Every finding on record at Aerius Health Center

Based on observation, interview and record review the facility failed to ensure residents were assessed for safe self-administration of medication for five residents (R11, R16, R60, R64 and R68) of five residents reviewed for self-administration. Findings include: R68 On 6/24/24 at approximately 10:54 a.m., R68 was observed in their room, laying in their bed and was observed to have a bottle of Vanquish headache medication (a combination medication containing aspirin, acetaminophen, and caffeine) on their bedside table. R68 was queried regarding the medication and they indicated they take it for headaches. R68 was queried if the Nursing staff knew about them taking it and they reported that they did. On 6/25/24 at approximately 10:05 a.m., R68 was observed in their room, laying in their bed and was observed to still have the bottle of Vanquish headache medication in the room. On 6/25/24 at approximately 3:58 p.m., R68 was observed in their room, laying in their bed and was observed to still have the bottle of Vanquish headache medication in the room. On 6/24/25 the medical record for R68 was reviewed and revealed the following: R68 was initially admitted to the facility on [DATE] and had diagnoses including Sepsis and Chronic pain. A review of R68's MDS (minimum data set) with an ARD (Assessment reference date) of 4/2/24 revealed R68 needed assistance from facility staff with activities of daily living. R68's BIMS score (brief interview for mental status) was 12 indicating moderately impaired cognition. Further review of the medical record did not reveal any Physician orders for Vanquish medication or any orders for R68 to self-administer the medication. A review of R68's comprehensive careplan did not reveal self-administration of medication was part of their plan of care. On 6/26/24 at approximately 10:28 a.m., during a conversation with the Director of Nursing, (DON) the DON was queried regarding R68's Vanquish medicine and indicated that they had taken it out of R68's room and that nobody in the facility had been assessed for safe self administration of medication. The DON indicated that the self administration of medication is accessed on the admission nursing assessment and that a Physicians order is needed along with a careplan for it. 30675 R11 On 6/24/24 at 10:42 AM, R11 was observed laying in a recliner chair. Upon approach the resident was able to respond minimally as they had difficulty staying awake and reported they didn't sleep well last night. At that time, the room was observed to have many personal items cluttered throughout the room and there were multiple inhalers, nasal spray, and saline drops observed on a bedside table. When asked about the medications in the room, R11 reported they used those when needed. Review of the clinical record revealed R11 was admitted into the facility on [DATE], readmitted on [DATE] with diagnoses that included: acute diastolic heart failure, mild intermittent asthma, other pneumonia, anxiety disorder, allergic rhinitis, acute respiratory failure with hypoxia, and other pulmonary embolism without acute cor pulmonale. According to the MDS assessment dated documented R11 had moderately impaired cognition. There was no documentation i.e assessments, care plan, or physician order to identify R11 was able to safely self-administer medications. Review of the physician orders included: Fluticasone propionate 50 mcg (micrograms)/actuation spray, suspension once a day - 1 spray each nostril, nasal, once a day. (Started on 10/6/23.) Trelegy Ellipta (fluticasone-umeclidin-vilanter) 200-62.5-25 mcg blister with device - once a day 1 puff, inhalation, once a day for shortness of breath. (Started on 10/6/23.) Restasis MultiDose (cyclosporine) 0.05% drops twice a day - 1 drop, opthalmic (eye), twice a day, left eye for other specified disorders of eye and adnexa. (Started on 5/23/24.) Dry Eye Relief (peg 400-hypromellose-glycerin) 1-0.2-0.2% drops twice a day prn (as needed). (Started on 4/2/23.) R64 On 6/24/24 at 10:29 AM, Nurse 'F' was observed setting up R64's nebulizer (breathing treatment) and exited the room and proceeded to go further down the hallway to continue administering morning medications to other residents. At that time, R64 was observed yelling and stated, It fell , it fell , timber. There was no other staff in the area to respond to R64's yelling out for help. Review of the clinical record revealed R64 was admitted into the facility on [DATE] with diagnoses that included: unspecified glaucoma, allergic rhinitis, wheezing, and polyneuropathy. According to the MDS assessment dated [DATE], R64 had moderately impaired cognition. There was no documentation i.e assessments, care plan, or physician order to identify R64 was able to safely self-administer their nebulizer treatment. Review of the physician orders included: Albuterol sulfate 2.4 mg / 3 mL (Milliliters) (0.083%) solution for nebulization every 6 hours - PRN 1 vial, inhalation, Every 6 Hours - PRN wheezing. (Started on 6/20/24.) Albuterol sulfate 90 mcg/actuation HFA aerosol inhaler every 6 hours - PRN 2 puffs, inhalation, Every 6 Hours - PRN Wheezing. (Started on 6/5/24.) On 6/25/24 at 3:45 PM, an interview was conducted with the Director of Nursing (DON). When asked about medications and biologicals at bedside, the DON reported they were not aware of any resident had been assessed as able to self-administer their own medication. The DON further explained if there was, there should be an assessment and care plan. When asked about administration of nebulizer treatments, and whether the nurse should stay with the resident, or if it was ok for the nurse to set it up and walk away, the DON reported the nurse should always stay with the resident. They were informed of the above observations for R11 and R64. 34208 R16 and R60. On 6/24/24 at 9:20 AM, Nurse 'F' was observed from the hallway exiting R16's room. At approximately 9:22 AM, an observation of R16's room was conducted and they were observed in bed with their eyes closed receiving a nebulizer breathing treatment via a nebulizer mask. On 6/24/24 at 9:25 AM, Nurse 'F' was observed preparing medications for administration for R60. Nurse 'F' prepared multiple medications including a Pulmicort nebulizer treatment. Nurse 'F' entered R60's room administered the oral medications and set up the nebulizer machine for R60. After the nebulizer treatment was initiated, Nurse 'F' exited the room, signed out the medications as given and moved down the hallway to prepare medications for the next resident. Nurse 'F' was not observed to remain with either R16 or R60 to ensure proper administration of the nebulizer treatments. A review of R16 and R60's clinical records was conducted and did not reveal assessments or orders for self-administration of any medications. A review of a facility provided policy titled, SELF ADMINISTRATION OF MEDICATION was conducted and read, It is the policy of the facility to allow the resident and or legal representative of the resident the right to self-administer medication when it has been deemed by the interdisciplinary team that it is clinically appropriate .9. Once the resident has been deemed safe by the IDT (interdisciplinary team) an order will be obtained from the resident's physician or physician extender listing the medication(s) that may be self-administered, where the medications will be stored, who will be responsible for documentation and the location of administration .

Based on observation, interview, and record review the facility failed to ensure appropriate labeling and storage of insulin medication in three of four medication carts reviewed. Findings include: On [DATE] at 10:25 AM, a review of the 200 unit low cart (medication cart) was conducted with Nurse 'L'. Upon review, it was discovered two of six insulin pens stored in the cart were not labeled with a patient name or a date of when they were placed in the cart. Nurse 'L' said the pens should be labeled with a patient name and dated of when they were placed in the cart. On [DATE] at 10:36 AM, a review of the 100 unit low cart (medication cart) was conducted with Nurse 'M'. Upon review, it was discovered seven of nine insulin pens did not have a date of when they were placed in the cart and one pen did not have a patient name or a date. At that time, Nurse 'M' said they were going to make the unit manager aware of the discovery. On [DATE] at 10:51 AM, a review of the 100 unit high cart (medication cart) was conducted with Nurse 'N'. Upon review, it was discovered two of six insulin pens did not have a date of when they were placed in the cart. Nurse 'N' was asked if they knew when they were placed in the cart and said they did not know, but if they were not in use, they should be stored in a refrigerator. On [DATE] at approximately 2:00 PM, the Director of Nursing reported their staff made them aware of the unlabelled/undated insulin pens stored in the medication carts. A review of a facility provided policy titled, Storage of Medications was conducted and read, The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .3. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing .4 .b. Medication is expired after the last day of the designated time frame for each medication. Expiration time frames are as follows: .Insulin-28 days from date of opening or manufacturers expiration date, which ever comes first .

Based on observation, interview and record review, the facility failed to treat residents with dignity and respect for one (R15) of four residents reviewed for dignity. Findings include: R15 On 6/24/24 at 10:20 AM, while talking with the resident, a nurse aide was observed entering the room and asking the resident about their call light that was activated. R15 reported they had to go to the bathroom. This nurse aide reported they were not assigned to the resident and wasn't sure of their transfer status, but R15 stated they were able to just hold on to them. Upon stepping out of the room into the hallway, another nurse aide was then observed to enter the resident's room and approach R15 and the nurse aide. At that time, the nurse aide that joined the other nurse aide began to loudly discuss with the other nurse aide they weren't aware of the resident's transfer status, talking above and about the resident as if they weren't present. The first nurse aide was overhead asking the other nurse aide if they were having a bad day and discussion continued loudly in front of the resident. On 6/25/24 at 9:15 AM, an interview was conducted with the Director of Nursing (DON). When informed of the observation of R15 from 6/24/24, the DON reported they were aware of what occurred as they were also in the hallway at the same time and reported that should not have occurred. Review of the clinical record revealed R15 was admitted into to the facility on [DATE], readmitted on [DATE] with diagnoses that included: sciatica left side, metabolic encephalopathy, retention of urine, anxiety disorder, difficulty in walking, and neuromuscular dysfunction of bladder. According to the Minimum Data Set (MDS) assessment dated [DATE], R15 had intact cognition and required assistance of one person for transfers. 38271 On 6/26/24 a facility document titled Quality of Life-Dignity was reviewed and revealed the following: Policy Statement-Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality 1. Residents shall be treated with dignity and respect at all times. 2. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth 7. Staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs. 8. Staff shall keep the resident informed and oriented to their environment. Procedures shall be explained before they are performed and residents will be told in advance if they are going to be taken out of their usual or familiar surroundings .

Based on interview and record review, the facility failed to ensure accurate assessments were completed for one (R13) of 27 residents reviewed for Minimum Data Set (MDS) assessments. Findings include: A review of R13's clinical record revealed the resident was initially admitted into the facility on [DATE] with diagnoses that included: acute kidney failure, end stage renal disease, and dependence on dialysis. Review of the physician orders since admission included: RESIDENT TO RECEIVE DIALYSIS EVERY MONDAY, WEDNESDAY, AND FRIDAY PICK UP AT 4:15 PM/START DIALYSIS AT 05:15 PM. (This order was changed to reflect the current/correct schedule for Monday, Wednesday, and Friday pick up at 2:00 PM, Chair Time at 3:25 PM on 6/25/24.) Monitor right chest wall double lumen perma cath is covered and no s/s (signs/symptoms) of infection . Monitor access site for redness, pain, bruising, and for bruit/thrill every shift. Review of the completed Minimum Data Set (MDS) assessments dated 4/2/24, 4/5/24, and 4/13/24 all failed to identify R13 as receiving dialysis or having a port (intravenous dialysis access). On 6/26/24 at 10:35 AM, an interview was conducted with the MDS Coordinator (Nurse 'A') and MDS Nurse 'B'. They both reported they had completed portions of the MDS assessments. When asked about the lack of identification of R13's dialysis status and use of port, both reviewed their documentation and were unable to offer any explanation. Nurse 'A' reported they would have to complete a modification.

