility tour and at the exit conference on September 4, 2024 that storage in many areas where within eighteen (18) inches of the sprinkler heads and the weathered wooden covering located along the southeast portion of the facility was not sprinklered.

Based on observation, the facility failed to display a current hydraulic plate on the sprinkler riser. Failure to require a current date on the riser hydraulic plate could result in errors during modifications and failure of the sprinkler system.

NFPA 25 2011 Standard for the inspection, testing, and maintenance of water-based fire protection systems.
5.2.6* Hydraulic Design Information Sign. The hydraulic design information sign for hydraulically designed systems shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible.

A.5.2.6 The hydraulic design information sign should be secured to the riser with durable wire, chain, or equivalent. (See Figure A.5.2.6.)

Paragraph 5.2.6 requires that the hydraulic design information sign (also called a nameplate or placard) be inspected on a quarterly basis.

NFPA 13 requires a hydraulic design information sign on hydraulically designed systems so that the design criteria and system demand can be readily determined. The hydraulic design information sign can provide useful information to the owner. If the design information sign is missing, the owner should contact a design professional to determine the demand for the system, which can be written on a new design information sign. The details are also documented on the approved plans and hydraulic calculations, but these plans can be misplaced and may not be available when the property changes owners. A hydraulic design information sign that is securely fastened to the riser can provide the details when these other data are missing (see Exhibit 5.21). If the sign becomes loose or is difficult to read, it must be repaired or replaced.

Findings include:

Observation made while on tour on September 04, 2024, revealed the sprinkler riser located on the outside north portion of the facility was missing the required hydraulic plate. The quarterly inspections did not identify the missing plate.

The management team confirmed during the tour as well as the exit conference on September 04, 4024, that the sprinkler riser hydraulic plate was missing.

Based on observation the facility failed to fill two penetrations in a smoke barrier. Failing to the penetrations, holes in the smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility which could cause harm to the patients in time of a fire.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a fire-resistance rating of at least \'bd hour." Chapter 8, Section 8.5.6.2 Penetrations for cables cable trays, conduits, pipes, tubes, vents wires, and similar items to accommodate electrical, plumbing, and communications systems that pass through a wall, floor or /ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof /ceiling of a smoke barrier assembly shall be protected by a system or material capable of restricting the transfer of smoke.

Findings include:

Observations made while on tour on September 04, 2024, revealed unsealed penetrations, (holes in a smoke barrier) located in the northwest mechanical room the penetrations was softball sized north wall.

The management team confirmed during the exit conference conducted on September 04, 2024, (holes in a smoke barrier) located in the northwest mechanical room the penetration was softball sized north wall.

Based on record review and staff interview the facility failed to have written documentation of the Annual Inspection and Testing of Door openings in accordance with NFPA 80, 2010 Edition, "Standard for Fire doors and Other Opening Protectives." Failing to inspect and test fire-rated door assemblies in accordance with NFPA 80 annually could cause harm to the patients.

NFPA 101 2012 Life Safety Code Section 8.3.3. Fire door and Windows Section 8.3.3.1 "Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening protective, except as otherwise specified in this code."

NFPA 80 Section 5.2* Inspections Section 5.2.1*"Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for the AHJ. Section 5.2.3 Functional Testing. Section 5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing."

Findings include:

Based on record review and staff interview on September 04, 2024, the facility failed to provide documentation of a required annual fire door inspection.

Facility Management confirmed during the tour and exit conference on September 04, 2024, that no door inspections had been performed in the last year.

Based on observations and staff interviews the facility failed to properly maintain an emergency call light system in resident rooms as well as the emergency pull cords in resident bathrooms. Failure to properly the emergency call light system can lead to harm of the residents.

NFPA 99: Health Care Facilities Code, 2012 Edition - Chapter 7 Information Technology and Communications Systems for Health Care Facilities. 7.3.3.1 Nurse Call Systems. 7.3.3.1.1 General. The nurse call systems shall communicate patient and staff calls for assistance and information in health care facilities. The nurse call systems shall be the audiovisual type and listed for the purpose. 7.3.3.1.1.1 The nurse call systems shall provide for communication of patient and staff calls for assistance and information, medical device alarms, and patient safety and security alarms. 7.3.3.1.6 Emergency Call. Each calling station shall be capable of initiating a visual and audible emergency signal, distinct from the regular nurse call signal, that can be turned off only at that station. The emergency call shall activate an annunciator at the nearest associated nursing station and a visual signal in the corridor at the patient room door and at other locations as directed by the facility. 7.3.3.1.6.1 Emergency calling devices shall be provided at each inpatient toilet, bath, shower, or sitz bath and shall be accessible to a patient lying on the floor. A pull cord shall be permitted to be used for this access.

Findings include:

Based on observations and staff interview on September 04, 2024, revealed the 4th-floor emergency call light system in resident rooms, as well as the emergency pull cord system in resident bathrooms, had been disabled by facility staff a number of years ago.

3rd-floor findings include the following:

1) Room 3007 bathroom pull cord was wrapped behind the toilet paper dispenser.
2) Room 3004 bathroom pull cord was wrapped around the pull bar.
3) Room 3001 bathroom pull cord was missing.

Facility management confirmed the emergency call system deficiencies during the exit conference conducted on September 04, 2024.

-Regarding Foley catheter bag

An observation was conducted on August 28, 2024 at 7:51 AM. The resident (#19) was lying in bed with his indwelling catheter bag laying on the floor beside the resident's bed.

Another observation was conducted on August 28, at 11:07 AM and revealed the resident (#19) was in bed with the indwelling catheter bag on the floor beside the resident's bed.

In an interview on August 28, 2024, at 11:37 AM, a certified nursing assistant (CNA/staff #11) stated that the catheter bag should not be on the floor in order to stay clean.

An interview with another CNA (staff #1) was conducted on August 28, 2024, at 11:42 AM. The CNA (staff #1) stated that the catheter bag should not be on the floor, and if it is on the floor, then there is a risk of infection. An observation of resident #19 was conducted with the CNA (staff #1) during the interview; and, the CNA stated that the resident's indwelling catheter bag was on the floor and it should not be. The CNA said that she would get a bag for it in order to hang it on the side of the bed.

During an interview conducted on August 29, 2024, at 12:44 PM, the Director of Nursing (DON/staff #12) stated that a catheter bag should not be on the floor, and that there was risk of infection if it was on the floor.

Review of the facility's policy titled Appropriate Use of Indwelling Catheters revealed that indwelling catheters (urethral or suprapubic) will be utilized with current standards of practice, with interventions to prevent complications to the extent possible. Possible complications include but are not limited to: urinary tract infection, blockage of catheter, pain, discomfort, and bleeding.

Based on personnel file review, staff interviews, and facility policy review, the facility failed to maintain an effective training program for two of 15 sampled staff (#70 and #19).

Findings include:

-Regarding the registered nurse (RN/staff #70)

Review of personnel file for the RN (staff #70) revealed a hire date of November 07, 2022.

The annual training transcript for the RN revealed that the most recent annually required training modules covering the topics of abuse, neglect, and exploitation, elder justice act, resident rights, dementia management, and infection control had been completed on November 08, 2022.

There was no evidence found that the RN had taken any training modules after November 8, 2022.

-Regarding the housekeeper (staff #19)

The personnel file for the housekeeper (staff #19) included a hire date of August 21, 2023.

Review of the housekeeper's annual training transcripts revealed that the most recent annually required training modules covering the topics of abuse, neglect, and exploitation, elder justice act, resident rights, dementia management, and infection control had been completed on August 21, 2023.

There was no evidence found that the RN had taken any training modules after August 21, 2023.

An interview with the human resources assistant (HR assistant/staff #90) was conducted on August 28, 2024 at 9:57 AM. The HR assistant stated that she could not tell specifics regarding which annual training modules are required for all employees, contract staff, and volunteers.

In an interview with the Administrator (Staff #59) conducted on August 29, 2024 at 11:15 AM, the administrator reviewed the provided annually required training module transcripts for Staff #70 and Staff #19. The administrator then stated that there were no annual training module transcripts on the topics of abuse, neglect, and exploitation, elder justice act, resident rights, dementia management, and infection control for the RN (staff #70) and the housekeeper (staff #19). The administrator also stated that "annual" training meant "within the past 365 days".

During an interview with the Vice President of Human Resources and Risk Management (VP of HR/staff #40) conducted on August 30, 2024 at 08:35 AM, she stated that when COVID hit, the facility did not update their training; and when the Administrator came on board, the administrator was not aware of that. The VP of HR also said that the facility was missing their old policy and was currently writing a new one. The VP of HR also said that their new written policy included what topics of training were required annually.

Review of the facility's policy titled New Hire Training and Annual In-Service Policy revealed that orientation training for newly hired staff members and volunteers, as well as annual training for current staff and volunteers is to include training on the topics of "nursing care institution policies and procedures, resident rights, infection control, hand washing, linen handling, prevention of communicable diseases, and disaster plans".

Based on personnel file review, staff interviews, and facility policy review, the facility failed to ensure two of 15 sampled staff (#70 and #19) received ongoing education on residents rights, abuse, neglect and exploitation and infection control.

Findings include:

-Regarding the registered nurse (RN/staff #70)

Review of personnel file for the RN (staff #70) revealed a hire date of November 07, 2022.

The annual training transcript for the RN revealed that the most recent annually required training modules covering the topics of abuse, neglect, and exploitation, elder justice act, resident rights, dementia management, and infection control had been completed on November 08, 2022.

There was no evidence found that the RN had taken any training on resident rights, abuse, neglect and exploitation and infection control after November 8, 2022.

-Regarding the housekeeper (staff #19)

The personnel file for the housekeeper (staff #19) included a hire date of August 21, 2023.

Review of the housekeeper's annual training transcripts revealed that the most recent annually required training modules covering the topics of abuse, neglect, and exploitation, elder justice act, resident rights, dementia management, and infection control had been completed on August 21, 2023.

There was no evidence found that the housekeeper had taken any training on resident rights, abuse, neglect and exploitation and infection control after August 21, 2023.

An interview with the human resources assistant (HR assistant/staff #90) was conducted on August 28, 2024 at 9:57 AM. The HR assistant stated that she could not tell specifics regarding which annual training modules are required for all employees, contract staff, and volunteers.

In an interview with the Administrator (Staff #59) conducted on August 29, 2024 at 11:15 AM, the administrator reviewed the provided annually required training module transcripts for Staff #70 and Staff #19. The administrator then stated that there were no annual training module transcripts on the topics of abuse, neglect, and exploitation, elder justice act, resident rights, dementia management, and infection control for the RN (staff #70) and the housekeeper (staff #19). The administrator also stated that "annual" training meant "within the past 365 days".

During an interview with the Vice President of Human Resources and Risk Management (VP of HR/staff #40) conducted on August 30, 2024 at 08:35 AM, she stated that when COVID hit, the facility did not update their training; and when the Administrator came on board, the administrator was not aware of that. The VP of HR also said that the facility was missing their old policy and was currently writing a new one. The VP of HR also said that their new written policy included what topics of training were required annually.

Review of the facility's policy titled New Hire Training and Annual In-Service Policy revealed that orientation training for newly hired staff members and volunteers, as well as annual training for current staff and volunteers is to include training on the topics of "nursing care institution policies and procedures, resident rights, infection control, hand washing, linen handling, prevention of communicable diseases, and disaster plans".

Based on clinical record review, interviews, facility documentation and a policy review, the facility failed to ensure that one sampled resident (#37) was notified prior to the room change.

Findings include:

Resident #37 was admitted on February 16, 2023 with diagnoses of vascular dementia, moderate, with other behavioral disturbance; major depressive disorder, recurrent, moderate; and unspecified dementia, severe, with other behavioral disturbance.

Review of a quarterly Medicare Minimum Data Set (MDS) assessment dated June 26, 2024, revealed a Brief Interview for Mental Status (BIMS) score of 00 indicating resident had severe cognitive impairment.

A social service note dated July, 15, 2024, revealed that Power of Attorney (POA) had called the Social Worker (SW/staff #38); and that, the SW re-iterated information regarding the cancelled room change, that had been previously discussed during a scheduled quarterly care plan meeting. The note also revealed the resident enjoyed the 4th floor and the connections made on the 4th floor.

Review of the electronic health records (EHR) revealed no evidence that the resident or responsible party were provided a written notice prior to the re-initiation of the room change that occurred approximately between the dates of July 22, 2024 and August 3, 2024.

Further review of the EHR revealed that the resident or responsible party did not complete a consent form for a room of change that occurred approximately between July 22, 2024 and August 3, 2024.

An interview was conducted on August 26, 2024 at 11:29AM with the resident's POA, who stated that they had a concern with the resident moving rooms. The POA reported that to their knowledge, a room change took place while the social services coordinator was out of office. The POA stated that there had been a discussion previously to complete a room change, however, it was then discussed that the room change was cancelled. The POA reported that they were unaware of the room change, until they made a visit to the facility; and, was advised that the resident was no longer on the 4th floor, but now on the 3rd floor.

An interview was conducted on August 29, 2024 at 11:20AM with the SW (staff # 38), who stated the room change process start with reaching out to the POA, and/or representative for the update in treatment; and then, a 30-day notice letter are to be sent out to the resident and/or representative. Regarding resident #37, the SW stated that a room change letter had been sent out in June; and that, the POA should have received it. The SW also said that following the letter, they had reached out to the POA and relayed to the POA that the room change had been cancelled. However, the SW admitted that the room change decision and implementation happened while she was out of town. Staff #38 stated that there was miscommunication regarding that room change for resident #37; and that, the room change happened without the proper room change notification expectations.

Review of a facility policy titled, "Notification of Room or Roommate Change", revealed that notification of room changes will be documented according to the facility's established practices, and to include completion of a "Notification of Room or Roommate Changes" form signed by the resident and/or resident's legal representative. The policy included that the resident has the right to notification of room or roommate changes and to agree prior to the change taking place.

Based on observation, record review, interviews, and facility policy review the facility failed to ensure one resident (#44) was assessed and care planned for the use of a power wheelchair seatbelt and bed rails/mobility bars.

Findings include:

Resident #44 was admitted into the facility on October 12, 2022 with diagnoses that included acute transverse myelitis, hemiplegia following cerebral infarction, major depressive disorder, and myocardial infarction.

The care plan dated October 13, 2022 indicated that the resident required assist with completion of activities of daily living and with mobility due to transverse myelitis and hemiplegia.

Another care plan dated October 13, 2022 revealed the resident had a functional decline related to CVa (cerebrovascular disease). Interventions included assistance with ADLs (activities of daily living) as needed) and use cushion in wheelchair.

Further review of the care plan revealed no evidence that use of the power wheelchair seatbelt or bedrails/mobility bars on her bed were addressed with interventions implemented.

Review of the physician orders revealed no evidence of any orders regarding use or assessment of seatbelt on her power wheelchair or bedrails/mobility bars on her bed.

Further, there was no evidence in the clinical record that the resident was assessed for seatbelt use on her power wheelchair or bedrails/mobility bars on her bed.

Review of the Treatment Administration Record (TAR) for July 2024 revealed no assessment, intervention, or monitoring, for Resident #44's seatbelt on her power wheelchair or bedrails/mobility bars on her bed.

The quarterly Minimum Data Set (MDS) assessment dated August 14, 2024 included a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident had intact cognition. The MDS also included that restraints and alarms, bed rail in bed and trunk restraint used in chair were coded as not used.

An observation conducted on August 26, 2024 at 11:57 AM revealed Resident #44 in bed with mobility bars present on the sides of her bed and a power wheelchair with a seatbelt present positioned in front of the bed against the wall. Resident #44 confirmed that this was her personal wheelchair.

In an interview conducted on August 29, 2024 at 08:06 AM, Resident #44 stated that the mobility bars sometimes get in her way, but that they were there for a reason.

In an interview conducted on August 29, 2024 at approximately 8:10 AM, a licensed practical nurse (LPN/staff #76) stated that he was not aware of any process that the facility had for assessing and monitoring possible restraints. Staff #76 stated that a restraint was considered to be a full side rail on a bed; and, anything that keeps a resident from getting out of bed, chair alarms or straps that restrain a patient. He further stated there were no residents at the facility that had been assessed for possible restraints because the facility does not use restraints.

In an interview on August 29, 2024 at 10:07 AM, the Director of Nursing (staff #12) stated that the facility does not restrain anybody; and that, restraints were anything that keeps the resident from getting up from the bed or chair. The DON said that a seatbelt was a restraint if the resident could not self-release; or, siderails were restraints if they cover the whole end of the bed. The DON said that if a resident had a seatbelt on their chair, then the facility conducts an assessment if the resident can self-release the seatbelt and this is documented in the electronic record. During the interview, a review of the clinical record was conducted with the DON who stated that resident #44 did not have any assessment for seatbelt use and bed rail/mobility bars and she could not find any documentation that the resident was assessed for ability to self-release seatbelt and/or use of bedrails/mobility bars. The DON said that if a resident was not assessed for a possible restraint, there was a risk of possible harm such as choking, if resident slide down in the chair, or contractures if they are restrained. Further, the DON said that the expectation was that staff would complete restraint assessment for residents who had a potential restraint and to document it on the TAR as per the facility policy.

Review of the facility's policy on Restraint Free Environment revealed that restraints was defined as any physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Physical restraints may include but are not limited to: using bed rails that keep the resident from voluntarily getting out of bed and using devices in conjunction with a chair such as trays, bars, or belts, that the resident cannot remove and prevents the resident from rising. Before a resident is restrained, the facility will determine the specific medical symptom that warrants the use of the restraint, the type of direct monitoring and supervision that will be provided during the use of the restraint, how the resident will request staff assistance while the restraint is in place, and how to assist the resident in attaining or maintaining his or her highest practicable level of physical well-being. Finally, the care plan should be updated accordingly to include the development and implementation of interventions, to address any risks related to the use of the restraint.

Based on observations and staff interviews, the facility failed to ensure daily staff posting was current and posted at the beginning of each shift. The deficient practice could result in the accurate daily staffing information not available to residents and visitors.

Findings include:

An observation in 4th floor was conducted on August 26, 2024 at 8:36 a.m. The daily staff posting was located on the wall by the elevators and across from the 4th floor nurse's station. The daily staff posting was dated January 3, 2024.

On August 26, 2024, at 8:40 AM, an observation in the 3rd floor was conducted; and, the daily staff posting was found on the wall by the elevators and across from the 3rd floor nurse's station. The daily staff posting was dated August 6, 2024.

An observation in the 4th floor was conducted on August 27, 2024 at 7:57 AM. There was no daily staff posting found on the 4th floor.

An observation in the 4th floor was conducted on August 28, 2024 at 8:00 AM. There was no daily staff posting found on the 4th floor.

In an interview with the director of nursing (DON/staff #12) conducted on August 29, 2024 at 12:25 PM, the DON stated that the daily staff posting was located on the 3rd floor by the nurse's station; and that, the residents on the 4th floor and their family can ask for the daily staffing information. The DON provided a copy of the daily staff posting dated August 26, 2024 and stated that this posting was previously posted on the 3rd floor on August 26, 2024. Review of the daily staff posting provided by the DON revealed that the date was altered from what appeared to be 8/06/24 and changed to "8/26/24."

An interview with the administrator (staff #59) was conducted August 29, 2024 at approximately 12:27 PM. The Administrator stated that a lot of residents from the 4th floor frequently come to the 3rd floor for activities, resident council, or to meet with the Director of Nursing in her office, and would be able to see the daily staff posting. The administrator said that the residents from the 4th floor who do not participate in activities, resident council, or to meet with the Director of Nursing in her office can be brought to the 3rd floor any time or the resident can go to the 3rd floor themselves if they want. Further, the administrator said that staff had not educated residents and their families on the daily staff posting located on the 3rd floor.

In an interview with a registered nurse (RN/staff #49) at the 4th floor conducted on August 30, 2024 at 6:56 AM. The RN stated that there usually was a daily staff posting on the 4th floor. The RN then pointed to the empty space on the wall by the elevator across from the nurse's station where there was a pushpin present in the wall. However, there was no daily staff posting posted on the wall; and, the RN stated that there was a daily staff posting found on the 3rd floor as well.

Based on clinical record review, staff interview, and policies and procedures, the facility failed to ensure that a comprehensive person-centered care plan with interventions related to use of oxygen was developed for one resident (#38).

Findings include:

Resident #38 was readmitted to facility March 28, 2024 with diagnoses of chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure.

The physician note dated March 29, 2024 revealed that resident had an oxygen saturation of 90% on room air, had an oxygen flow rate of 2 liters, and a respiratory rate of 18 breaths per minute. The documentation included that resident was oxygen dependent without any shortness of breath or wheezing while on 2 liters of oxygen. Diagnoses included emphysema and chronic hypoxemic respiratory failure. Plan was to continue oxygen at 2 liters for chronic hypoxemic respiratory failure.

A physician order dated March 30, 2024 included to change oxygen tubing weekly and to initial and date when the change was done.

Another physician order dated March 30, 2024 included for supplemental oxygen at 1-4 liters via nasal cannula in order to keep resident oxygen level above 90%.

Review of the Significant change in status Minimum Data Set (MDS) assessment dated July 2, 2024 revealed a Brief Interview for Mental Status (BIMS) score of 11 which indicated resident had cognitive impairment. The MDS also included that resident experienced shortness of breath while lying flat or with exertion and used oxygen.

Review of hospice comprehensive assessment and plan of care dated July 15, 2024 revealed an order to initiate oxygen at 2-4 liters via nasal cannula continuously or as needed as indicated.

The pain/palliative care consult notes dated July 24, 2024 revealed the resident was oxygen dependent.

The physician visit note dated July 31, 2024 assessment statement stated resident was oxygen dependent due to COPD.

Despite documentation that the resident was on oxygen therapy, the care plan related to oxygen use was not developed with interventions until August 28, 2024.

The care plan with revision date of August 28, 2024 included the resident was expected to lose weight related to emphysema, angina at rest, paroxysmal atrial fibrillation and chronic hypoxemic respiratory failure. Intervention included to administer oxygen as ordered.

An interview was conducted with a licensed practical nurse (LPN/staff #60) on August 26, 2024 at 1:09 p.m. The LPN stated that resident #38 should have the oxygen via nasal cannula on.

An interview with Assistant Director of Nursing (ADON/staff #68) conducted on August 27, 2024 at approximately 1:00 p.m. The ADON stated that care plans were created on admission, and updated as needed to meet the needs of the resident. ADON located the administrate oxygen intervention in Beatitudes care plan version. ADON believes the oxygen care planning portion was handled by Hospice of the Valley, and will obtain a copy for the surveyor.

An interview with the ADON and the restorative nurse assistant (RNA/staff#78) was conducted on August 29, 2024 at 1:28 p.m. Both the ADON and the RNA said that the resident should have the oxygen on her.

In an interview with the ADON conducted on August 30, 2024 at approximately 9:00 a.m., the ADON stated that resident #38 was often encouraged to wear oxygen as ordered on a regular basis to prevent shortness of breath and discomfort.