Based on observation, interview, and record review, the facility failed to ensure peripherally inserted central catheter (PICC) line (intravenous line for the administration of intravenous medications)dressing changes for one resident (R183), of one resident reviewed for PICC lines, resulting in the potential for PICC line complications. Findings include: On 6/24/24 at 10:43 AM, R183 was observed seated in their wheelchair in their room. A transparent PICC line dressing was observed on their left upper arm. The dressing had become loose, but information written on the dressing indicated the line had been inserted and the dressing had been applied on 6/11/24. On 6/24/24 at 1:30 PM, a review of R183's physician's orders was conducted and revealed they were on intravenous medications and also had an order for the PICC line dressing to be changed. A review of R183's paper medication administration record revealed the dressing for the PICC line was scheduled to be changed on 6/14/24 and 6/21/24, however; both entries in the record were not signed off as having been completed. On 6/24/24 1:35 PM-Interview with Unit Manager 'K' was conducted regarding PICC line dressing changes. They said the dressings should be changed once a week and signed off as being completed. At that time, Unit Manager 'K' observed the dressing on R183's left arm and confirmed it was dated 6/11/24. A review of a facility provided policy titled, PICC Line Dressing Change was conducted and read, .PICC line dressings are to be changed every 7 days and PRN (as needed) if the integrity of the dressing becomes compromised .

Based on observation, interview and record review the facility failed to ensure a physician ordered peg-tube treatment was documented, completed accurately and timely for one R58) of one resident reviewed for professional standards. Findings include: On 6/24/24 at 9:15 AM, R58 was observed laying in bed, with soft music playing. The top of the dresser was observed to have four treatments, which two were dated 6/23/24 and a gauze bandage that was cut to a square with a slit (to go around a feeding tube - medical device used to provide liquid nourishment, fluids and medications by bypassing oral intake). On 6/24/24 at 9:45 AM, an interview was conducted with R58's assigned nurse (Nurse 'D'). When asked about R58's feeding status, they reported the resident received bolus tube feeding. At that time, Nurse 'D' was asked to observe the resident's peg-tube site (percutaneous endoscopic gastrostomy tube). Upon entering the room, Nurse 'D' was asked about the treatments on the dresser and confirmed several were dated 6/23/24 and the square one was used for the peg-tube dressing. Nurse 'D' then proceeded to observe R58's peg-tube site and confirmed there was no dressing in place and should've been. When asked when the treatments were done, Nurse 'D' reported usually on the evening shift, but would put a treatment on. On 6/24/24 at 1:45 PM, review of R58's Treatment Administration Record (TAR - which was a paper copy as the facility did not yet utilize electronic records for medications & treatments) included a physician ordered treatment for: Cleanse peg tube with N/S (Normal Saline) pat dry apply D/D (Dry Dressing) and cover QHS (Every Evening)/PRN (As Needed) At Bedtime. This order had started on 12/27/23 and was noted to be completed 7:00 PM - 7:00 AM. There were multiple blank entries for the above peg tube order on: 6/1, 6/2, 6/15, 6/16, 6/17, 6/19, and 6/23. Additionally, there was nothing documented as completed on 6/24/24, despite the earlier observation and interview with Nurse 'D'. On 6/25/24 at 8:20 AM, review of the TAR now documented R58 had initials by Nurse 'H' on 6/23 and 6/24, indicating the treatment had been completed. Further review of the clinical record revealed R58 was initially admitted into the facility on [DATE], and readmitted on [DATE]. Diagnoses included: ulcerative colitis without complications, vascular dementia unspecified severity with other behavioral disturbance, unspecified visual loss, anxiety disorder due to known physiological condition, type 1 diabetes mellitus with hyperglycemia, and dysphagia. On 6/25/24 at 8:25 AM, an interview was conducted with Wound Care Nurse 'G'. When asked about R58's peg tube treatment, Nurse 'G' reported they had heard about the lack of treatments and reported if there was a concern such as the resident refused care at that time, the Nurse should've documented a note and confirmed there was no documentation that occurred. When asked about how the documentation now reflected it had been completed on 6/23 when it was already confirmed on 6/24 it was not, Nurse 'G' was unable to offer any further explanation. On 6/25/24 at approximately 10:00 AM, an interview was conducted with the Director of Nursing (DON). When informed about R58's observation and interview of their lack of peg-tube treatment, they acknowledged that they had been made aware. When informed of the concern that the treatment had been documented as completed on 6/23/24, when it had been verified on 6/24/24 that had not been completed, the DON reported they would have to review further and was unable to offer any further explanation. Review of the facility policy titled, Wound Care dated 9/2018: .Documentation .8. Any problems or complaints made by the resident related to the procedure. 9. If the resident refused the treatment and the reason(s) why. 10. The signature and title of the person recording the data. Reporting 1. Notify the supervisor if the resident refuses the wound care. 2. Report other information in accordance with facility policy and professional standards of practice.

Based on interview and record review, the facility failed to ensure consistent dialysis communication documentation and assessments were completed for one (R13) of one resident reviewed for dialysis. Findings include: A review of R13's clinical record revealed the resident was initially admitted into the facility on [DATE] with diagnoses that included: acute kidney failure, end stage renal disease, and dependence on dialysis. Review of the physician orders since admission included: RESIDENT TO RECEIVE DIALYSIS EVERY MONDAY, WEDNESDAY, AND FRIDAY PICK UP AT 4:15 PM/START DIALYSIS AT 05:15 PM. (This order was changed on 6/25/24 after brought to the facility's attention during the survey to reflect the current/correct schedule for Monday, Wednesday, and Friday pick up at 2:00 PM, Chair Time at 3:25 PM.) Nurse to enter progress note when resident returns from dialysis. Check dialysis communication sheet for new orders from dialysis center and enter in progress note. Once A Day on Mon, Wed, Fri 08:00 PM. Review of R13's dialysis communication binder revealed there were three communication forms from the resident's dialysis treatments on 6/19/24, 6/21/24, and 6/24/24 had no documentation of communication from the dialysis staff post treatment. On 6/25/24 at 3:30 PM, Nurse 'D' (who was R13's assigned Nurse) was asked about the lack of documentation from the dialysis center on the communication forms. At that time, Nurse 'D' reported there was difficulty in having the dialysis company complete their portion of the communication forms, but if they didn't complete that, the nurse should follow-up with dialysis at that time. When asked about the most recent on 6/24/24, Nurse 'D' reported they had notified the oncoming nurse that needed to be done, but it wasn't and was unable to offer any further explanation. On 6/25/24 at 3:45 PM, an interview was conducted with the Director of Nursing (DON). When asked to clarify the dates R13 went to dialysis, given the order and binder indicated different times, the DON reported the binder times were correct and would have to update the order. When asked about the lack of dialysis communication from the dialysis center for 6/19, 6/21, and 6/24, they reported that should've been completed and the nurse should've followed up on that and they would look into it themselves. According to the facility's policy titled, Dialysis dated 8/2020: .Resident will be transported with a communication binder to ensure communication between the Long Term Care facility and the Dialysis Center.

Based on interview and record review, the facility failed to ensure physician visits/assessments were completed and documented timely for two (R62 and R20) of two residents reviewed for physician visits, resulting in the lack of documentation and increased potential for coordination of care due to lack of documentation. Findings include: R62 Review of the clinical record revealed R62 was admitted into the facility on [DATE] with diagnoses that included: anxiety disorder, cellulitis, fracture of unspecified part of neck of right femur, non-ST elevation myocardial infarction, chronic systolic (congestive) heart failure, acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity, chronic kidney disease stage 3, hyperlipidemia, hypothyroidism, disturbances of salivary secretion, nausea with vomiting, and neuromuscular dysfunction of bladder. As part of a review of psychotropic medication use (antipsychotic and antianxiety), review of Physician 'I's progress notes revealed multiple delayed entries into the clinical record which included: An entry on 6/24/24 at 11:07 PM read, Seen on 04/26/2024 for monthly follow-up . An entry on 5/25/24 at 5:33 PM read, Seen on 03/24/2024 for monthly follow-up . An entry on 1/27/24 at 3:53 PM read, Seen on 01/19/2024 for follow-up . On 6/25/24 at 10:51 AM, a phone interview was conducted with Physician 'I'. When asked how frequent they followed R62 since they were on hospice, Physician 'I' reported they followed for medical needs once a month or in between if needed. When asked about the delay in documentation of when the resident was seen and when their documentation was provided, including the progress note that was entered yesterday on 6/24/24 at 11:07 PM for 4/26/24, Physician 'I' reported they hand wrote their notes, and when they were in to visit they saw that note wasn't in the computer, they forgot to put in the computer and put it in yesterday. When asked to clarify if they may have made an error in their visit date, and to clarify if the documentation was approximately two months late, Physician 'I' confirmed and further reported they weren't aware of any timeframe requirements for their notes. When asked how other staff and team members could coordinate care/services if their documentation was not made available for months at a time, Physician 'I' only reported they understood the concern. On 6/25/24 at 9:40 AM, an interview was conducted with the Director of Nursing (DON). When asked when practitioner notes should be made available for review in the clinical record, the DON reported within 48-72 hours. The DON was informed of the concern with Physician 'I's delayed documentation and they indicated they were not aware of that before today. 38271 R20 On 6/24/24 the medical record for R20 was reviewed and revealed the following: R20 was initially admitted to the facility on [DATE] and had diagnoses including Vascular dementia and Liver disease. A review of R20's MDS (minimum data set) with an ARD (assessment reference date) of 4/14/24 revealed R20 needed assistance from facility staff with their activities of daily living. R20's BIMS score (brief interview for mental status) was five indicating severely impaired cognition. A review of R20's Physician progress notes that were entered late revealed the following: A note entered into the record on 6/22/24 reflected an evaluation by Physician I on 4/26/24 for monthly follow up A note entered into the record on 5/25/24 reflected an evaluation by Physician I on 3/24/24 for monthly follow up. A note entered into the record on 4/8/24 reflected an evaluation by Physician I on 2/23/24 for monthly follow up On 6/26/24 at approximately 10:45 a.m., during a conversation with the Director of Nursing (DON), the DON was queried regarding the timeliness of Physician I's evaluations being entered into the record late and they indicated that they were aware and that the Physician I should be entering their evaluations not later than a few days after they complete their evaluations. On 6/26/24 a facility document titled Physician Services was reviewed and revealed the following: PURPOSE: It is the policy of the facility to provide Physician Services in accordance to State and Federal regulations .11. The physician will: a. Review the resident's total program of care, including medications and treatments, at each visit; b. Write, sign, and date progress notes at each visit; .