The facility policy on Oxygen Therapy included that care planning for oxygen should include oxygen delivery type, time to administer, equipment settings, monitoring of oxygen saturation levels, and monitoring for complications.

Review of the facility policy on Comprehensive Care Plan revealed that the care plan will include measurable objectives and timeframes to meet the resident's needs. The objectives will be utilized to monitor the resident's progress.

Based on clinical record review, observations, interviews, and policy review; the facility failed to ensure oxygen was administered as ordered for one resident (#38); and, failed to ensure there was a physician order for the use of oxygen for one resident (#50).

Findings include:

-Resident #38 was readmitted to facility March 28, 2024 with diagnoses of chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure.

The physician note dated March 29, 2024 revealed that resident had an oxygen saturation of 90% on room air, had an oxygen flow rate of 2 liters, and a respiratory rate of 18 breaths per minute. The documentation included that resident was oxygen dependent without any shortness of breath or wheezing while on 2 liters of oxygen. Diagnoses included emphysema and chronic hypoxemic respiratory failure. Plan was to continue oxygen at 2 liters for chronic hypoxemic respiratory failure.

A physician order dated March 30, 2024 included to change oxygen tubing weekly and to initial and date when the change was done.

Another physician order dated March 30, 2024 included for supplemental oxygen at 1-4 liters via nasal cannula in order to keep resident oxygen level above 90%.

The pain/palliative care consult notes dated April 26, May 1 and May 16, 2024 revealed the resident was oxygen dependent.

Review of the Significant change in status Minimum Data Set (MDS) assessment dated July 2, 2024 revealed a Brief Interview for Mental Status (BIMS) score of 11 which indicated resident had cognitive impairment. The MDS also included that resident experienced shortness of breath while lying flat or with exertion and used oxygen.

The pain/palliative care consult notes dated July 24, 2024 revealed the resident was oxygen dependent.

The physician visit note dated July 31, 2024 assessment statement stated resident was oxygen dependent due to COPD.

The care plan with revision date of August 28, 2024 included the resident was expected to lose weight related to emphysema, angina at rest, paroxysmal atrial fibrillation and chronic hypoxemic respiratory failure. Intervention included to administer oxygen as ordered.

An interview was conducted with a licensed practical nurse (LPN/staff #60) on August 26, 2024 at 1:09 p.m. The LPN stated that the oxygen concentrator was turned on at 1.5 liters but was not on the resident because the resident's nasal cannula was on the floor. She stated that the resident should have the oxygen via nasal cannula on; and that, the LPN encouraged the resident compliance with oxygen use and the importance of keeping the nasal cannula on. Further, the LPN instructed the resident to notify staff if the nasal cannula falls off or causes discomfort.

On August 27, 2024 from 8:00 p.m. through 10:00 p.m., the facility had a power outage and was using their emergency power system.

An observation was conducted on August 29, 2024 at 1:28 p.m. The resident was lying supine in bed and was pushing the buttons on the bed controls which were not working. The resident laid flat with three pillows on head of bed and tried to reposition herself in bed and attempted to sit up; and, did not have the oxygen via nasal cannula on. The resident attempted to reach the call light but was unable to because it was on the side table by her bed. The resident's wheelchair was close to bottom right of bed, with an oxygen tank attached to back of chair; and, the arrow on the oxygen tank pressure gauge pointed to distal end of red area. There was no nasal cannula or tubing attached to the tank. The oxygen concentrator was uncovered and unplugged to the left of resident's dresser with the nasal cannula wrapped around concentrator handle. The nasal cannula was labeled with date August 26, 2024 only and was uncovered while on concentrator. There was no red wall outlet found in the resident's room. The resident complained of not being able to get comfortable, was having difficulty in breathing and requested to have her oxygen brought over and to help elevate her head. The assistant director of nursing (ADON/staff #68) and the restorative nurse assistant (RNA/staff#78) were called to join in the observation. The ADON elevated the resident head using a pillow, and placed pulse oximeter on the resident's finger. The resident's oxygen saturation reading was 87% at 1:45 p.m. and 86% at 1:59 p.m. Both the ADON and RNA stated that the resident's portable oxygen tank on the wheelchair had a pressure gauge in red zone. Both staffs stated that the resident should have the oxygen on her. The RNA immediately left the resident room and came back with an oxygen tank replacement; and, the resident was transferred from bed to chair and was brought to the medication cart area by dining room. At 2:02 p.m., the resident's oxygen saturation was 89 % at 2 liters via nasal cannula. At 2:07 p.m., oxygen was increased to 4 liters; and at 2:09 p.m., resident's oxygen saturation was 92%.

In an interview with the ADON conducted on August 30, 2024 at approximately 9:00 a.m., the ADON stated that resident #38 was often encouraged to wear oxygen as ordered on a regular basis to prevent shortness of breath and discomfort.

Review of the facility policy entitled "Oxygen Concentrator" states to keep the oxygen concentrator set up turned off when not actively in use. Facility policy further instructs to keep oxygen delivery devices covered in a plastic bag when not in use. Policy also includes that it is the nurse responsibility to change oxygen tubing and cannula weekly, and as needed if it becomes soiled or contaminated.

Review of the policy entitled "Oxygen Therapy" states the reason for the administration of oxygen is to treat or prevent the symptoms and manifestations of hypoxia. Policy further dictates that staff shall notify the physician of any changes in the resident's condition, including changes in vital signs, oxygen concentrations, or evidence of complications associated with the use of oxygen.

Based on observations, staff interview, and policy review, the facility failed to ensure that the third-floor resident nourishment refrigerator food was stored in accordance with professional standards for food service safety. The deficient practice could result in food growing harmful bacteria that is a risk factor to cause foodborne illness.

Findings include:

During an observation of the third-floor nourishment refrigerator conducted on August 27, 2024 at 12:50 PM, revealed two undated partially uncovered fruit plates with green grapes and banana slices. There were red color liquid stains or spots the partially uncovered plates.

An interview was conducted on August 27, 2024 at 12:57 PM with the registered dietician (RD/staff #35) who stated that by the two fruit plates found in the third-floor resident nourishment refrigerator were from the night-shift; and, they should have been dated. The RD then proceeded to removing the two un-dated fruit plates from the nourishment refrigerator.

Review of the facility policy titled, Production, Purchasing, Storage; Food and Supply Storage revealed that the procedures are to cover, label and date unused portions and open packages with a completed orange-color label system. Products are good through the close of business on the date noted on the orange label and to discard food past the use-by or expiration date.

Based on observations, staff and resident interviews, and the facility's documentation and policies, the facility failed to ensure a safe and comfortable environment for residents.

Findings include:

Review of the open work order report generated on July 15, 2024 did not reveal any work order pertaining to any of the issues identified during the walk-through observations.

During the initial tour of the 4th floor unit conducted on August 28, 2024 at 12:17 PM., multiple rooms were found to have the following:
-Water stains on the ceiling tile;
-Door frame had a splatter of a brown substance; and,
-Temperature probe above the dining area on the 4th floor had built up substance and appeared to be leaking.

An interview with a Licensed Practical Nurse (LPN/ #29) was conducted on August 29, 2024 at 12:58 PM. The LPN (staff #29) stated that there was a work order website to put an order in and that staff can always call into the maintenance department.

An interview with the Senior Maintenance Engineer (staff #205) was conducted on August 30, 2024 at 8:04 a.m. Staff #205 stated that he conducts a "walkthrough" of the facility unit/s at least once a week; and that, the maintenance technician for the building does daily walkthroughs to check in and speak with nursing staff to see if anything needs to be done that was not currently in their work orders. Staff #205 stated that staining on the walls/ceilings would be suspicious and the facility would try to get them changed out to find the source of the problem. Staff #205 stated that the staining could occur due to moisture coming from something. Staff #205 further stated that it may be aesthetically unpleasing and anytime there was a high moisture situation there was the chance of mildew.

An interview with the Administrator (staff #110) was conducted on July 17, 2024 at 1:09 p.m. The administrator stated that the expectation was that the living area for residents was clean, free of obstruction, without significant odors and safe from hazards. The administrator said that repairs such as paint and upkeep should be maintained to have a homelike environment; and, this was important since the facility was the home for people living here and they deserve a good quality of life. The administrator also said that it has to be safe so that residents were not put at risk for accidents or injuries. Further, the administrator stated that if the facility was not homelike and not safe, the residents might feel discomfort, might reduce the homelike environment feel until things were repaired and could result in a risk for some type of injury i.e. if legs extend beyond the wheelchair there could be a risk of injury.

Review of the facility policy titled "Preventive Maintenance Program" revised January 11, 2023 and reviewed January 22, 2024 indicated that the facility must be designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel and the public.

The facility policy titled "Work Request System" revised May 14, 2019 and reviewed January 15, 2024 indicated that the work order request system was designed to provide an established and effective means of requesting, coordinating, and completing maintenance of a corrective nature.

A facility policy titled "Resident Rights" issued June 8, 2020 and reviewed September 25, 2023 indicated that residents have a right to a safe, clean, comfortable, and homelike environment.

Based on clinical record review, staff interviews, and facility documentation and policy review, the facility failed to ensure that three residents (#56, #55, #60) are free from abuse by another resident. The sample size was eight residents.

Findings Include:

Regarding resident #54 and #56:

- Resident #54 was admitted to the facility on August 1, 2019, with diagnoses that included Alzheimer's with late onset, Dementia with behavioral disturbance, epilepsy, neoplasm of unspecified behavior of brain, psychosis and major depressive disorder.

The facility report dated March 12, 2020 included, that on March 7, 2020, while resident #56 was standing in the hallway on station 4, resident #54 approached resident #56 and resident #54 placed both hands on resident #56's shoulders and pushed resident #56 up to the wall. Resident #56 lost her balance and slid down to the floor.

A review of resident #54's clinical record revealed that he was assessed on May 13, 2020, with a BIMS (Brief Interview for Mental Status) score of "99" and this interview also revealed that resident #54's cognitive skills for daily decision making is moderately impaired, indicating that resident #54 had poor decision-making skills and resident #54 required cues and/or supervision with daily decision-making.

- Resident #56 was admitted to the facility on August 1, 2019, with diagnoses that included dementia, major depressive disorder, insomnia, history of falling, dementia, psychosis and tremors.

A review of an incident report entered by LPN/staff #37 (Licensed Practical Nurse) dated March 7, 2020, revealed that CNA/staff#36 (Certified Nurse Assistant) witnessed resident #54 push resident #56 out of his way, which caused resident #56 to be pushed up to the wall and slide down to the floor.

A review of resident #56's clinical record dated May 6, 2020, revealed that resident #56's cognition is severely impaired.

A review of resident #56's care plan revealed that resident #56 required assistance with completion of her activities of daily living and mobility due to advanced dementia, psychosis and depression.

Regarding resident #54 and #55:

The facility report dated April 17, 2020, included, that on April 13, 2020, resident #54 went into resident #55's room without permission from resident #55 and began taking items off of resident #55's bed. Resident #55 asked resident #54 several times to stop, however, resident #54 would not listen. Instead, resident #54 became agitated and began hitting resident #55 on his right shoulder. Resident #55 then began hitting resident #54 back on resident #54's shoulder.

A review of resident #54's clinical record dated May 13, 2020, revealed that he was assessed with a BIMS (Brief Interview for Mental Status) score of "99" and this interview also revealed that resident #54's cognitive skills for daily decision making is moderately impaired, indicating that resident #54 had poor decision-making skills and resident #54 required cues and/or supervision with daily decision-making.

- Resident #55 was admitted to the facility on December 3, 2019, with diagnoses that included sepsis, Chronic embolism and thrombus of right lower extremity, chronic gout and type 2 diabetes.

A review of resident #55's clinical record revealed that he was assessed on March 10, 2020, with a BIMS score of 15/15, indicating that resident #55 was cognitively intact at the time the incident occurred.

A review of an incident report entered by LPN/staff#38 on April 12, 2020, revealed that resident #54 wandered into resident #55's room, resident #54 was trying to remove a "chux" pad off resident's bed while resident #55 was asking resident #54 to leave. Resident #54 hit resident #55 on the shoulder and resident #55 retaliated by hitting resident #54 on the shoulder.

Regarding resident #59 and #60:

- Resident #59 was admitted to the facility on March 23, 2021 with diagnoses that included mental disorder due to unknown physiological condition, TIA (transient ischemic accident), major depressive disorder, urinary incontinence and history of falling.

The facility report dated June 22, 2021, included, that on June 17, 2021, resident # 59 kicked resident #60 in the shin.

A review of resident #59's clinical record dated June 30, 2021, revealed that resident #59 was assessed with a BIMS score of 6/15, indicating that resident #59's cognition was severely impaired.

- Resident #60 was admitted to the facility on May 12, 2020, with diagnoses that included dementia, urinary infections, history of falling, PVD (peripheral vascular disease), anxiety disorder and major depressive disorder.

A review of resident #60's clinical record dated revealed that resident #60 was assessed on May 17, 2021, with a BIMS score of "99" and moderately impaired with cognitive skills for daily decision-making and resident #59 required cues and supervision for daily decision-making.

A telephone call to CNA/staff #39 on July 30, 2024, at 3:03pm, was made and her voicemail picked without call back.

A telephone call to staff #40 on July 30, 2024, at 3:05pm was made, who stated that the staff #40 did not remember that incident as it happened so long ago.

A telephone call to staff# 41/Diet Aide on July 30, 2024, at 3:10pm was made. Staff #41 stated that the staff did not recall witnessing an argument or abuse or an altercation that involved resident #60 and resident #59 as the incident happened a long time ago.

An interview was conducted with the facility administrator/staff # 43 on July 30, 2024, at 3:45pm who stated that abuse, neglect and misappropriation are reported to the Department of Health Services, Adult Protective Services, the Police, the Ombudsman, hospice if the residents on hospice and the family.

A review of the facility's abuse, neglect and exploitation policy and procedure dated September, 2022, revealed that, "it is the policy of this facility to maintain an environment where residents are free from abuse, neglect, exploitation and misappropriation. The intent of this policy is to ensure each resident has the right to be free from abuse, neglect and corporal punishment of any type by anyone."

Based on observation the facility failed to prevent the fire alarm pull station to be accessible and unobstructed. Obscuring the fire alarm pull stations from view may prevent or delay the initiating of the fire alarm system in an emergency and this has potential harm to the patients during a fire.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.4.2.1 "Initiation of the required fire alarm systems shall be by manual means in accordance with 9.6.2 and by means of any required sprinkler system waterflow alarms, detection devices, or detection systems, unless otherwise permitted by 19.3.3.2.2 through 19.3.4.2.4." Chapter 9, Section 9.6.2.7, "Each manual fire alarm box on a system shall be accessible, unobstructed, and visible."

Findings include:

Observation made while tour on January 18, 2023, revealed the pull station in the kitchen was blocked by a microwave oven which had a toaster on it.

During the exit conference on January 18, 2023 the above finding was again acknowledged by management staff.

Based on observation, the facility failed to ensure that staff did not plug appliances into power strips. Appliances plugged into power strips could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients.

NFPA 101, Life Safety Code, 2012. Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 2012 Edition. NFPA 99, Chapter 6, Section 6.3.2.2.6.2 , "All Patient Care Areas," Sections 6.3.2.2..6.2 (A) through 6.3.2.2.6.2 (E) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area.

Findings include:

Observations made while on tour on January 18, 2023, revealed a refrigerator plugged into a power strip in the activities office.

During the exit conference conducted on January 18, 2023, the above findings were again acknowledged by the management team.

Based on clinical record, staff interview and facility policy and procedures, the facility failed to ensure that a PASARR (Preadmission Screening and Resident Review) Level 1 screening was completed as required for one resident (#25).

Findings include:

Resident #25 was admitted on November 27, 2022 with diagnosis of bipolar disorder.

The admission MDS (Minimum Data Set) assessment dated December 4, 2022 revealed the resident was not evaluated by level II PASARR and was not determined to have serious mental illness and/or mental retardation or a related condition. However, the assessment revealed the resident had an active diagnosis of manic depression/bipolar disease.

Review of the clinical record revealed no evidence that a PASARR level 1 screening was completed for resident #25 until January 17, 2023.

The PASARR Level 1 screening dated January 17, 2023 revealed the resident had serious mental illness and diagnosis of bipolar disorder. It also included that the resident was not on a 30-day convalescent care, not on respite admission and did not have terminal state or severe illness. Per the screening, there was no referral necessary for any level II.

An interview was conducted with social services (staff #70) and the admissions coordinator (staff #13) conducted on January 17, 2023 at 3:17 p.m. The admission coordinator (staff #13) stated that he could not find a PASARR Level 1 screening for resident #25 in the clinical records. The social services (staff #70) stated that there was no PASARR Level 1 screening completed for resident #25 prior to January 17, 2023. Staff #70 stated they are required to complete a PASSAR Level 1 for a resident upon admission; and that, resident #25 recently transitioned long term care. Staff #70 said she reviewed the resident's records, did a status change and completed a PASARR level 1 screening for resident #25 only this morning.

In an interview with the admissions coordinator (staff #13) conducted on January 19, 2023 at 10:05 a.m., staff #13 said he did not receive from previous facility the completed PASARR screening for resident #25. He stated he reached out to the previous facility yesterday and will do so again this morning. Staff #13 further stated that he normally does not miss a resident not having a PASARR level 1 screening on admission; however, this one has slipped by.

During another interview with the social services (staff #70) conducted on January 19, 2023 at 10:44 a.m., staff #70 stated that PASARR Level 1 screening is an evaluation to determine the level of care the resident need; and, the type of facility appropriate for the resident. Staff #70 said not having PASSAR Level 1 may result in the resident with mental illness not receiving the level of care they need. Further, staff #70 stated that it was important to have the baseline for care purposes.

A review of the facility policy, "Resident Assessment-Coordination with PASSAR Program" reviewed/revised on April 2021 revealed that all applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening; and, a record of the pre-screening shall be maintained in the resident's medical record.

Based on clinical record review, staff interviews, facility documentation and policy, the facility failed to ensure an allegation of abuse for one resident (#39) was reported as required.

Findings include:

Resident #39 admitted on January 30, 2019 with diagnoses of cerebral infarction, hemiplegia and hemiparesis and dysphagia.

Review of the facility investigation revealed the incident occurred on January 3, 2023 at 4:00 p.m. The investigation included that on January 4, 2023, a certified nursing assistant (CNA/staff #27) reported that the resident told her that the "big girl with the red hair" had punched her in the head; and that, the date of the alleged abuse was January 3, 2023. Continued review of the investigation included that on interview with the resident the facility during a resident interview, the resident described the alleged perpetrator and identified a CNA (staff #19). The investigation also included a statement from the CNA (staff #27) that on January 4, 2023 resident #39 reported multiple times throughout the day at the nursing station that the big girl with the red hair punched her in the head. The statement also included that when the resident reported that the incident happened "yesterday"; and that, later that day the resident repeated the same statement.

Further review of the facility investigation revealed that staff #35 was called to the room to assist with resident #39 on January 3, 2023 at approximately 4:30 p.m. she was asked by CNA (staff #19) for help in assisting resident #39. Staff #35 wrote in her statement that resident #39 told her to "get her (referring to staff #19) away from me, she's (referring to staff #19) tossing me around and hitting me".

Despite documentation of an allegation of abuse, there was no evidence the facility that the facility reported the allegation of abuse to the State agency until January 4, 2023 on the after-office hour message line.

An interview was conducted on January 18, 2023 at 1:01 p.m. with CNA (staff #27) who stated resident #39 came to the nurse's station and reported that the lady with the red hair hit her in the back of her head. She stated the resident kept saying the same thing and she went and reported to the administrator right away.

In an interview with another CNA (staff #35) conducted on January 18, 2023 at 1:07 p.m., staff #35 stated she received training on types of abuse and reporting abuse; and that, she supposed to report abuse right away to her nurse/supervisor, nurse manager and administrator. The CNA stated in her written statement, the resident #39 described that the alleged CNA (#19) was "tossing me (referring to resident) around and hitting me (referring to resident)" was an allegation of abuse. However, staff #35 said resident #39 had paranoia and she figured it was just one of those times. Staff #35 that at the time the resident made the allegation, she approached the resident and asked her if she was ok and the resident said yes. She stated after she got the resident up she went to nurses' station and told nurse (staff #55) about the report she received from resident #39. She stated she does not know whether or not the nurse had reported the allegation.

An interview was conducted on January 18, 2023 at 1:26 p.m. with Licensed Practical Nurse (LPN/staff #55) who stated that no abuse allegation was reported to her on January 3, 2023. She stated if a resident stated a staff member was tossing and hitting a resident, that would be an allegation of abuse and she would have expected it to be reported. The LPN stated if it had been reported to her she would have contacted the nurse manager or nurse administrator immediately as the facility has two hours to file a report to the State Agency. Further, the LPN said they had to take every allegation seriously and act as if the allegation happened.

During an interview with the Administrator/Director of Nursing (DON/staff #12) conducted on January 18, 2023 at 3:22 p.m., staff #12 stated she was the abuse coordinator; and that, if there was an allegation of staff abuse from a resident, it should be reported to the nurse on duty that day, preferably nurse assigned to resident. Staff #12 said staff was not expected to figure out if abuse happened, it was their job to report. She stated the nurse was expected to notify the Administrator or the nurse manager right away so they could do the required reporting. She stated it was important to report immediately to protect their residents from being harmed, and to make sure the resident was safe and secure. Regarding the incident with resident #39, she said the reporting CNA (staff #27) came to her office on January 4, 2023 at approximately 4:30 p.m. and told her the resident reported that the girl with the big red hair had hit the resident in the head. She stated an allegation from a resident that a staff member was tossing them around and hitting them was allegation of abuse; and, she expected that it would be reported immediately, she stated in reference to the statement from CNA (staff #35) the date of the alleged abuse was January 3, 2023; and, it should have been reported immediately and was not. However, she stated that staff did not follow facility protocol on abuse reporting.

Review of the facility Policy on Abuse, Neglect and Exploitation revised on April 2022 revealed that it was their policy to maintain an environment where residents are free from abuse, neglect, exploitation and misappropriation of resident property and all residents, staff, families, visitors, volunteers and resident representatives are encouraged and supported in reporting any suspected acts of abuse, neglect, exploitation and misappropriation of resident property, or exploitation. It also included that the nursing home administrator or designee will report abuse to the State Agency per State and federal requirements. Further, it is their policy to ensure the reporting of crimes against resident or individual receiving care within prescribed timeframes to the appropriate entities; and that, the facility will report alleged violations related to mistreatment, exploitation, neglect or abuse, including injuries of unknown source and misappropriation of resident property and report the results of all investigation to the proper authorities within prescribed timeframes.

Based on clinical record review, review of facility documentation, staff interviews and review of facility policy, the facility failed to prevent further potential abuse by staff following an abuse allegation for one resident (#39).

Findings include:

Resident #39 admitted to the facility on January 30, 2019 with diagnoses of cerebral infarction, hemiplegia and hemiparesis, and dysphagia.