Based on observation, interview, and record review, the facility failed to ensure appropriate infection control practices related to enhanced barrier precautions (EBP) for two residents (R112 and R131) of four residents revived for transmission based precautions, resulting in the potential for the spread of infection. Findings include: R112 On [DATE] at 11:05 AM, R112's room was observed to have a sign to indicate they were on EBP. At that time, Certified Nurse Aide (CNA) 'O' and CNA 'P' were observed to enter R112's room. They were not observed to don an isolation gown or gloves. Upon completing their tasks, they exited the room. They were asked they type of care they provided to R112 and said they provided incontinence care and washed them up. 38271 R131 On [DATE] at approximately 8:37 a.m., Nurse J was observed entering R131's room which had a sign on the door indicating enhanced barrier precautions (EBP) were to be utilized by all staff when providing direct care to them. Nurse J was then observed managing R131's PICC line (Peripherally inserted central catheter) without donning a protective gown (part of EBP). On [DATE] at approximately 8:44 a.m., Nurse J was queired if they should have had a protective gown on when managing R131's PICC line in their room and they reported they should have put one on but forgot R131 was on enhanced barrier precautions. On [DATE] the medical record for R131 was reviewed and revealed the following: R131 was initially admitted to the facility on [DATE] and had diagnoses including Encounter for prophylactic measures, unspecified and Acute kidney failure. On [DATE] a facility document titled Enhanced Barrier Precautions (EBP) was reviewed and revealed the following: Policy Statement-It is the policy of this facility to adhere to the CDC guidelines as related to Enhanced Barrier Precautions (EBP) to prevent the transmission of multi-drug resistant organisms (MDROs). CMS notes that facilities have some discretion when implementing EBP to promote a resident's quality of life along with maintaining a homelike environment Enhanced barrier precautions (EBP) are infection control interventions designed to reduce transmission of multi-drug resistant organisms (MDRO) in nursing homes. Enhanced barrier precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO, as well as those at increased risk of acquiring a MDRO. High-contact resident activities include: Dressing, Bathing/showering, Providing hygiene care, Changing linen, Changing briefs or assisting with toileting, Wound care: any skin opening requiring a dressing, Devise care or use: central line, urinary catheter, feeding tube tracheostomy, Transferring, Therapy .Procedure: 1. The facility will review hospital transfer/discharge documentation, a physician's order will be obtained for EBP for any resident with active or colonized MDRO or wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. 2. The facility shall communicate to staff which residents shall require EBP prior to providing high-contact care activities. 3. Gowns and gloves shall be made available for providing high-contact care. Face protection may also be needed if performing activity with risk of splash or spray (i.e. wound irritation, tracheostomy care). 4. Position a trash can inside the resident's room and near the exit for discarding PPE after removal, prior to exiting the resident's room or before providing care for another resident in the same room [ROOM NUMBER]. Staff will perform hand hygiene and don PPE before entering a resident's room .

Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were signed and submitted to CMS (Centers for Medicare and Medicaid Services) in a timely manner for five residents (R36, R42, R51, R52, and R56) of five residents reviwed for MDS transmission. Findings include: 1. Resident #36 that was admitted on [DATE] had an MDS assessment that was incomplete and over 120 days old that had not been submitted. 2. Resident #42 that was admitted on [DATE] had an MDS assessment that was incomplete and over 120 days old that had not been submitted. 3. Resident #51 that was admitted on [DATE] had an MDS assessment that was incomplete and over 120 days old that had not been submitted. 4. Resident #52 that was admitted on [DATE] had an MDS assessment that was incomplete and over 120 days old that had not been submitted. 5. Resident #56 that was admitted on [DATE] had an MDS assessment that was incomplete and over 120 days old that had not been submitted. On 6/25/24 at approximatley 10:30 a.m., during a conversation with both MDS Nurses (MDS Nurse A) and (MDS Nurse B), MDS Nurse A was queried why the assessments were not completed and transmitted per the RAI manual (resident assessment instrument) and they reported that a previous Nurse had indicated they were going to complete and transmit them but they went on leave and the assessments were not completed. MDS Nurse A indiciated that they were attempting to keep up with the current assessments and that they were aware that those assessments had not been completed.

Based on observation, interview, and record review the facility failed to maintain dignity by not providing a foley catheter privacy bag for two Residents (R402 and R404) to maintain dignity out of three Residents reviewed for dignity, resulting in embarrassment and the potential to affect resident psychosocial well-being. Findings include: R402 On 5/7/2024 at approximately 8:30 a.m., R402 was observed in therapy with a foley catheter anchored behind a wheelchair with no privacy bag. Observed the content of the foley catheter bag from the doorway of entering the therapy room. Observed multiple of staffs, visitors, and other residents in therapy room at this time. Observed multiples of staff members walking by R402 without providing a privacy bag. R402 reported during an interview that a privacy bag would keep everyone from seeing what's in the foley bag. Review of the medical records on 5/7/2024 at 9:00 a.m. revealed, R402 was admitted into the facility on [DATE] with diagnoses of pressure ulcer of left buttock stage three, hypertension, and neuromuscular dysfunction of bladder. R402's admission Minimum Data set (MDS) with a reference date of 3/3/2024 indicated R402 had intact cognition with a BIMS (brief interview for mental status) score of 13/15. Review of the Resident's Activity Daily Living (ADLs) care plan, date initiated 4/23/2024, documented, R402 need assistance with ADL's and care related to impaired mobility, impaired balance, and muscle weakness. Review of the Indwelling catheter care plan date initiated 4/23/2024 documented, R402 require the use of an indwelling catheter related to diagnoses of Benign prostate hyperplasia (BPH) .Interventions: Apply a foley bag cover for my dignity. R404 On 5/7/2024 at approximately 9:30 a.m., R404 was observed in bed with a foley catheter anchored to the bed frame with no privacy bag. Observed the content of the foley catheter bag from the hallway of entering R404's room. R404 reported being interested in having a privacy bag to prevent everyone from seeing the urine in the foley bag. Certified Nursing Assistant (CNA) C was interviewed in R404's room regarding the resident's privacy bag. CNA C said R404 did not have a privacy bag when the foley was emptied previously during the shift. CNA C also said that R404 did not had a privacy bag at the beginning of the shift. According to the medical records, R404 was admitted into the facility 4/25/2024 with diagnoses of congestive heart failure, chronic kidney disease, malignant neoplasm of upper lobe, chronic obstructive pulmonary disease, and hypertension. R404's admission Minimum Data set (MDS) with a reference date of 4/29/2024 indicated R404 had moderate cognition impairment with a BIMS (brief interview for mental status) score of 10/15. There was no care plan related to foley catheter care in the resident's medical record. Review of the Resident's Activity Daily Living Functional (ADL) care plan, date initiated 4/26/2024, documented, R404 have decreased bed mobility, decreased transfer skills, decreased activity tolerance, decreased muscle strength, decreased balance, decreased independence with ambulation related to diagnosis of muscle weakness and difficulty in ambulation. On 5/7/2024 at 1:52 P.m. the Director of Nursing (DON) was informed during an interview of the residents who had a foley catheter with no privacy bags. The DON reported that residents should have a privacy bag with foley catheters. The DON was asked what the purpose of residents with foley catheters to have privacy bags. The DON stated, The purpose is for the resident's dignity .and not to cause the residents embarrassment. According to the facility's 12/10/2010 Quality of Life-Dignity policy: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality.