Review of the facility investigation revealed the incident occurred on January 3, 2023 at 4:00 p.m. The investigation included that on January 4, 2023, a certified nursing assistant (CNA/staff #27) reported that the resident told her that the "big girl with the red hair" had punched her in the head; and that, the date of the alleged abuse was January 3, 2023. Continued review of the investigation included that on interview with the resident the facility during a resident interview, the resident described the alleged perpetrator and identified a CNA (staff #19). The investigation also included a statement from the CNA (staff #27) that on January 4, 2023 resident #39 reported multiple times throughout the day at the nursing station that the big girl with the red hair punched her in the head. The statement also included that when the resident reported that the incident happened "yesterday"; and that, later that day the resident repeated the same statement.

Further review of the facility investigation revealed that staff #35 was called to the room to assist with resident #39 on January 3, 2023 at approximately 4:30 p.m. she was asked by CNA (staff #19) for help in assisting resident #39. Staff #35 wrote in her statement that resident #39 told her to "get her (referring to staff #19) away from me, she's (referring to staff #19) tossing me around and hitting me".

There was no evidence found in the clinical record and facility documentation that resident #39 was protected from further abuse from the alleged CNA (staff #19).

Review of the employee time card for the alleged CNA (staff #19) revealed that staff #19 worked on January 3, 2023 from 5:58 a.m. through 6:11 p.m.

A review of facility documentation revealed that the alleged CNA (staff #19) was suspended only on January 4, 2023.

The HR (human resources)/progressive discipline form dated January 4, 2023 revealed that on January 4, 2023, there was an allegation of abuse from a resident against CNA (staff #19) who was informed that she would be removed from schedule during the investigation and findings.

In an interview with another CNA (staff #35) conducted on January 18, 2023 at 1:07 p.m., staff #35 stated she received training on types of abuse and reporting abuse; and that, she supposed to report abuse right away to her nurse/supervisor, nurse manager and administrator. The CNA stated in her written statement, the resident #39 described that the alleged CNA (#19) was "tossing me (referring to resident) around and hitting me (referring to resident)" was an allegation of abuse. However, staff #35 said resident #39 had paranoia and she figured it was just one of those times. Staff #35 that at the time the resident made the allegation, she approached the resident and asked her if she was ok and the resident said yes. She stated after she got the resident up she went to nurses' station and told nurse (staff #55) about the report she received from resident #39. She stated the alleged CNA (staff #19) continued to work with resident #39 and the rest of her assigned residents for the remainder of the shift. She further stated it was important to remove the alleged perpetrator/staff from patient care to prevent potential abuse to residents; and that, staff #19 should have not continued to give care based on facility protocol.

An interview was conducted on January 18, 2023 at 1:26 p.m. with Licensed Practical Nurse (LPN/staff #55) who stated that no abuse allegation was reported to her on January 3, 2023. She stated if a resident stated a staff member was tossing and hitting a resident, that would be an allegation of abuse and she would have expected it to be reported. The LPN stated if it had been reported to her she would have contacted the nurse manager or nurse administrator immediately as the facility has two hours to file a report to the State Agency. Further, the LPN said they had to take every allegation seriously and act as if the allegation happened. She stated the alleged CNA (staff #19) would not have continued to work with resident #39; and, she would not have allowed the alleged CNA (staff #19) to give further resident care until direction was received from administration. The LPN said it was important to keep an alleged perpetrator from working to keep them from hurting other residents and to keep residents safe.

During an interview with the Administrator/Director of Nursing (DON/staff #12) conducted on January 18, 2023 at 3:22 p.m., staff #12 stated she was the abuse coordinator; and that, in a case of an allegation of staff to resident abuse, the alleged perpetrator would be immediately removed from the floor and sent home. She stated the alleged perpetrator would not be able to return until the completion of investigation determined substantiation. Staff #12 said that it was important to report the allegation of abuse immediately to protect their residents from being harmed, and to make sure the resident was safe and secure. Regarding the incident with resident #39, she stated there was an allegation from a resident that a staff member was tossing around and hitting the resident. Staff #12 also said that the nurse working the shift at the time the alleged event was not interviewed and should have been interviewed. She stated in reference to the statement from CNA (staff #35) the date of the alleged abuse was January 3, 2023; and, there was a risk for further resident abuse since the alleged CNA (staff #19) continued to work with resident #39 and the rest of her assigned residents for the remainder of the shift. She stated the protocol was not followed to protect residents from further abuse.

Review of the facility Policy on Abuse, Neglect and Exploitation revised on April 2022 revealed that it was their policy to maintain an environment where residents are free from abuse, neglect, exploitation and misappropriation of resident property. The facility will take actions in response to an alleged violation of abuse, neglect, exploitation or mistreatment to include preventing further abuse from occurring while the investigation is in progress. All staff will cooperate during the investigation to assure the resident is fully protected. During the investigation the alleged perpetrator will immediately be removed and resident protected. Employees accused of alleged abuse will be immediately removed from the resident's area and will remain removed pending the results of a thorough investigation.

Based on clinical record review, staff interviews, and review of facility policy and procedure, the facility failed to ensure one resident (#18) or resident representative was informed in advance of the risks and benefits prior to administration of a psychotropic medication. The deficient practice could result in not having the right to choose the option the resident prefers.

Findings include:

Resident #18 admitted on August 4, 2020 with diagnoses of dementia, depressive disorder, and Parkinson's disease.

The care plan initiated on July 5, 2022 revealed the resident was receiving an antidepressant for depression and was at risk for adverse effects.

A physician order dated September 23, 2022 included for Mirtazapine (antidepressant) for depression as evidenced by restlessness and low appetite.

The MAR (medication administration record) from September 2022 through January 2023 revealed the resident received Mirtazapine as ordered.

Review of the quarterly Minimum Data Set (MDS) assessment dated December 1, 2022 revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated resident had severe cognitive impairment. The assessment also included the resident received daily antidepressant use in the assessment time period.

However, further review of the clinical record revealed no evidence the resident/representative was informed of the risks and benefits of Mirtazapine prior to administering the medication.

An interview was conducted on January 20, 2023 at 8:30 a.m. with the Administrator/Director of Nursing (DON/staff #12) who stated she was unable to find documentation that the risks/benefits of Mirtazapine was discussed and provided to resident #18 or resident representative. Staff #12 also said that the facility failed to obtain informed consent for use of Mirtazapine from the resident #18 or resident representative.

In an interview conducted with a Licensed Practical Nurse (LPN/staff # 54) on January 20, 2023 at 9:43 a.m., the LPN stated when staff gets a new medication order for a psychotropic medication, a consent for its use is obtained from and explained to the resident or the resident's Power of Attorney (POA). She stated she would explain to the resident and/or POA what the psychotropic medication would be used for, the dose, the expected benefits, and adverse effects. She stated staff was not supposed to administer a psychotropic medication without obtaining the psychotropic consent. The LPN also stated it was important to make the resident or family aware of the risks because a psychotropic medication use had side effects and could "snow" people. Further, she stated staff did not follow policy if consent was not obtained prior to the use or administration of a psychotropic medication to the resident. The LPN also said that if there is no documentation found in the clinical record that a consent and risk/benefits for its use, there was no way to show that the consent was obtained.

During a second interview with the Administrator/DON (staff #12) conducted on January 20, 2023 at 9:59 a.m., staff #12 stated the informed consent was the documentation for the risk and benefit for psychotropic medication use. She stated staff were expected to obtain the informed consent with the resident/responsible party; and that, the documentation or discussion of informed consent included providing the name and dose of the medication, possible contributing factors for use, diagnosis of why the resident was taking the medication, and adverse effects. Staff #12 also said the nurse and family member were supposed to sign the form and if obtained by phone staff would note it as verbal consent. She stated that if the resident or representative did not give informed consent, there should be a discussion with the resident or representative by the nursing, administrative team, and physician to alleviate concerns and answer questions; and that, if consent was still not obtained, the medication would not be given or will be discontinued. Regarding resident #18, she stated staff did not obtain informed consent for Mirtazapine prior to its administration to the resident.

The facility policy on Psychotropic Medication revised on November 2021 revealed that based on each resident's comprehensive assessment, the facility will ensure to provide the resident/resident representative with information on the medication, indication, dose, side effects, adverse consequences and goal of treatment; and, obtain informed consent from the resident and/or resident representative and document education, information regarding the medication indication and directions for use, side effects and potential adverse consequences, risks and benefits of the medication and resident choice. The resident and/or responsible party will be notified regarding dose changes and this will be documented in the nurse notes. Consents and any psychotropic medications will be reviewed quarterly at resident care conference.

Based on clinical record review, staff interviews, facility documentation and policy, the facility failed to ensure an allegation of abuse for one resident (#39) was reported as required. The deficient practice could lead to continued abuse of the resident or other residents.

Findings include:

Resident #39 admitted on January 30, 2019 with diagnoses of cerebral infarction, hemiplegia and hemiparesis and dysphagia.

Review of the facility investigation revealed the incident occurred on January 3, 2023 at 4:00 p.m. The investigation included that on January 4, 2023, a certified nursing assistant (CNA/staff #27) reported that the resident told her that the "big girl with the red hair" had punched her in the head; and that, the date of the alleged abuse was January 3, 2023. Continued review of the investigation included that on interview with the resident the facility during a resident interview, the resident described the alleged perpetrator and identified a CNA (staff #19). The investigation also included a statement from the CNA (staff #27) that on January 4, 2023 resident #39 reported multiple times throughout the day at the nursing station that the big girl with the red hair punched her in the head. The statement also included that when the resident reported that the incident happened "yesterday"; and that, later that day the resident repeated the same statement.

Further review of the facility investigation revealed that staff #35 was called to the room to assist with resident #39 on January 3, 2023 at approximately 4:30 p.m. she was asked by CNA (staff #19) for help in assisting resident #39. Staff #35 wrote in her statement that resident #39 told her to "get her (referring to staff #19) away from me, she's (referring to staff #19) tossing me around and hitting me".

Despite documentation of an allegation of abuse, there was no evidence the facility that the facility reported the allegation of abuse to the State agency until January 4, 2023 on the after-office hour message line.

An interview was conducted on January 18, 2023 at 1:01 p.m. with CNA (staff #27) who stated resident #39 came to the nurse's station and reported that the lady with the red hair hit her in the back of her head. She stated the resident kept saying the same thing and she went and reported to the administrator right away.

In an interview with another CNA (staff #35) conducted on January 18, 2023 at 1:07 p.m., staff #35 stated she received training on types of abuse and reporting abuse; and that, she supposed to report abuse right away to her nurse/supervisor, nurse manager and administrator. The CNA stated in her written statement, the resident #39 described that the alleged CNA (#19) was "tossing me (referring to resident) around and hitting me (referring to resident)" was an allegation of abuse. However, staff #35 said resident #39 had paranoia and she figured it was just one of those times. Staff #35 that at the time the resident made the allegation, she approached the resident and asked her if she was ok and the resident said yes. She stated after she got the resident up she went to nurses' station and told nurse (staff #55) about the report she received from resident #39. She stated she does not know whether or not the nurse had reported the allegation.

An interview was conducted on January 18, 2023 at 1:26 p.m. with Licensed Practical Nurse (LPN/staff #55) who stated that no abuse allegation was reported to her on January 3, 2023. She stated if a resident stated a staff member was tossing and hitting a resident, that would be an allegation of abuse and she would have expected it to be reported. The LPN stated if it had been reported to her she would have contacted the nurse manager or nurse administrator immediately as the facility has two hours to file a report to the State Agency. Further, the LPN said they had to take every allegation seriously and act as if the allegation happened.