Based on observation, interview, and record review the facility failed to maintain sanitary conditions in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting all residents who receive oral food meal services (74 residents, with 1 NPO) out of the facility's total census of 75 residents. Findings include: 1. On 6/27/23 at 11:38 AM, Dietary aide, staff D, was observed removing and donning new pairs of gloves during the assembly, plating, and loading of meals into hall carts for lunch service. On 6/27/23 at 11:42 AM, surveyor inquired with the Certified Dietary Manager, staff A, on the hand hygiene expectations for staff when they choose to use gloves as a hand barrier to which they replied, Wash their hands before they put them on. At this time the surveyor requested the facility's hand hygiene policy to review to which staff A replied, yes, I will get it for you. On 6/27/23 at 11:49 AM, at 12:02 PM, and at 12:19 PM Cook, staff B, was observed removing and donning new gloves without washing their hands in between while plating meals for the resident's lunch. On 6/27/23 at 12:22 PM, and at 12:38 PM, Dietary Aide, staff C, was observed donning gloves prior to washing their hands after touching refrigerator door handles, prep counters, a cutting board and their clothing prior to preparing grilled cheese and egg salad sandwiches. On 6/27/23 at 12:30 PM, Cook, staff B, was observed with a gloved hand grabbing a chicken breast from the steam well, placing on a plate and then assembling the rest of the resident's tray while handling the plates lid, a soup bowl and serving utensils with the same gloved hand. At this time the surveyor inquired with staff B on if using a gloved hand to take ready to eat food out of the seam well was a normal process for them to do which they replied, No, not usually. I guess I would normally use tongs or something else depending on what it was. On 6/28/23 at 2:25 PM, record review of a policy titled, Hand Hygiene (4 pgs.) last dated 10/20/20, revealed that the facility has a glove use procedure in place identifying when it is required to change their gloves and how it should be conducted. Review of the U.S. Public Health Service 2017 Food Code, Chapter 2-301.14 When to Wash directs that: FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLEUSE ARTICLES and: and contamination and to prevent cross contamination when changing tasks; (H) Before donning gloves for working with FOOD; and (I) After engaging in other activities that contaminate the hands. 2. On 6/27/23 at 10:46 AM, and at 11:41 AM, Dietary aide, staff C, was observed not using a hand barrier to shut off the faucet when done washing their hands. On 6/27/23 at 11:42 AM, the surveyor requested the facility's hand hygiene policy from Certified Dietary Manager, staff A, to review to which staff A replied, Yes, I will get it for you. At this time the surveyor asked staff A if they had conducted any trainings with staff on the proper procedure to wash their hands to which they stated, Yes, and we have signs above our sinks in case they forget. On 6/27/23 at 11:00 AM, and at 11:17 AM, Cook, staff B, was observed not using a hand barrier to shut off the faucet when done washing their hands. On 6/27/23 at 12:09 PM, at 12:18 PM, and on 6/28/23 at 12:42 PM, Dietary aide, staff D, was observed not using a hand barrier to shut off the faucet when done washing their hands. On 6/28/23 at 2:25 PM, record review of a policy titled, Hand Hygiene (4 pgs.) last dated 10/20/20, revealed that the facility has a hand washing procedure in place identifying when it is required to wash hands and how it should be conducted. Review of the U.S. Public Health Service 2017 Food Code, Chapter 2-301.12 Cleaning Procedure, directs that: (C) TO avoid recontaminating their hands or surrogate prosthetic Devices, FOOD EMPLOYEES may use disposable paper towels or similar clean barriers when touching surfaces such as manually operated faucet handles on a HANDWASHING SINK or the handle of a restroom door. 3. On 6/27/23 at 9:37 AM, 49 meal serving trays located on the clean air-dry storage rack were observed with a white paper like residue on their surface. On 6/27/23 at 9:38 AM, the surveyor inquired with Certified Dietary Manager, staff A, on the current state of the serving trays to which they stated, It's from the place mats. They are paper and when they get wet by a resident's food or their drink it sticks to it. At this time the surveyor asked staff A if the staff had tried to scrub the residue off during the cleaning process to which they replied, I'm not sure. On 6/27/23 at 9:40 AM, the surveyor observed staff A taking a serving tray off the air-dry storage rack and using their finger nail, began scratching at the residue. At this time staff A stated, it comes right off and then was observed directing Dietary Aide, staff C, to start scrubbing these trays before they go through the dish machine. On 6/27/23 at 10:32 AM, the number ten can opener's cutting blade was observed with visible debris on its surface. Upon observation staff A commented, I'll set it aside to be cleaned. On 6/27/23 at 1:27 PM, the flooring underneath the fryer, the top and sides of the fryer, and sides of the oven next to the fryer were observed with a thick coating of fryer oil. At this time upon interview with staff A, the surveyor asked if they had the fryer on a regular cleaning schedule to which they stated, yes, it was supposed to be done over the weekend, but it looks like they just did the inside. I will remind them to do it again. Review of 2017 U.S. Public Health Service Food Code, Chapter 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils directs that: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.

Based on observation, interview, and record review the facility failed to provide a safe, functional, and sanitary environment in the facility's laundry, and its clean and soiled holding rooms, resulting in the increased potential for harm to its 75 residents and staff. Findings include: On 6/27/23 at 2:03 PM, an accumulation of dust and debris was observed underneath both of the dryers and on its filters. At this time the surveyor inquired with the Certified Dietary Manager, staff A, on the current state of the dryers to which they replied, I'm not exactly sure when it happened, they are supposed to be cleaned after each use. I'll let them know. At this time the surveyor requested a dryer cleaning policy to review to which they replied, of course. On 6/27/23 at 2:04 PM, dark color staining was observed in multiple areas on the interior of both dryers. At this time the surveyor inquired with staff A on what they thought the stains might be on the interior of these units to which they replied, I'm not sure. Maybe it's make-up that went through the washer I'll have maintenance see what they can do about it. On 6/28/23 at 3:01 PM, record review of a document titled, laundry area practices dated, 09/2018 revealed in item number one, under the Dryer Protocol heading that, the lint filter is cleaned after each load. The dryer is checked prior to each load to ensure no lint remains. On 6/27/23 at 2:05 PM, the side mounted filter on the number one washing machine was observed covered over with dust and debris with a posted sign stating, clean daily. On 6/27/23 at 2:07 PM, the surveyor observed that the discharge lines from both washing machines terminated into a floor trough without any safety grates level with the floors surface. At this time the surveyor inquired with staff A on the current state of the floor in this area and they stated, it's always been like this since I took over. The girls are always getting their shoes wet when they have to change out the five gallon containers of detergent. On 6/27/23 at 2:08 PM, upon interview with staff A the surveyor the surveyor inquired if they felt this area was safe to which they replied, I would prefer it to be covered so no one sprains an ankle. It can be a struggle for some of the girls to position the full buckets where they need to be on their first try. On 6/27/23 between 2:05 PM and 2:14 PM, multiple areas of the ceiling in the laundry and clean linen folding rooms were observed with brown staining. On 6/27/23 at 2:15 PM, the surveyor inquired with staff A on if they were aware of any active roof leaks in the laundry area to which they stated, No. that's old. Maintenance just needs to paint it. On 6/27/23 at 2:16 PM, an accumulation of dust and debris was observed on the blades and protective grate of the clean linen folding room's wall mounted fan. At this time the surveyor inquired with staff A on the current state of fan to which they stated, we try to clean it weekly, but it looks like it was missed this last week. On 6/27/23 between 2:23 PM, and 2:49 PM, during an environmental tour of the facility multiple carboard boxes were observed being reused for storage bins, as the labels on the boxes did not match the contents which they contained in the 100 and 200 halls clean linen/ supply storage closets. On 6/27/23 at 2:25 PM, a trash can was observed overflowing on to the floor with a variety of items such as hair pins, gloves, open alcohol prep pads, and tissues in the 200 halls clean linen/ supply storage closet. At this time the surveyor inquired with staff A why they facility kept a trash can in a clean area to which they replied, I'm not really sure. Everything could be taken with them and thrown out in a resident's room. I can talk to the nurses about this. On 6/27/23 at 2:33 PM, the 200 hall's soiled utility room was observed with a lift battery, and its charging station plugged into an electrical outlet. Upon observation the surveyor inquired if the storage of items like these in a soiled utility room was a normal practice in the facility to which they responded, that would be more of a nursing question, but I would say probably not. On 6/27/23 at 2:45 PM, the 100 hall's soiled utility room was observed with staining, and an accumulation debris on its flooring. On 6/27/23 at 2:46 PM, the hopper in 100 hall's soiled utility room was observed with a variety of debris floating in its basin. At this time the surveyor inquired with staff A on the frequency in which these rooms are monitored to ensure a clean and sanitary state to which they replied, throughout the day. On 6/28/23 at 9:46 AM, the surveyor observed the same conditions in this room.

Based on observation and interview the facility failed to ensure that all kitchen equipment is maintained in safe operating condition resulting in an increased potential for harm. Findings include: On 6/27/23 at 1:50 PM, upon inspection of the stove top ovens in the facility's primary kitchen by the surveyor, the Certified Dietary Manager, staff A, stated, be careful it's hot. At this time the surveyor inquired with staff A what they meant by that statement to which they replied, the temperature dial says that it is off, but it's on. We can't get it to shut off, so it's always on. On 6/27/23 at 1:51 PM, the surveyor inquired with staff A on if a work order had been placed for the repair or replacement of the oven for the temperature control issue to which they replied, maintenance is aware of it, but it has been like this for a while now. It's something I need to remind my newer staff of, so they don't accidently get burned. We are making the most of it.

Based on observation, interview, and record review the facility failed to ensure a care plan for a communication deficit was created upon admission for one (R73) of one resident reviewed for baseline care plan, resulting in the potential for unmet care needs. Findings include: On 6/28/23 at 12:05 P.M. R73 was observed in his room watching television. The resident was asked a few questions concerning his care and whether he had any concerns with physical therapy. R73 struggled with responses to the questions. R73 appeared to understand the questions and began pointing and using gestures. There was a delay in verbalizing his response and formation of words and sentences. During this observation there were no observations of a communication device, cards, or communication board. On 6/29/23 at 11:59 A.M. while R73 was observed in Physical Therapy additional observations of the resident's room was performed. Upon entering the room lying on top of the resident's bed was a laminated communication board which had corresponding words and pictures to assist the resident in communicating and expressing his thoughts Review of the Face Sheet for R73 documented the resident was admitted to the facility on [DATE], with diagnoses of cerebral infraction due to embolism of the left anterior cerebral artery (stroke), diabetes mellitus and aphasia. According to the Minimum Data Set (MDS) dated [DATE] R73 was moderatedly impaired in cognition (thought process), was rarely understood, had short and long term memory problems, had upper and lower impairements on one side, and required extensive assistance with one person physical assist to perform activities of daily living. At 1230 P.M. review of the care plan section of the electronic medical record revealed no language deficits or communication barriers care plans or interventions were present. On 7/3/23 at 1:30 P.M. the Administrator was quired concerning the observations with R73 and was asked If the resident's care plan for language barrier/communication deficit could be reviewed. A copy of another resident's communication deficit care plan was presented instead of the requested communication deficit care plan for R73. A request for the facility's policy for care planning was requested and provided. No additional information was provided concerning the communication deficit care plan for R73,prior to exiting the facility at 4:30 P.M. On 7/6/23 at approximately 12:00 P.M, review of the facility's policy, Effective date: 3/2011, Titled: Communicating with cognitively Impaired residents stated in part 1). Upon admission assess resident to identify any communication deficits or barriers., 2). Initiate care plan to include resident's communication style and develop interventions that will assist with communication needs. Speech impaired, Aphasia (Aphasia-Trouble speaking or understanding, often result of a stroke), use visual devices like a message board, pictures, or gestures.

Based on interview and record review the facility failed to obtain information related to post-dialysis treatment for one (R320) of one resident reviewed for dialysis resulting in the potential for unmet post-dialysis care needs. Findings include: A review of R320's Electronic Medical Record (EMR) revealed R320 was initially admitted to the facility on [DATE] and readmitted on [DATE]. R320 had medical diagnoses including hypertension, hypotension, end stage renal disease, and chronic kidney disease stage four and five. A review of R320's Minimum Data Set (MDS), dated [DATE], revealed R320 had a Brief Interview of Mental Status (BIMS) score of 13/15 (cognitively intact). A review of R320's care plan, dated 6/23/23, revealed, Problem: I am at risk for SOB, chest pain, elevated b/p, infected shunt access site, itchy skin, nausea, vomiting secondary to ESRD/Dialysis .Goal: I want to be free from SOB, chest pain, elevated b/p, infection in access site, itchy skin or bleeding through next review .Interventions: Monitor my vital signs and weight Q dialysis day and PRN. On 6/29/23 at 9:43 am, dialysis communication forms were obtained form Unit Manager (UM) E for the dates of 6/24/23 and 6/27/23. The dialysis communication forms revealed missing documented sections titled, Post Dialysis Information on both dialysis communication forms. On 7/3/23 at 12:14pm in an interview with UM E regarding the partially documented communication forms, UM E said the bottom section of the dialysis communication form is suppose to be filled out by the dialysis staff at the center. She said if the dialysis communication form comes back without the lower section filled out it is up to the nursing home facility staff to fax the document over to be completed and have the form faxed back over. On 7/3/23 at 12:30pm in an interview the Director of Nursing (DON) she said it was her expectation for the nursing staff to call the dialysis center for any partially documented communications to have them completed. A review of the policy titled, Hemodialysis Communication Form, undated , revealed in part:, The Hemodialysis Communication Form: Provides the dialysis unit with information pertaining to significant changes in resident condition, and provides the facility and attending physician with post-dialysis reccomendations .The dialysis unit completed section Two of the form.

This citation pertains to Intake MI00135669. Based on interview and record review, the facility failed to provide adequate post fall assessments for one resident (R21) of four residents reviewed for falls, resulting in missed opportunities to identify the potential latent effects of a fall. Findings include: An event report documented that on 3/1/2023 at 2:35 PM, Resident #21 (R21) fell on her buttocks after walking into another resident. R21 was assessed and vital signs were obtained, range of motion completed with no difficulty. R21 was unable to state what she was trying to do. R21 denied pain and no pain or discomfort was noted during assessment. A review of the clinical record for R21 revealed an admitted [DATE] with diagnoses that included atrial fibrillation, Alzheimer's disease, insomnia, and depression. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment, extensive one-person assistance for bed mobility, extensive two+-person assistance for transfers, and the use of a walker or wheelchair to move about the facility. Documentation in R21's clinical record after the 3/1/2023 fall included the following: 1. OT (Occupational Therapy) note of 3/2/2023, Fall Safety Assessment: Completed and conferred with nursing. Reviewed safety awareness and fall prevention with resident, as well as use of call light when in need of assistance. Educated patient on her current functional abilities and amount of assist pt. requires. Follow ALARMS (fall safety program) program to ensure patient's safety and needs are met. Therapy will continue to screen as needed. 2. OT note of 3/3/2023 documented in part the following: .Pt. groans in pain due to bruising on R (right) buttocks, however made jokes and presented in pleasant mood 3. Nursing note of 3/4/2023 at 2:06 AM: .Resident has no complaints of pain or S/S (signs/symptoms) of distress . During an interview and record review on 5/24/2023 at 2:39 PM, the Director of Nursing (DON) said that nursing follow-up related to R21's fall was not according to the facility's policy. The DON went on to say, There was no order for monitoring (after the fall) for (R21) and that the nursing standard of practice was to observe and document the monitoring of a resident for three days if there was no obvious injury because injuries can occur after the fact. There can be latent bruising and pain. A review of the facility policy titled, Assessing Falls and Their Causes, dated February 2012, documented in part the following: The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall . 1. After a Fall: . e. Nursing staff will observe for delayed complications of a fall for approximately forty-eight (48) hours after an observed or suspected fall and will document findings in the medical record. f. Documentation will include any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility; and any changes in level of responsiveness/consciousness and overall function. It will note the presence or absence of significant findings . On 5/24/2023 at approximately 4:15 PM during the exit conference, the Nursing Home Administrator (NHA) and DON were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey. The NHA requested an opportunity to gather documentation regarding the stated concern. No substantially new information was provided.

This citation pertains to intake MI 571. Based on interview and record review the facility failed to individualize interventions for a resident at high risk for falls, affecting one resident (R101) out of three residents reviewed for falls, resulting in fall with facial fractures, a brain bleed, and hospitalization . Findings include: Record review of R101's face sheet documented admission into the facility on [DATE] with diagnoses of cerebral infarction (stroke), difficulty walking, muscle weakness, altered mental status. According to the MDS (Minimum Data Set) dated 3/14/22, R101 had impaired cognition and required extensive assist with 1 person for bed mobility, transfers, walking, and toileting. Record review of Admission Fall Risk dated 3/9/22, documented the following information: 1.Mental Status/Level of Consciousness- 2 (points)- Disoriented x 3. 2.Balance and Gait- 1-Balance problem while standing and 1-balance problem while walking. 3.Activity Level- 3- Confined to chair, totally unable to ambulate without assist: wheelchair for locomotion. 4.Elimination-3-Assistance to/from, on/off toilet/commode and or with cares. 5.Medication Scoring- 2- One or two of these medications are/were taken in the last 7 days. Further review revealed resident had taken antidepressants and antihypertensives (blood pressure). 6.Does the resident have a history of falls in the last 3 months? - 2-one or two falls. 7. Evaluation- Total the points on each box above and record total. Score of 10 or higher represent a high risk for falls. 14 (R101 score) 8.Interventions- Falls Prevention (interventions selected by writer of document) Record review of R101's Fall care plan Resident at risk for falling r/t (related to) muscle weakness. dated 3/10/22. Two approaches were documented: 1. Call light within reach at all times. 2. Place resident in a fall prevention program. Record review of Resident Progress Notes dated 3/10/22 at 7:26 PM documented, Pt (patient) observed sitting upright in wheelchair near nursing station with no s/x (signs) of distress. She is A(alert)&0 (oriented) X 2 (to person and place) and pleasant but can be uncooperative with care r/t Dx (diagnosis) of dementia. Pt frequency (frequently) stands up from wheelchair and walks and must be redirected back to chair. Record review of Resident Progress Notes dated 3/11/22 at 4:27 AM documented, Resident observed sitting in wheelchair in common area and is A&O x2. Resident continues to try and self-transfer and is redirected. Record review of Resident Progress Notes dated 3/13/22 at 4:57 AM, documented, .She would get up out of her wheelchair and began to walk if she could not use the wheelchair to get around. redirected but did not last long. Pt. did sit for about 25 minutes and then began to ask for her family and that she needed to get to them. Record review of Resident Progress Notes dated 3/16/22 at 6:11 PM, documented Resident in common area most of the day except when daughter was present. Record review of Resident Progress Notes dated 3/17/22 at 6:24 PM, documented Resident agitated and anxious this afternoon, multiple self-transfers attempted. Record review of Resident Progress Notes dated 3/18/22 at 9:34 PM, documented At approximately 2052 (8:52 PM). Pt. observed on bathroom floor by CNA (certified nursing assistant). Pt. was laying on her back with blood around and on head and face when staff entered bathroom. Record review of hospital records dated 3/18/22 at 9:35PM, documented . She has circumferential (around) [CONDITION(S)] and contusion (bruising) around the right eye, her nose is swollen with blood in both nostrils and the right leg seems to be somewhat internally rotated. Further review of hospital documentation revealed, Pt (patient) CT (X-ray images at different angles) head shows: Small polypoid hyper-attenuation (growth) seen along the back wall of the right lateral ventricle along the [NAME] (image of nasal area), which may reflect a small ependymal hemorrhage (escape of blood through vessel). As well as diffuse soft tissue swelling overlying the nasal bone and right supraorbital soft tissues, with a comminuted (small particles) displaced fracture of the bilateral nasal bones with rightward shift, with minimally displaced fracture of the nasal septum. During interview on 4/14/22 at 2:15 PM with Administrator (ADM) and Director of Nursing (DON), it was confirmed that R101 had a fall and was sent to hospital for examination. When asked if the fall risk assessment for R101 reflected resident was at high risk for falls and was found to be disoriented x 3 (person, place and time), Adm answered Yes. When asked if resident's fall care plan had only two approaches for a call light within reach and place resident on fall prevention program, ADM. answered Yes. When asked if all residents that were admitted to the facility were to have a call light and placed on the same fall prevention program, ADM answered Yes. When asked if the fall prevention program was titled Alarms Prevention Program, ADM. said Yes. While reviewing resident's progress notes, ADM was asked the reason the resident was kept in the common area, Adm stated, To monitor her for falls. When asked did the facility document and implement an individualized fall care plan for R101 to prevent falls and ensure all staff were aware of the needs of this resident, ADM. Stated, No. Record review of ALARMS PREVENTION PROGRAM (revised 1/2017) documented the following: The ALARM program is designed based on extensive research into the cause and prevention of falls. The theory of the program is that residents whose needs are met and who live in a safe environment will have fewer falls with a reduced risk of injuries. While the program is called ALARMS it is a program that does not utilize personal alarms as a safety device in the prevention of falls as with other fall programs. Research indicates that personal alarms lead to increased falls rather than prevent residents from falling. This facility has developed a comprehensive approach to resident safety that focuses upon assessment, individualized interventions, supervision and resident specific care planning. Residents admitted and residing in the facility are in the ALARM program for prevention and safety. The ALARMs program encompasses all facility staff and is an ongoing program 24 hours a day 7 days a week. ALARMS lead the staff to focus individualized needs through: A- Assess routines - On admission, quarterly, annually with a significant change and as needed L- Learn your residents - Consistent assignments, medications and side effects, cognition A- Anticipate Needs - The 5 P's - Positioning - while in bed, offloading while in chair - Personal Needs - frequent urination patterns, hydration, nutrition - Pain - discomfort addressed to maintain comfort - Placement - of personal items to eliminate the need for the resident to get them themselves - Profile - know the professional directives given for the resident's plan of care R- Respond - Answer call lights and call for assistance timely M- Meet Needs - Provide assistance ordered and requested through the one-hour checks and zig zag assignments S- Safety - Ensure throughout the facility Falls occurs as a result of: 1. Clutter in rooms and hallways 2. Wet floors 3. Personal items not within reach - call light, glasses, tv remote, Kleenex, books, etc. 4. Lack of resident safety awareness - not locking wheelchair brakes, poor transfer techniques, cognitive impairment, etc. 5. Medications - producing side effects such as dizziness, weakness, frequent urination, drowsiness, etc. 6. Needing to use the bathroom or wet undergarments 7. Factors specific to the individual resident.