During an interview with the Administrator/Director of Nursing (DON/staff #12) conducted on January 18, 2023 at 3:22 p.m., staff #12 stated she was the abuse coordinator; and that, if there was an allegation of staff abuse from a resident, it should be reported to the nurse on duty that day, preferably nurse assigned to resident. Staff #12 said staff was not expected to figure out if abuse happened, it was their job to report. She stated the nurse was expected to notify the Administrator or the nurse manager right away so they could do the required reporting. She stated it was important to report immediately to protect their residents from being harmed, and to make sure the resident was safe and secure. Regarding the incident with resident #39, she said the reporting CNA (staff #27) came to her office on January 4, 2023 at approximately 4:30 p.m. and told her the resident reported that the girl with the big red hair had hit the resident in the head. She stated an allegation from a resident that a staff member was tossing them around and hitting them was allegation of abuse; and, she expected that it would be reported immediately, she stated in reference to the statement from CNA (staff #35) the date of the alleged abuse was January 3, 2023; and, it should have been reported immediately and was not. However, she stated that staff did not follow facility protocol on abuse reporting.

Review of the facility Policy on Abuse, Neglect and Exploitation revised on April 2022 revealed that it was their policy to maintain an environment where residents are free from abuse, neglect, exploitation and misappropriation of resident property and all residents, staff, families, visitors, volunteers and resident representatives are encouraged and supported in reporting any suspected acts of abuse, neglect, exploitation and misappropriation of resident property, or exploitation. It also included that the nursing home administrator or designee will report abuse to the State Agency per State and federal requirements. Further, it is their policy to ensure the reporting of crimes against resident or individual receiving care within prescribed timeframes to the appropriate entities; and that, the facility will report alleged violations related to mistreatment, exploitation, neglect or abuse, including injuries of unknown source and misappropriation of resident property and report the results of all investigation to the proper authorities within prescribed timeframes.

Based on clinical record review, review of facility documentation, staff interviews and review of facility policy, the facility failed to prevent further potential abuse by staff following an abuse allegation for one resident (#39). The deficient practice could lead to continued abuse of the resident or other residents.

Findings include:

Resident #39 admitted to the facility on January 30, 2019 with diagnoses of cerebral infarction, hemiplegia and hemiparesis, and dysphagia.

Review of the facility investigation revealed the incident occurred on January 3, 2023 at 4:00 p.m. The investigation included that on January 4, 2023, a certified nursing assistant (CNA/staff #27) reported that the resident told her that the "big girl with the red hair" had punched her in the head; and that, the date of the alleged abuse was January 3, 2023. Continued review of the investigation included that on interview with the resident the facility during a resident interview, the resident described the alleged perpetrator and identified a CNA (staff #19). The investigation also included a statement from the CNA (staff #27) that on January 4, 2023 resident #39 reported multiple times throughout the day at the nursing station that the big girl with the red hair punched her in the head. The statement also included that when the resident reported that the incident happened "yesterday"; and that, later that day the resident repeated the same statement.

Further review of the facility investigation revealed that staff #35 was called to the room to assist with resident #39 on January 3, 2023 at approximately 4:30 p.m. she was asked by CNA (staff #19) for help in assisting resident #39. Staff #35 wrote in her statement that resident #39 told her to "get her (referring to staff #19) away from me, she's (referring to staff #19) tossing me around and hitting me".

There was no evidence found in the clinical record and facility documentation that resident #39 was protected from further abuse from the alleged CNA (staff #19).

Review of the employee time card for the alleged CNA (staff #19) revealed that staff #19 worked on January 3, 2023 from 5:58 a.m. through 6:11 p.m.

A review of facility documentation revealed that the alleged CNA (staff #19) was suspended only on January 4, 2023.

The HR (human resources)/progressive discipline form dated January 4, 2023 revealed that on January 4, 2023, there was an allegation of abuse from a resident against CNA (staff #19) who was informed that she would be removed from schedule during the investigation and findings.

In an interview with another CNA (staff #35) conducted on January 18, 2023 at 1:07 p.m., staff #35 stated she received training on types of abuse and reporting abuse; and that, she supposed to report abuse right away to her nurse/supervisor, nurse manager and administrator. The CNA stated in her written statement, the resident #39 described that the alleged CNA (#19) was "tossing me (referring to resident) around and hitting me (referring to resident)" was an allegation of abuse. However, staff #35 said resident #39 had paranoia and she figured it was just one of those times. Staff #35 that at the time the resident made the allegation, she approached the resident and asked her if she was ok and the resident said yes. She stated after she got the resident up she went to nurses' station and told nurse (staff #55) about the report she received from resident #39. She stated the alleged CNA (staff #19) continued to work with resident #39 and the rest of her assigned residents for the remainder of the shift. She further stated it was important to remove the alleged perpetrator/staff from patient care to prevent potential abuse to residents; and that, staff #19 should have not continued to give care based on facility protocol.

An interview was conducted on January 18, 2023 at 1:26 p.m. with Licensed Practical Nurse (LPN/staff #55) who stated that no abuse allegation was reported to her on January 3, 2023. She stated if a resident stated a staff member was tossing and hitting a resident, that would be an allegation of abuse and she would have expected it to be reported. The LPN stated if it had been reported to her she would have contacted the nurse manager or nurse administrator immediately as the facility has two hours to file a report to the State Agency. Further, the LPN said they had to take every allegation seriously and act as if the allegation happened. She stated the alleged CNA (staff #19) would not have continued to work with resident #39; and, she would not have allowed the alleged CNA (staff #19) to give further resident care until direction was received from administration. The LPN said it was important to keep an alleged perpetrator from working to keep them from hurting other residents and to keep residents safe.

During an interview with the Administrator/Director of Nursing (DON/staff #12) conducted on January 18, 2023 at 3:22 p.m., staff #12 stated she was the abuse coordinator; and that, in a case of an allegation of staff to resident abuse, the alleged perpetrator would be immediately removed from the floor and sent home. She stated the alleged perpetrator would not be able to return until the completion of investigation determined substantiation. Staff #12 said that it was important to report the allegation of abuse immediately to protect their residents from being harmed, and to make sure the resident was safe and secure. Regarding the incident with resident #39, she stated there was an allegation from a resident that a staff member was tossing around and hitting the resident. Staff #12 also said that the nurse working the shift at the time the alleged event was not interviewed and should have been interviewed. She stated in reference to the statement from CNA (staff #35) the date of the alleged abuse was January 3, 2023; and, there was a risk for further resident abuse since the alleged CNA (staff #19) continued to work with resident #39 and the rest of her assigned residents for the remainder of the shift. She stated the protocol was not followed to protect residents from further abuse.

Review of the facility Policy on Abuse, Neglect and Exploitation revised on April 2022 revealed that it was their policy to maintain an environment where residents are free from abuse, neglect, exploitation and misappropriation of resident property. The facility will take actions in response to an alleged violation of abuse, neglect, exploitation or mistreatment to include preventing further abuse from occurring while the investigation is in progress. All staff will cooperate during the investigation to assure the resident is fully protected. During the investigation the alleged perpetrator will immediately be removed and resident protected. Employees accused of alleged abuse will be immediately removed from the resident's area and will remain removed pending the results of a thorough investigation.

Based on clinical record, staff interview and facility policy and procedures, the facility failed to ensure that a PASARR (Preadmission Screening and Resident Review) Level 1 screening was completed as required for one resident (#25). The deficient practice could result in specialized services not provided to meet resident's needs.

Findings include:

Resident #25 was admitted on November 27, 2022 with diagnosis of bipolar disorder.

The admission MDS (Minimum Data Set) assessment dated December 4, 2022 revealed the resident was not evaluated by level 2 PASARR and was not determined to have serious mental illness and/or mental retardation or a related condition. However, the assessment revealed the resident had an active diagnosis of manic depression/bipolar disease.

Review of the clinical record revealed no evidence that a PASARR level 1 screening was completed for resident #25 until January 17, 2023.

The PASARR Level 1 screening dated January 17, 2023 revealed the resident had serious mental illness and diagnosis of bipolar disorder. It also included that the resident was not on a 30-day convalescent care, not on respite admission and did not have terminal state or severe illness. Per the screening, there was no referral necessary for any level II.

An interview was conducted with social services (staff #70) and the admissions coordinator (staff #13) conducted on January 17, 2023 at 3:17 p.m. The admission coordinator (staff #13) stated that he could not find a PASARR Level 1 screening for resident #25 in the clinical records. The social services (staff #70) stated that there was no PASARR Level 1 screening completed for resident #25 prior to January 17, 2023. Staff #70 stated they are required to complete a PASSAR Level 1 for a resident upon admission; and that, resident #25 recently transitioned long term care. Staff #70 said she reviewed the resident's records, did a status change and completed a PASARR level 1 screening for resident #25 only this morning.

In an interview with the admissions coordinator (staff #13) conducted on January 19, 2023 at 10:05 a.m., staff #13 said he did not receive from previous facility the completed PASARR screening for resident #25. He stated he reached out to the previous facility yesterday and will do so again this morning. Staff #13 further stated that he normally does not miss a resident not having a PASARR level 1 screening on admission; however, this one has slipped by.

During another interview with the social services (staff #70) conducted on January 19, 2023 at 10:44 a.m., staff #70 stated that PASARR Level 1 screening is an evaluation to determine the level of care the resident need; and, the type of facility appropriate for the resident. Staff #70 said not having PASSAR Level 1 may result in the resident with mental illness not receiving the level of care they need. Further, staff #70 stated that it was important to have the baseline for care purposes.

A review of the facility policy, "Resident Assessment-Coordination with PASSAR Program" reviewed/revised on April 2021 revealed that all applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening; and, a record of the pre-screening shall be maintained in the resident's medical record.

Based on clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure care provided met professional standards of care by failing to follow physician orders regarding insulin for one resident (#14). The deficient practice could result in adverse outcomes and/or complications related to diabetes mellitus (DM).

Findings include:

Resident #14 admitted to the facility on January 15, 2019 with diagnoses that included dysphagia, dementia, and type two diabetes mellitus (DM).

The care plan dated January 17, 2019 revealed the resident had DM and was at risk for complications to this disease process, especially if blood sugars were not well controlled. The goal was that the resident's blood sugars would be controlled within normal limits. Intervention included insulin as ordered.

The physician order dated March 31, 2021 revealed an order for Novolog Flex pen U-100 insulin Aspart 100 unit/milliliter (ml) subcutaneous 17 units plus sliding scale insulin (SSI) three times a day for DM type 2:
-150-199 mg/dl (milligrams/deciliter), give 3 units;
-200-249 mg/dl, give 6 units;
-250-299 mg/dl give 9 units;
-300-349 mg/dl give 12 units;
-350-399 mg/dl give 15 units;
-400-449 mg/dl give 18 units;
-450-499 mg/dl give 21 units; and to notify physician if glucose was over 500 mg/dl.

Review of the Medication Administration Record (MAR) for Novolog for November 2022 revealed that on the following dates for the 7:30 a.m. dose, Novolog insulin was not administered according to the physician's ordered parameter for insulin:
-November 2 - blood sugar (BS) was 215 mg/dl and 6 units of insulin was administered. However, the resident should have received 23 units of insulin per the physician's order;
-November 6 - BS was 211 mg/dl and 6 units of insulin was administered. However, the resident should have received 23 units of insulin per the physician's order;
-November 13 - BS was 107 mg/dl and no insulin were administered; and that, medication was not administered with no noted reason. However, the resident should have received 17 units of insulin per the physician's order; and,
-November 15 - BS was 216 mg/dl and 26 units of insulin was administered. However, the resident should have received 23 units of insulin per the physician's order.