This citation has two deficient practice statemnts. Deficient Practice Statement #1 Based on observations, interviews, and record reviews, the facility failed to provide comfortable hot water supply temperatures for 17 (101, 106, 112, 118, 121, 126, 130, 137, 204, 208, 211, 212, 216, 218, 219, 221, 231) of 17 sampled restrooms effecting 65 residents, resulting in the increased likelihood for resident decreased comfort and shower acceptance. Findings include: On 03/31/22 at 09:30 A.M., A common area environmental tour was conducted with Maintenance Technician J. The following items were noted: Main Lobby The kitchenette hand sink hot water temperature, located adjacent to the Human Resources Office, was monitored to read 92.2 degrees Fahrenheit. Men's Restroom: The hand sink hot water temperature was monitored to read 95.2 degrees Fahrenheit. Women's Restroom: The hand sink hot water temperature was monitored to read 95.1 degrees Fahrenheit. 100 Unit Staff Restroom: The hand sink hot water temperature was monitored to read 95.6 degrees Fahrenheit. Nourishment Room: The hand sink hot water temperature was monitored to read 93.1 degrees Fahrenheit. Clean Linen Room: The hand sink hot water temperature was monitored to read 94.7 degrees Fahrenheit. Soiled Utility Room: The hand sink hot water temperature was monitored to read 95.6 degrees Fahrenheit. 200 Unit Private Dining Room: The hand sink hot water temperature was monitored to read 93.2 degrees Fahrenheit. Nurse Station: The hand sink hot water temperature was monitored to read 93.3 degrees Fahrenheit. Shower Room: The restroom hand sink hot water temperature was monitored to read 76.5 degrees Fahrenheit. Soiled Utility Room: The hand sink hot water temperature was monitored to read 98.4 degrees Fahrenheit. Service Corridor Staff Break Room: The hand sink hot water temperature was monitored to read 96.2 degrees Fahrenheit. On 03/31/22 at 12:30 P.M., An environmental tour of sampled resident rooms was conducted with Maintenance Technician J. The following items were noted: 101: The restroom hand sink hot water temperature was monitored to read 92.0 degrees Fahrenheit. 106: The restroom hand sink hot water temperature was monitored to read 95.2 degrees Fahrenheit. 112: The restroom hand sink hot water temperature was monitored to read 97.8 degrees Fahrenheit. 118: The restroom hand sink hot water temperature was monitored to read 94.7 degrees Fahrenheit. 121: The restroom hand sink hot water temperature was monitored to read 95.9 degrees Fahrenheit. 126: The restroom hand sink hot water temperature was monitored to read 94.6 degrees Fahrenheit. 130: The restroom hand sink hot water temperature was monitored to read 94.0 degrees Fahrenheit. 137: The restroom hand sink hot water temperature was monitored to read 93.3 degrees Fahrenheit. 204: The restroom hand sink hot water temperature was monitored to read 94.1 degrees Fahrenheit. 208: The restroom hand sink hot water temperature was monitored to read 87.6 degrees Fahrenheit. 211: The restroom hand sink hot water temperature was monitored to read 84.7 degrees Fahrenheit. 212: The restroom hand sink hot water temperature was monitored to read 96.1 degrees Fahrenheit. 216: The restroom hand sink hot water temperature was monitored to read 92.3 degrees Fahrenheit. 218: The restroom hand sink hot water temperature was monitored to read 91.0 degrees Fahrenheit. 219: The restroom hand sink hot water temperature was monitored to read 92.7 degrees Fahrenheit. 221: The restroom hand sink hot water temperature was monitored to read 92.3 degrees Fahrenheit. 231: The restroom hand sink hot water temperature was monitored to read 78.2 degrees Fahrenheit. Note: The facility hot water temperatures were monitored utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. On 03/31/22 at 02:00 P.M., An interview was conducted with Maintenance Technician J regarding the facility hot water supply system. Maintenance Technician J indicated the facility has two separate boilers with two separate hot water storage tanks controlled by a single mixing valve. Maintenance Technician J further indicated the hot water supply system has two alternating circulation pumps for moving the hot water through the facility plumbing system. On 03/31/22 at 03:15 P.M., Record review of the Maintenance Repair Log for the last 60 days revealed no specific entries related to facility hot water temperatures. Deficient Practice Statement #2 Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 65 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, decreased illumination, and potential cross-connections between the potable (drinking) and non-potable (non-drinking) water supplies. Findings include: On 03/31/22 at 09:30 A.M., A common area environmental tour was conducted with Maintenance Technician J. The following items were noted: Main Lobby Men's Restroom: The return exhaust ventilation grill was observed soiled with dust and dirt accumulations. Occupational/Physical Therapy: The microwave oven interior door frame surface was observed corroded, exposing the metal sub-surface. The damaged area was also observed to measure approximately 4-5 inches long. Beauty Shop: The return exhaust ventilation grill was observed soiled with dust and dirt accumulations. The small desk fan was also observed soiled with dust and dirt accumulations. Main Dining Room: The two large return exhaust air ventilation grills were observed soiled with dust and dirt accumulations. The two large return exhaust air ventilation grills measured approximately 4-feet-wide by 8-feet-long combined. 100 Unit Staff Restroom: The return exhaust ventilation grill was observed soiled with dust and dirt accumulations. Shower Room: The shower stall return exhaust ventilation grill was observed soiled with dust and dirt accumulations. The shower stall atmospheric vacuum breaker was also observed missing on the shower wand assembly, creating a potential cross-connection between the potable (drinking) and non-potable (non-drinking) water supplies. Soiled Utility Room: The return exhaust ventilation grill was observed soiled with dust and dirt accumulations. 200 Unit Shower Room: The restroom return exhaust ventilation grill was observed heavily soiled with dust and dirt accumulations. The shower stall atmospheric vacuum breaker was additionally observed missing on the shower wand assembly, creating potential cross-connection between the potable (drinking) and non-potable (non-drinking) water supplies. Janitor Closet: The return exhaust ventilation grill was observed soiled with dust and dirt accumulations. The mop sink basin was also observed heavily soiled and stained (Yellow). Clean Linen Room: The return exhaust ventilation grill was observed soiled with dust and dirt accumulations. MDS Office: The return exhaust ventilation grill was observed heavily soiled with dust and dirt accumulations. Staff Development Office: The return exhaust ventilation grill was observed soiled with dust and dirt accumulations. Central Supply: Two return exhaust ventilation grills were observed soiled with dust and dirt accumulations. Service Corridor Activity Office: The return exhaust ventilation grill was observed soiled with dust and dirt accumulations. Staff Break Room: The microwave oven interior was observed soiled with accumulated food residue. The return exhaust ventilation grill was also observed soiled with dust and dirt accumulations. The return exhaust ventilation grill, located adjacent to the staff lockers, was additionally observed soiled with dust and dirt accumulations. The staff restroom return exhaust ventilation grill was further observed heavily soiled with dust and dirt accumulations. On 03/31/22 at 12:30 P.M., An environmental tour of sampled resident rooms was conducted with Maintenance Technician J. The following items were noted: 101: The atmospheric vacuum breaker was observed missing on the shower wand assembly. The overbed light assembly lower 48-inch-long fluorescent bulb was also observed non-functional. 106: The atmospheric vacuum breaker was observed missing on the shower wand assembly. The restroom return exhaust ventilation grill was also observed soiled with dust and dirt accumulations. 112: The atmospheric vacuum breaker was observed missing on the shower wand assembly. The shower stall overhead light assembly was also observed non-functional. The shower stall overhead light assembly wire connection was additionally observed exposed. The shower stall overhead light assembly was further observed missing the protective plastic lens cover plate. The closet door mechanical stop plate was also observed missing, allowing the closet door to swing inward beyond the stop plate. The overbed light assembly upper 48-inch-long fluorescent light bulb was additionally observed non-functional. The restroom return exhaust ventilation grill was finally observed soiled with dust and dirt accumulations. 118: The atmospheric vacuum breaker was observed missing on the shower wand assembly. The overbed light assembly toggle switch was also observed broken and missing. The overbed light assembly pull string extension was additionally observed missing. Resident #269's oxygen nasal canula and tubing was further observed resting directly on the flooring surface, adjacent to the bed. 121: The atmospheric vacuum breaker was observed missing on the shower wand assembly. The shower stall overhead light was also observed non-functional. The restroom return exhaust ventilation grill was additionally observed soiled with dust and dirt. The wall mounted air conditioning unit filters were further observed soiled with dust and dirt accumulations. 126: The atmospheric vacuum breaker was observed missing on the shower wand assembly. The overbed light assembly lower 48-inch-long fluorescent light bulb was also observed non-functional. The restroom return exhaust ventilation grill was additionally observed soiled with dust and dirt accumulations. The restroom sharps container was further observed full and exceeding the fill line limit. 130: The atmospheric vacuum breaker was observed missing on the shower wand assembly. The shower stall overhead light was also observed non-functional. The restroom return exhaust ventilation grill was additionally observed soiled with dust and dirt accumulations. 137: The atmospheric vacuum breaker was observed missing on the shower wand assembly. The restroom sharps container was also observed full and exceeding the fill line limit. 204: The atmospheric vacuum breaker was observed missing on the shower wand assembly. The restroom sharps container was also observed full and exceeding the fill line limit. 208: The atmospheric vacuum breaker was observed missing on the shower wand assembly. The wall mounted air conditioning unit filters were also observed soiled with dust and dirt accumulations. The closet door hinges were additionally observed loose to mount, allowing the door to not close easily. 211: The atmospheric vacuum breaker was observed missing on the shower wand assembly. The closet door hinges were also observed loose to mount, allowing the door to not close easily. The restroom return exhaust ventilation grill was additionally observed soiled with dust and dirt accumulations. 212: The atmospheric vacuum breaker was observed missing on the shower wand assembly. The wall mounted air conditioning unit filters were also observed soiled with dust and dirt accumulations. The restroom return exhaust ventilation grill was additionally observed soiled with dust and dirt accumulations. 216: The atmospheric vacuum breaker was observed missing on the shower wand assembly. The wall mounted air conditioning unit filters were also observed soiled with dust and dirt accumulations. The landing strip was additionally observed (etched, scored, worn), exposing the inner Styrofoam padding. The closet door mechanical stop plate was observed missing, allowing the closet door to swing inward beyond the mechanical stop plate. 218: The atmospheric vacuum breaker was observed missing on the shower wand assembly. The restroom sharps container was also observed full and exceeding the fill line limit. The restroom return exhaust ventilation grill was additionally observed soiled with dust and dirt accumulations. The wall mounted air conditioning unit filters were further observed soiled with dust and dirt accumulations. The overbed light assembly upper 48-inch-long fluorescent light bulb was finally observed non-functional. 219: The atmospheric vacuum breaker was observed missing on the shower wand assembly, creating a potential cross-connection between the potable (drinking) and non-potable (non-drinking) water supplies. 221: The atmospheric vacuum breaker was observed missing on the shower wand assembly. The Bed 2 landing strips were also observed (etched, scored, worn), exposing the inner Styrofoam padding. The wall mounted air conditioning unit filters were additionally observed soiled with dust and dirt accumulations. The Bed B overbed light assembly upper 48-inch-long fluorescent light bulb was further observed non-functional. The Bed B overbed light assembly pull string extension was finally observed missing. 231: The atmospheric vacuum breaker was observed missing on the shower wand assembly. The closet door mechanical stop plate was also observed missing, allowing the closet door to swing inward beyond the mechanical stop plate. The Bed A overbed light assembly lower 48-inch-long fluorescent light bulb was additionally observed non-functional. On 03/31/22 at 02:30 P.M., An interview was conducted with Maintenance Technician J regarding housekeeping and maintenance issues discovered during the common area and sampled resident room environmental tours. Maintenance Technician J indicated he would complete all maintenance concerns as soon as possible. Maintenance Technician J additionally indicated he would communicate all housekeeping concerns to Director of Housekeeping and Laundry Services K as soon as possible. On 03/31/22 at 03:15 P.M., Record review of the Maintenance Repair Log for the last 60 days revealed no specific entries related to the aforementioned maintenance concerns. On 03/31/22 at 03:30 P.M., Record review of the Policy/Procedure entitled: Sharps Disposal dated 09/2018 revealed under Policy Statement: This facility shall discard contaminated sharps into designated containers. Record review of the Policy/Procedure entitled: Sharps Disposal dated 09/2018 further revealed under Policy Interpretation and Implementation: (3.)(c.) Designated individuals will be responsible for sealing and replacing containers when they are 75% to 80% full to protect employees from punctures and/or needlesticks when attempting to push sharps into the container. (4.)(d.) Seal and replace containers when they are 75% to 80% full to protect employees from punctures and/or needlesticks when attempting to push sharps into the container. (8.) Sharps containers will be changed every 90 days by the designated individual and documented to ensure compliance.