The MAR for December 2022 revealed that on the following dates for the 7:30 a.m. dose, Novolog insulin was not administered according to the physician's ordered parameter for insulin:
-December 2 - BS was 221 mg/dl and 6 units of insulin was administered. However, the resident should have received 23 units of insulin per the physician's order.
-December 4 - BS was 327 mg/dl and 32 units of insulin was administered. However, the resident should have received 29 units of insulin per the physician's order.
-December 31 - BS was 228 mg/dl and 6 units of insulin was administered. However, the resident should have received 23 units of insulin per the physician's order.

A review of the MAR for January 2023 revealed on the following dates for the 12:00 noon dose, Novolog insulin was not administered according to the physician's ordered parameter for insulin:
-January 1 - BS was 109 mg/dl. Zero insulin was administered and the documentation included that the medication was not administered with no noted reason. However, the resident should have received 17 units of insulin per the physician's order;
-January 6 - BS was 131 mg/dl and 20 units of insulin was administered. However, the resident should have received 17 units of insulin per the physician's order;
-January 14 - BS was 162 mg/dl and 3 units of insulin was administered. However, the resident should have received 20 units of insulin per the physician's order;
-January 18 - BS was 219 mg/dl and 13 units of insulin was administered. However, the resident should have received 23 units of insulin per the physician's order; and,
-January 19 - BS was 266 mg/dl and 29 units of insulin was administered. However, the resident should have received 26 units of insulin per the physician's order.

Review of the progress notes for November 2022 through January 2023 revealed no documentation why Novolog insulin was not administered according to the physician ordered parameters; and that, the physician was notified.

The annual Minimum Data Set (MDS) assessment dated January 26, 2023 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident's cognition was severely impaired. The assessment included a diagnosis of DM and daily insulin injections.

An interview was conducted on January 20, 2023 at 9:04 a.m. with a Registered Nurse (RN/staff #81) who stated staff was expected to follow the physician orders as written, including insulin and sliding scales. He stated the risks for insulin not given as ordered included resident having hyperglycemia, insulin shock; altered mental status, and it could lead to ketoacidosis. The RN said that if the resident was given too much insulin they could become hypoglycemic, sweaty, clammy, drowsy, and could pass out. During the interview, a review of the clinical record was conducted with the RN who stated the insulin orders included that resident #14 was supposed to get 17 units of Novolog insulin plus additional sliding scale insulin whose was dependent on the resident's blood sugar. The RN said that if he thinks the blood sugar was low, he would give the resident food/drink, and hold the medication until he could call the doctor and get direction. The RN said that the January 2023 MAR in the three entries he reviewed, insulin was not administered according to the physician ordered parameter for the sliding scale.

During an interview with the Administrator/Director of Nursing (DON/staff #12) conducted on January 20, 2023 at 9:52 a.m., staff #12 stated staff are expected to follow the physician's orders as written, including following the orders for insulin and SSI administration. Staff #12 said that if the resident refuse, staff was still expected to follow the physician's order until they had an updated order from physician. She stated the risk factor if the ordered amount of insulin was not given could be adverse health effects. During the interview, a review of the clinical record was conducted with staff #12 who stated that the January 2023 MAR revealed that staff had not administered the insulin as ordered by the physician.

The facility policy on Timely Administration of Insulin reviewed/revised on April 2021 revealed that it was their policy to provide timely administration of insulin in order to meet the needs of each resident and to prevent adverse effects on a resident's condition. All insulin will be administered in accordance with physician's orders. Review the insulin order to include resident name, medication name, medication dosage, time to be administered, route of administration.

Review of a facility policy on Medication Management policy revised on June 2021 revealed that medications will be administered to residents as prescribed and by persons lawfully authorized to do so in a manner consistent with good infection control and standards of practice. Prior to administration, the medication and dosage schedule on the Medication Administration Record (MAR) is compared with the medication label. Medications are administered in accordance with written orders of the attending physician or physician extender.

A review of the facility policy on Physician's Orders updated on April 2021 included that to ensure accuracy, physician orders will be written, noted and carried out as ordered.

Based on staff interviews and review of facility documentation and policy, the facility failed to use the services of a Registered Nurse (RN) for at least eight hours consecutive hours a day, seven days a week. The census was 57 and the sample was 15. The deficient practice could result in not enough staff to meet the resident's needs.

Findings include:

Review of facility punch detail for registered nurses revealed no evidence of RN coverage on February 13, 2022

The Facility Assessment revealed that nursing shifts are twelve hours with a goal of consistent assignments.

On January 20, 2023 at 8:23 a.m., the Director of Nursing (DON/staff #12) stated that her expectation was to have an RN scheduled to work at least 8 hours per day, that included weekends. The DON stated that she and the Nurse Manager also cover; however, they do not have a punch detail of the time they are in the facility as they are salaried employees.

In a later interview conducted with the DON/staff #12 on January 20, 2023 at 9:44 a.m., the DON stated that she reviewed the PBJ (Payroll Based Journal) staffing for February 13, 2022 and there was no evidence that an RN had been scheduled to work in the building on that day. She stated that this did not meet the facility policy or expectation; and, the risk could include no staff available to administer intravenous medications, and not having the higher critical thinking of an RN available.

The facility policy on Abuse Prevention, revealed that the facility deploys trained, qualified and competent staff on each shift in sufficient numbers to meet the needs of the residents. Staff have knowledge of the individual resident's care needs, as identified by the Facility Assessment.

Based on staff interviews and review of facility documentation and policy, the facility failed to ensure he Daily Staff Postings for nursing staff were accurate for actual hours worked by licensed and unlicensed direct care nursing staff. The deficient practice could result in residents and visitors not being informed of accurate and current staffing information.

Findings include:

A review of five randomly chosen days of staff postings compared with the staff assignment sheets revealed that none of the staff postings matched the actual number of staffs that worked.

Further review of the Daily Staff Postings revealed no evidence of the actual and total hours worked by licensed and unlicensed nursing staff on December 8, 9, 10, 11 and 12.

The Daily Staff Postings from December 8 through 12, 2022 also revealed inaccurate staffing data posted on the following dates:
-December 8 - there were 7 CNAs (Certified Nursing Assistants) who worked on the day shift, and 6 CNAs worked on the evening shift. However, a review of the punch detail revealed that 6 CNAs actually worked on the day shift, and five CNAs worked on the evening shift;
-December 9 - there was one Registered Nurses (RN) and one Licensed Practical Nurse (LPN) who worked on the day shift. However, the punch detail for December 9, 2022 revealed that two RNs and 1 LPN worked on the day shift;
-December 10 - there was one Registered Nurses (RN) and one Licensed Practical Nurse (LPN) worked on the day shift. Review of the punch detail revealed that there were two RNs and 1 LPN who worked on the day shift;
-December 11 - there were 7 CNAs worked the day shift, and 6 CNAs worked the night shift. Review of the punch detail revealed that 8 CNA's actually worked on the day shift, and 5 CNAs actually worked on the night shift; and,
-December 12 - there were 6 CNAs who worked on the evening shift, but the punch detail revealed there were only 5 CNAs who actually worked the evening shift.

An interview was conducted on January 19, 2023 at 10:50 a.m. with the Staffing Coordinator (staff #71) who stated the Human Resources (HR) department tracks the nursing productivity; and the administrator was responsible for updating the staff posting form on a daily basis. The Staffing Coordinator stated the expectation was for staff postings to be accurate with the actual number of staffs that worked for the day. She further stated they currently do not document the total hours worked by licensed or unlicensed staff on the daily staff posting form. During the interview, the staffing coordinator reviewed the daily staff posting forms and compared them to the staff assignment forms from December 8 through December 12, 2022. The staffing coordinator stated the daily staffing forms were not accurate and this did not meet the facility expectation.

During an interview with the Director of Nursing (DON/staff #12) conducted on January 19, 2023 at 1:08 p.m., the DON stated her expectation was that the daily staff posting accurately reflect the staff that worked each day. She also stated she expected the staff posting to be updated with any changes throughout the day. During the interview, the DON reviewed the daily staff postings for December 8 through December 12, 2022 and stated that they were not accurate. Further, the DON said that an inaccurate staff posting could result in residents/family not having accurate staffing information.

The facility policy on Posting Direct Care Daily Staffing Numbers, revealed that the facility will post on a daily basis, the total number of hours worked by the nursing staff on each shift, who are responsible for providing direct care to residents. A daily posting of the number of hours for Nurses (RN, LPN) and the number of CNAs for each shift who are responsible for providing direct care will be posted in a prominent location, accessible to residents and visitors in a clear and readable format.

Based on observation, staff interview and review of facility policy, the facility failed to ensure food items were stored in accordance with professional standards for food service safety by failing to ensure temperatures for the refrigerators were consistently monitored, maintained and documented. The deficient practice could result in food served to residents not safe for consumption.

Findings include:

During an initial kitchen tour conducted on January 17, 2023 conducted with the executive chef (staff #91) revealed no recorded refrigerator temperature for the following dates and times:
-January 06, 2023 for the p.m. shift;
-January 08, 2023 for the a.m. shift;
-January 09, 2023 for a.m. shift;
-January 15, 2023 for a.m. shift; and,
-January 16, 2023 for the a.m. shift.

In an interview conducted immediately following the observation, the Executive Chef (staff # 91) stated that regular staff were not present and temporary staff was on shift on the days that temperatures were not recorded. Staff #91 stated that the expectations was that regardless of which staff are on shift, the refrigerator temperatures are recorded each morning and evening and should be recorded.

A review of the facility policy on Production, Purchasing, Storage, and Cold Storage Temperatures revealed that at the beginning of each month a new log is to be started. It also included that each morning at opening and evening at closing, record temperatures of each storage unit; initial each entry; and to circle any deviant readings.

Based on clinical record review, staff interviews, and review of facility policy and procedure, the facility failed to ensure one resident (#18) or resident representative was informed in advance of the risks and benefits prior to administration of a psychotropic medication.

Findings include:

Resident #18 admitted on August 4, 2020 with diagnoses of dementia, depressive disorder, and Parkinson's disease.

The care plan initiated on July 5, 2022 revealed the resident was receiving an antidepressant for depression and was at risk for adverse effects.

A physician order dated September 23, 2022 included for Mirtazapine (antidepressant) for depression as evidenced by restlessness and low appetite.

The MAR (medication administration record) from September 2022 through January 2023 revealed the resident received Mirtazapine as ordered.

Review of the quarterly Minimum Data Set (MDS) assessment dated December 1, 2022 revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated resident had severe cognitive impairment. The assessment also included the resident received daily antidepressant use in the assessment time period.

However, further review of the clinical record revealed no evidence the resident/representative was informed of the risks and benefits of Mirtazapine prior to administering the medication.

An interview was conducted on January 20, 2023 at 8:30 a.m. with the Administrator/Director of Nursing (DON/staff #12) who stated she was unable to find documentation that the risks/benefits of Mirtazapine was discussed and provided to resident #18 or resident representative. Staff #12 also said that the facility failed to obtain informed consent for use of Mirtazapine from the resident #18 or resident representative.

In an interview conducted with a Licensed Practical Nurse (LPN/staff # 54) on January 20, 2023 at 9:43 a.m., the LPN stated when staff gets a new medication order for a psychotropic medication, a consent for its use is obtained from and explained to the resident or the resident's Power of Attorney (POA). She stated she would explain to the resident and/or POA what the psychotropic medication would be used for, the dose, the expected benefits, and adverse effects. She stated staff was not supposed to administer a psychotropic medication without obtaining the psychotropic consent. The LPN also stated it was important to make the resident or family aware of the risks because a psychotropic medication use had side effects and could "snow" people. Further, she stated staff did not follow policy if consent was not obtained prior to the use or administration of a psychotropic medication to the resident. The LPN also said that if there is no documentation found in the clinical record that a consent and risk/benefits for its use, there was no way to show that the consent was obtained.