Based on observations, interviews, and record reviews, the facility failed to: (1) effectively clean and maintain food service equipment, (2) effectively date mark all potentially hazardous ready-to-eat food products, and (3) maintain drywall surfaces within the chemical storage room effecting 65 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and resident foodborne illness. Findings include: On 03/30/22 at 08:23 A.M., An initial tour of the food service was conducted with Dietary Manager H. The following items were noted: 3 of 3 hand washing sinks were monitored for hot water supply temperatures. The hot water supply temperatures recorded ranged between 96.0 - 99.0 degrees Fahrenheit. Note: A ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer was utilized to monitor the hot water supply temperatures. The 2013 FDA Model Food Code section 5-202.12 states: (A) A HANDW ASHING SINK shall be equipped to provide water at a temperature of at least 38oC (100oF) through a mixing valve or combination faucet. (B) A steam mixing valve may not be used at a HANDW ASHING SINK. (C) A self-closing, slow-closing, or metering faucet shall provide a flow of water for at least 15 seconds without the need to reactivate the faucet. (D) An automatic handwashing facility shall be installed in accordance with manufacturer's instructions. The three-compartment sink, and two-compartment sink hot water supplies were observed extremely hot. The hot water supply temperatures ranged between 145.0-146.0 degrees Fahrenheit. Note: A ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer was utilized to monitor the hot water supply temperatures. 1 of 3 hand sinks were observed with a defective cold water supply handle. The cold-water handle could be rotated and moved 360 degrees without turning the cold-water supply on. 1 of 3 hand sinks were observed with handles out of adjustment. The hot and cold-water handles were observed to turn past the manufacturer recommended stop set point. The three-compartment sink, and two-compartment sink hot and cold water handles were observed out of adjustment. The handles were observed to turn past the manufacturer recommended stop set point. The 2013 FDA Model Food Code section 5-205.15 states: A PLUMBING SYSTEM shall be: (A) Repaired according to LAW; and (B) Maintained in good repair. Walk-In Cooler: One gallon of skim milk was observed with an open date of 3/29/22 with no labeled out or use-by-date. The manufacturer use-by-date was observed to read 4/5/22. One-half gallon of skim milk was observed with an open date of 3/29/22 with no labeled out or use-by-date. The manufacturer use-by-date was observed to read 4/4/22. One gallon of 2% milk was observed with and open date of 3/29/22 with no labeled out or use-by-date. The manufacturer use-by-date was observed to read 4/5/22. The 2013 FDA Model Food Code section 3-501.17 states: (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO -EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. Walk-in Freezer: The refrigeration unit condensate drain line was observed disconnected. The condensate was also observed to be draining into a stainless-steel hotel pan resting on top of the upper shelving storage unit within the walk-in freezer. The refrigeration unit Freon supply line was observed wrapped with an ice damn. The ice damn measured approximately 5-inches-wide by 12-inches-long, creating a potential cross-contamination issue. The 2013 FDA Model Food Code section 5-205.15 states: A PLUMBING SYSTEM shall be: (A) Repaired according to LAW; and (B) Maintained in good repair. The Mechanical Dish Machine final rinse temperature gauge was observed to read 164.0 degrees Fahrenheit during the final rinse cycle. This surveyor monitored the final rinse temperature utilizing a Thermal Tape adhesive strip. The Thermal Tape adhesive strip was observed to read a minimum of 160.0 degrees Fahrenheit and turned the indicator window black, suggesting a faulty final rinse temperature indicator gauge. The 2013 FDA Model Food Code section 4-501.112 states: (A) Except as specified in (B) of this section, in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90oC (194oF), or less than: (1) For a stationary rack, single temperature machine, 74oC (165oF); or (2) For all other machines, 82oC (180oF). (B) The maximum temperature specified under (A) of this section, does not apply to the high pressure and temperature systems with wand-type, hand-held, spraying devices used for the in-place cleaning and SANITIZING of EQUIPMENT such as meat saws. The Mechanical Dish Machine wash temperature gauge was observed to read 148.0 degrees Fahrenheit during the wash cycle. The 2013 FDA Model Food Code section 4-501.110 states: (A) The temperature of the wash solution in spray type ware washers that use hot water to SANITIZE may not be less than: (1) For a stationary rack, single temperature machine, 74oC (165oF); (2) For a stationary rack, dual temperature machine, 66oC (150oF); (3) For a single tank, conveyor, dual temperature machine, 71oC (160oF); or (4) For a multitank, conveyor, multitemperature machine, 66oC (150oF). (B) The temperature of the wash solution in spray-type ware washers that use chemicals to SANITIZE may not be less than 49oC (120oF). Chemical Storage Room: The upper wall surface (approximately 12-inches below the ceiling surface) and ceiling surface were observed unfinished. The drywall surfaces and joints were observed taped and covered with drywall compound. The drywall surfaces were also observed missing primer and the top finish seal coat. The 2013 FDA Model Food Code section 6-201.11 states: Except as specified under § 6-201.14 and except for antislip floor coverings or applications that may be used for safety reasons, floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are SMOOTH and EASILY CLEANABLE. On 03/31/22 at 02:45 P.M., Record review of the Policy/Procedure entitled: Food Safety and Sanitation Outline dated 09/2018 revealed under Policy: All local, state, and federal standards and regulations will be followed in order to assure a safe and sanitary department of food and nutrition services. On 03/31/22 at 03:00 P.M., Record review of the Policy/Procedure entitled: Food Storage dated 09/2018 revealed under Policy: Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contaminants. Food will be stored, at appropriate temperatures and by methods designed to prevent contamination or cross-contamination. Record review of the Policy/Procedure entitled: Food Storage dated 09/2018 further revealed under Procedure: (12.) Refrigerated Food Storage: (f.) All foods should be covered, labeled, and dated. All foods opened will have the open date wrote on each individual item. All foods will be checked daily to assure that foods (including leftovers) will be consumed by their individual safe use-by-dates, or frozen (where applicable), or discarded. Record review of the Policy/Procedure entitled: Food Storage dated 09/2018 finally revealed under Procedure: (13.) Frozen Foods: (c.) All foods should be covered, labeled, and dated.