During a second interview with the Administrator/DON (staff #12) conducted on January 20, 2023 at 9:59 a.m., staff #12 stated the informed consent was the documentation for the risk and benefit for psychotropic medication use. She stated staff were expected to obtain the informed consent with the resident/responsible party; and that, the documentation or discussion of informed consent included providing the name and dose of the medication, possible contributing factors for use, diagnosis of why the resident was taking the medication, and adverse effects. Staff #12 also said the nurse and family member were supposed to sign the form and if obtained by phone staff would note it as verbal consent. She stated that if the resident or representative did not give informed consent, there should be a discussion with the resident or representative by the nursing, administrative team, and physician to alleviate concerns and answer questions; and that, if consent was still not obtained, the medication would not be given or will be discontinued. Regarding resident #18, she stated staff did not obtain informed consent for Mirtazapine prior to its administration to the resident.

The facility policy on Psychotropic Medication revised on November 2021 revealed that based on each resident's comprehensive assessment, the facility will ensure to provide the resident/resident representative with information on the medication, indication, dose, side effects, adverse consequences and goal of treatment; and, obtain informed consent from the resident and/or resident representative and document education, information regarding the medication indication and directions for use, side effects and potential adverse consequences, risks and benefits of the medication and resident choice. The resident and/or responsible party will be notified regarding dose changes and this will be documented in the nurse notes. Consents and any psychotropic medications will be reviewed quarterly at resident care conference.

Based on staff interviews and review of facility documentation and policy, the facility failed to ensure he Daily Staff Postings for nursing staff were accurate for actual hours worked by licensed and unlicensed direct care nursing staff.

Findings include:

A review of five randomly chosen days of staff postings compared with the staff assignment sheets revealed that none of the staff postings matched the actual number of staffs that worked.

Further review of the Daily Staff Postings revealed no evidence of the actual and total hours worked by licensed and unlicensed nursing staff on December 8, 9, 10, 11 and 12.

The Daily Staff Postings from December 8 through 12, 2022 also revealed inaccurate staffing data posted on the following dates:
-December 8 - there were 7 CNAs (Certified Nursing Assistants) who worked on the day shift, and 6 CNAs worked on the evening shift. However, a review of the punch detail revealed that 6 CNAs actually worked on the day shift, and five CNAs worked on the evening shift;
-December 9 - there was one Registered Nurses (RN) and one Licensed Practical Nurse (LPN) who worked on the day shift. However, the punch detail for December 9, 2022 revealed that two RNs and 1 LPN worked on the day shift;
-December 10 - there was one Registered Nurses (RN) and one Licensed Practical Nurse (LPN) worked on the day shift. Review of the punch detail revealed that there were two RNs and 1 LPN who worked on the day shift;
-December 11 - there were 7 CNAs worked the day shift, and 6 CNAs worked the night shift. Review of the punch detail revealed that 8 CNA's actually worked on the day shift, and 5 CNAs actually worked on the night shift; and,
-December 12 - there were 6 CNAs who worked on the evening shift, but the punch detail revealed there were only 5 CNAs who actually worked the evening shift.

An interview was conducted on January 19, 2023 at 10:50 a.m. with the Staffing Coordinator (staff #71) who stated the Human Resources (HR) department tracks the nursing productivity; and the administrator was responsible for updating the staff posting form on a daily basis. The Staffing Coordinator stated the expectation was for staff postings to be accurate with the actual number of staffs that worked for the day. She further stated they currently do not document the total hours worked by licensed or unlicensed staff on the daily staff posting form. During the interview, the staffing coordinator reviewed the daily staff posting forms and compared them to the staff assignment forms from December 8 through December 12, 2022. The staffing coordinator stated the daily staffing forms were not accurate and this did not meet the facility expectation.

During an interview with the Director of Nursing (DON/staff #12) conducted on January 19, 2023 at 1:08 p.m., the DON stated her expectation was that the daily staff posting accurately reflect the staff that worked each day. She also stated she expected the staff posting to be updated with any changes throughout the day. During the interview, the DON reviewed the daily staff postings for December 8 through December 12, 2022 and stated that they were not accurate. Further, the DON said that an inaccurate staff posting could result in residents/family not having accurate staffing information.

The facility policy on Posting Direct Care Daily Staffing Numbers, revealed that the facility will post on a daily basis, the total number of hours worked by the nursing staff on each shift, who are responsible for providing direct care to residents. A daily posting of the number of hours for Nurses (RN, LPN) and the number of CNAs for each shift who are responsible for providing direct care will be posted in a prominent location, accessible to residents and visitors in a clear and readable format.

Based on clinical record review, staff interviews, and review of policy and procedure, the facility failed to maintain highest practicable well-being by failing to follow physician orders regarding insulin for one resident (#14).

Findings include:

Resident #14 admitted to the facility on January 15, 2019 with diagnoses that included dysphagia, dementia, and type two diabetes mellitus (DM).

The care plan dated January 17, 2019 revealed the resident had DM and was at risk for complications to this disease process, especially if blood sugars were not well controlled. The goal was that the resident's blood sugars would be controlled within normal limits. Intervention included insulin as ordered.

The physician order dated March 31, 2021 revealed an order for Novolog Flex pen U-100 insulin Aspart 100 unit/milliliter (ml) subcutaneous 17 units plus sliding scale insulin (SSI) three times a day for DM type 2:
-150-199 mg/dl (milligrams/deciliter), give 3 units;
-200-249 mg/dl, give 6 units;
-250-299 mg/dl give 9 units;
-300-349 mg/dl give 12 units;
-350-399 mg/dl give 15 units;
-400-449 mg/dl give 18 units;
-450-499 mg/dl give 21 units; and to notify physician if glucose was over 500 mg/dl.

Review of the Medication Administration Record (MAR) for Novolog for November 2022 revealed that on the following dates for the 7:30 a.m. dose, Novolog insulin was not administered according to the physician's ordered parameter for insulin:
-November 2 - blood sugar (BS) was 215 mg/dl and 6 units of insulin was administered. However, the resident should have received 23 units of insulin per the physician's order;
-November 6 - BS was 211 mg/dl and 6 units of insulin was administered. However, the resident should have received 23 units of insulin per the physician's order;
-November 13 - BS was 107 mg/dl and no insulin were administered; and that, medication was not administered with no noted reason. However, the resident should have received 17 units of insulin per the physician's order; and,
-November 15 - BS was 216 mg/dl and 26 units of insulin was administered. However, the resident should have received 23 units of insulin per the physician's order.

The MAR for December 2022 revealed that on the following dates for the 7:30 a.m. dose, Novolog insulin was not administered according to the physician's ordered parameter for insulin:
-December 2 - BS was 221 mg/dl and 6 units of insulin was administered. However, the resident should have received 23 units of insulin per the physician's order.
-December 4 - BS was 327 mg/dl and 32 units of insulin was administered. However, the resident should have received 29 units of insulin per the physician's order.
-December 31 - BS was 228 mg/dl and 6 units of insulin was administered. However, the resident should have received 23 units of insulin per the physician's order.

A review of the MAR for January 2023 revealed on the following dates for the 12:00 noon dose, Novolog insulin was not administered according to the physician's ordered parameter for insulin:
-January 1 - BS was 109 mg/dl. Zero insulin was administered and the documentation included that the medication was not administered with no noted reason. However, the resident should have received 17 units of insulin per the physician's order;
-January 6 - BS was 131 mg/dl and 20 units of insulin was administered. However, the resident should have received 17 units of insulin per the physician's order;
-January 14 - BS was 162 mg/dl and 3 units of insulin was administered. However, the resident should have received 20 units of insulin per the physician's order;
-January 18 - BS was 219 mg/dl and 13 units of insulin was administered. However, the resident should have received 23 units of insulin per the physician's order; and,
-January 19 - BS was 266 mg/dl and 29 units of insulin was administered. However, the resident should have received 26 units of insulin per the physician's order.

Review of the progress notes for November 2022 through January 2023 revealed no documentation why Novolog insulin was not administered according to the physician ordered parameters; and that, the physician was notified.

The annual Minimum Data Set (MDS) assessment dated January 26, 2023 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident's cognition was severely impaired. The assessment included a diagnosis of DM and daily insulin injections.

An interview was conducted on January 20, 2023 at 9:04 a.m. with a Registered Nurse (RN/staff #81) who stated staff was expected to follow the physician orders as written, including insulin and sliding scales. He stated the risks for insulin not given as ordered included resident having hyperglycemia, insulin shock; altered mental status, and it could lead to ketoacidosis. The RN said that if the resident was given too much insulin they could become hypoglycemic, sweaty, clammy, drowsy, and could pass out. During the interview, a review of the clinical record was conducted with the RN who stated the insulin orders included that resident #14 was supposed to get 17 units of Novolog insulin plus additional sliding scale insulin whose was dependent on the resident's blood sugar. The RN said that if he thinks the blood sugar was low, he would give the resident food/drink, and hold the medication until he could call the doctor and get direction. The RN said that the January 2023 MAR in the three entries he reviewed, insulin was not administered according to the physician ordered parameter for the sliding scale.

During an interview with the Administrator/Director of Nursing (DON/staff #12) conducted on January 20, 2023 at 9:52 a.m., staff #12 stated staff are expected to follow the physician's orders as written, including following the orders for insulin and SSI administration. Staff #12 said that if the resident refuse, staff was still expected to follow the physician's order until they had an updated order from physician. She stated the risk factor if the ordered amount of insulin was not given could be adverse health effects. During the interview, a review of the clinical record was conducted with staff #12 who stated that the January 2023 MAR revealed that staff had not administered the insulin as ordered by the physician.

The facility policy on Timely Administration of Insulin reviewed/revised on April 2021 revealed that it was their policy to provide timely administration of insulin in order to meet the needs of each resident and to prevent adverse effects on a resident's condition. All insulin will be administered in accordance with physician's orders. Review the insulin order to include resident name, medication name, medication dosage, time to be administered, route of administration.

Review of a facility policy on Medication Management policy revised on June 2021 revealed that medications will be administered to residents as prescribed and by persons lawfully authorized to do so in a manner consistent with good infection control and standards of practice. Prior to administration, the medication and dosage schedule on the Medication Administration Record (MAR) is compared with the medication label. Medications are administered in accordance with written orders of the attending physician or physician extender.

A review of the facility policy on Physician's Orders updated on April 2021 included that to ensure accuracy, physician orders will be written, noted and carried out as ordered.

Based on observation, staff interview and review of facility policy, the facility failed to ensure food items were stored in accordance with professional standards for food service safety by failing to ensure temperatures for the refrigerators were consistently monitored, maintained and documented.

Findings include:

During an initial kitchen tour conducted on January 17, 2023 conducted with the executive chef (staff #91) revealed no recorded refrigerator temperature for the following dates and times:
-January 06, 2023 for the p.m. shift;
-January 08, 2023 for the a.m. shift;
-January 09, 2023 for a.m. shift;
-January 15, 2023 for a.m. shift; and,
-January 16, 2023 for the a.m. shift.

In an interview conducted immediately following the observation, the Executive Chef (staff # 91) stated that regular staff were not present and temporary staff was on shift on the days that temperatures were not recorded. Staff #91 stated that the expectations was that regardless of which staff are on shift, the refrigerator temperatures are recorded each morning and evening and should be recorded.

A review of the facility policy on Production, Purchasing, Storage, and Cold Storage Temperatures revealed that at the beginning of each month a new log is to be started. It also included that each morning at opening and evening at closing, record temperatures of each storage unit; initial each entry; and to circle any deviant readings.