This citation pertains to Intake MI 338. Based on interview and record review the facility failed to accurately transcribe insulin orders from discharging hospital to nursing home, provide prescribed afternoon (PM) dose of insulin, or notify the physician of elevated blood sugars (BS) for one resident (R#1) from a total of 13 residents with known diabetes (DM-high blood sugar). As a result of failing to administer PM dose of insulin or monitor PM BS levels from 11/13/20 to 11/19/20 (6 days) or notify physician of change of condition (increasing blood sugars), lead to hospitalization for diabetic ketoacidosis (A serious problem that can happen in people with diabetes if their body starts to run out of insulin. When this happens, harmful substances called [MEDICATION NAME] build up in the body, which can be life-threatening if it's not found and treated quickly) due to a blood sugar level of 685 (normal range 60-120 milligrams per deciliter -mg/dl), being placed on an insulin drip and admitted to the Intensive Care Unit (ICU). The Immediate Jeopardy (IJ) was identified on 11/13/20 at 4:46 p.m., as a result of failure to accurately transcribe all prescribed orders and provide physician treatment as ordered, identify assessed changes in condition, closely monitor blood sugar levels and notify the physician for R#1 leading to hospitalization and the likelihood of other residents affected due to lack of assessment and monitoring when blood sugars were out of baseline to prevent the likelihood of serious injury, serious harm, serious impairment or death. The Administrator was notified of the Immediate Jeopardy (IJ) on 12/17/20 at 12:16 p.m. The Immediate Jeopardy began on 11/13/20. A plan to remove the immediacy was requested. The IJ was removed on 12/18/20, based on the facility's implantations of the plan of removal as verified by the Surveyor on site. Although the IJ was removed, the facility's deficient practice was not corrected and remained isolated with actual harm. Findings Include: Review of a complaint called into the State Agency (SA) by R#1's daughter documented, . the Staff at (name of facility) withheld afternoon insulin from (R#1) citing 'you didn't eat so you don't need the insulin' even though the staff didn't first test the blood sugar (BS) to find out if (resident) actually needed the insulin. On 12/16/20 at 3:43 PM, during a phone interview with R#1's daughter she stated, My mother checked her own (blood) sugars and was on insulin twice a day for over [AGE] years (long-term use of insulin). When she got to (name of facility), they never gave her the evening dose of insulin. They never checked her (blood) sugar in the evenings. Her sugar (level) shot sky high, and she had to go to the hospital. Her sugar at the hospital was over 600!. Electronic Medical record review revealed that R#1 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Clinical Observation dated 11/13/2020 indicated the resident cognition was alert and oriented to person, place and time and required one person physical assistance from staff for all activities of daily living. The Admission Clinical Observation also revealed that R#1's Attending Physician was MD E and .all orders verified with physician. Review of the discharging hospitals orders dated 11/13/20 (date R#1 was admitted into the facility) documented a medication list which included; Insulin NPH 100 UNIT/ML Suspension commonly known as: [MEDICATION NAME] N, [MEDICATION NAME] N (insulin [MEDICATION NAME] 12-18 hours) 20 units every (Q) AM (and)/ 26 UNITS Q PM. For Diagnoses: [REDACTED]. Last time this was given: 40 Units on November 13, 2020 8:50 AM .After discharge, ensure you take all your medications as prescribed and follow up with your physician. The census tab indicated the resident was discharged back out to the hospital six days later on 11/19/20. The Vital Sign record for Weights-indicated no admission or any other weight was obtained or recorded for R#1 between 11/13/2020 admission and 11/19/2020 discharge. Review of the unsigned physician order [REDACTED]. There was no order for the PM dose of insulin as indicated on the hospital discharge orders. Review of the facility's Medication Administration Record [REDACTED]. There was no documented evidence that the resident's blood sugar level was checked or that insulin was administered each evening. A document titled, New Admission History and Physical (H&P) dated 11/17/20 which was scribed by the Nurse Practitioner (NP) and scanned into the Electronic Medical Record (EMR) documented, Past medical history: .Type 2 diabetes .Continue with [MEDICATION NAME] N NPH insulin 20 units once a day .Patient seen with and case discussed with (name of Attending Physician E, who is also the Medical Director) .Reviewed hospital notes radiology studies and laboratory/ procedure results. Reviewed consultation notes. Completed admission medication reconciliation .Reviewed orders with nursing staff. The document was signed by Attending Physician E. Neither the New Admission History and Physical nor the electronic clinical record documented any evidence regarding the evaluation and subsequent discontinuation of the hospital ordered [MEDICATION NAME] N, [MEDICATION NAME] N 26 UNITS Q (every) PM (evening). There was no documented evidence that any assessment or monitoring measures for blood sugar levels were put into place for R#1 who had a documented order for PM insulin and a history of long-term PM insulin use. Review MAR's revealed the nursing staff checked R#1's BS level in the morning prior to administration of the 20 units of insulin. The AM blood sugar levels were as follows: 11/14/20 - 162; 11/15/20 - 178; 11/16/20 - 260; 11/17/20 - 283; 11/18/20 - 310: 11/19/20 - BS result illegible. The EMR food/fluid intake record for Breakfast, AM Snack, Lunch, PM Snack, Dinner, Bedtime Snack, Supplements, Fluids: Revealed only one meal intake documention dated 11/18/2020- Breakfast: 76-100%; Lunch: 1-25% (out of range); Dinner: 1-25% (out of range) out of the potential 17 meals provided during the residents stay from 11/13/20 to 11/19/20. There was no documented refusal of meals/fluids for R#1. There was no documented evidence in the EMR clinical record that the attending physician was notified of the residents elevating blood sugar levels or decreased oral intake. A routine lab test result dated 11/19/20 revealed a critically low (CL) sodium level ([MEDICAL CONDITION] - uncontrolled DM can also induce hypovolemia - low fluid volume- due to diuresis) of 117 (normal range 135-145) and a blood glucose level of 385 (up from 310 on 11/18/20). A nurses note dated 11/19/20 at 1:01 PM documented, Per Nurse Practitioner (NP) send resident to (hospital emergency room ) ER related to CL Sodium 117. Review of the hospital ER record dated 11/19/20 at 2:35 PM documented, .The patient states she has not been eating or drinking .Labs reviewed: Glucose: 685 (up from 385 at the facility) .Problem list items addressed this visit: [MEDICAL CONDITION], .[MEDICAL CONDITION] (infection), .DKA (diabetic ketoacidosis). Relevant Medications; Insulin ([MEDICATION NAME] N) 100 units/ml subcutaneous (SQ) suspension; Insulin ([MEDICATION NAME] R) High Alert 10 units .Insulin ([MEDICATION NAME] R) 100 units in sodium chloride 0.9% 100 ml infusion . [DIAGNOSES REDACTED]. Patient was given fluids, and labs repeated. Patient to be hypoglycemic .Patient started on insulin drip. Patient will be admitted to the intensive Care Unit (ICU) for management. On 12/17/20 at 9:31 AM, the facility's Director of Nursing (DON) was interviewed regarding the concern with R#1's omitted PM dose of insulin and no evidence of the physician notification for the elevating BS. After reviewing the resident's hospital discharge orders and the facility's admission's orders the DON stated, (name of R#1) should have been receiving 26 units of insulin every evening. I don't see where the order was transcribed from the hospital. At this time the DON was given the opportunity to respond to identified concerns for R#1. The DON had no follow up response. The Administrator was notified of the Immediate Jeopardy (IJ) on 12/17/20 at 12:16 p.m. On 12/17/20 at 1:05 PM (after the IJ was issued), Physician D approached the surveyor. Physician D stated, I was the one who took that resident off the PM dose of insulin. She would have bottomed out (blood sugar levels drop). I would rather her (BS's) be in the 200's than in the 60's. Physician D then present a paper document, which was not part of the Electronic Medical Record or previously available, titled History and Physical Exam dated 11/13/20 noting R#1's name and Attending Physician as Physician E. Physician D said he performed and signed the admission H&P for R#1 and discontinued the resident's PM insulin upon admission. Review of the 11/13/20 H&P done by Physician D documented no evidence regarding the evaluation and subsequent discontinuation of the hospital ordered [MEDICATION NAME] N, [MEDICATION NAME] N 26 UNITS Q (every) PM (evening). There was no documented evidence that any assessment or monitoring measures for blood sugar levels were put into place after the PM dose was allegedly discontinued for R#1 by Physician D. Physician D was then asked about his role as a physician to a resident that he was not assigned to, which he responded, (Name of Physician E) has bee ill. I'm covering for him. Physician D was asked why he did not document evidence of evaluating the use of the insulin and subsequently discontinuing it for a patient he was unfamiliar without placing monitoring measure into place to which he responded, You know us doctors, we don't document everything. On 12/18/20 at 9:35 AM, during an interview with the facility's Administrator, she was asked about the role of Physician D. The Administrator said that Physician D sits on the Board as an authorized official, oversees things and performs chart reviews. At this time the Administrator presented multiple hospital documents dated 11/19/20 to 12/3/20 (the 14 days after the resident had been discharged from the facility to the hospital with a CL sodium and elevated BS) which were not part of R#1's EMR. On 12/18/20 at 12:03 PM, at phone call was placed to Physician E (R#1's Attending Physician and Medical Director) for an interview and a message was left on his voicemail. At 12:41 PM, Physician D stated his was acting Medical Director due to Physician E being ill. The physician was asked if transcribing orders from the hospital to the nursing home, insulin administration or notifying physicians of resident change in condition had been problems identified during the Quality Assurance (QA) process, to which the physician said, No. There has never been a problem. Physician D went on to say that in the hospital after she discharged , the resident's BS were up and down and that she had a poor appetite and was septic (infection) when she went to the hospital and that is the reason why the BS were elevating. The physician could not explain why the insulin was discontinued at admission (prior to knowledge of fluctuating BS levels and decreased appetite). When asked if the physician should have been notified when the BS levels were elevating he stated, We got routine labs drawn. Review of the facility's Reconciliation of Medications on Admission policy dated 9/2018 documented, The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility .Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process If a medication history has not been obtained from the resident or family, complete this first Using an approved medication reconciliation form or other record, list all medications from the medication history, the discharge summary, the previous MAR (if applicable), and the admitting orders (sources) Review the list carefully to determine if there are discrepancies/conflicts . If there is a discrepancy or conflict in medications, dose, route or frequency, determine the most appropriate action to resolve the discrepancy .Document what actions were taken by the nurse to resolve the discrepancy If the discrepancy was unresolved, document how the discrepancy was communicated to the charge nurse, physician, pharmacy, and/or next shift. Review of the facility's Nursing Care of the Resident with Diabetes Mellitus policy dated 9/2018 documented, Diabetic ketoacidosis (DKA) or hyperosmolar (nonketotic) coma includes the following symptoms: a. high blood sugar; b. [MEDICATION NAME] in the urine (DKA only); c. nausea and/or vomiting; d. lethargy (drowsiness); e. weakness; f. short, labored, rapid respirations; g. abdominal pain; h. dehydration; i. oliguria (diminished urine); j. sweet or fruity odor of breath; k. dry and/or flushed skin; l. decreased awareness/senses; m. loss of consciousness; and/or n. coma. (Note: Diabetic ketoacidosis is a life-threatening emergency that needs immediate medical attention.) .The physician will order the frequency of glucose monitoring . Residents whose blood sugar is poorly controlled or those taking insulin may require more frequent monitoring, depending on the situation .Documentation should reflect the carefully assessed diabetic resident and include the following: . Vital signs as ordered; Accurate intake and output; Percentage of meals consumed; Blood sugar results and other pertinent laboratory studies. Review of the facility's Medication Utilization and Prescribing - Clinical Protocol dated 4/20/17 documented, The physician and staff will adjust existing medications based on their efficacy and the continued presence of relevant conditions and risks .The physician will provide and/or document a rationale when the dose, duration, or frequency of a prescribed medication is greater than commonly accepted practice or the manufacturer's recommendations or the medication is considered high-risk compared to other available, relevant alternatives. Review of the facility's Change In Condition Process dated 2/2019 documented, The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification .Situations requiring notification include: . Potential to require physician intervention .Clinical complications .A need to alter treatment significantly; that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment .Discontinuing a treatment or changing a medication due to: Exacerbation of a chronic condition .Upon the identification of a change in condition in a resident the Nurse will complete an evaluation of the resident's status, and document findings on the SBAR Change in Condition in the resident's electronic medical record. Aerius Health Center Immediate Jeopardy Abatement Amended 12-18-20 Resident #1 no longer resides within the facility 12/17/20 all residents receiving Insulin's Medical records were reviewed with no further areas of concern. 12/17/20 all residents receiving Insulin's Medication Orders were reviewed with no further areas of concern. 12/17/20 all residents receiving Insulin's Medication Administration Records were reviewed with no further areas of concern. 12/17/20 all residents receiving Insulin's Labs were reviewed with no further areas of concern. 12/17/20 all residents receiving insulin were assessed with [REDACTED]. Beginning on 12/18/20 education regarding Medication Reconciliation for new admits, Appropriate transcription and documentation of Medication orders, Receiving and Documenting medication orders from a physician, Nursing Care for Diabetic Patients, Blood Glucose Monitoring, Hyperglycemic/Hypoglycemic events, Progress Notes & Documentation, Resident Intakes, Change of Condition, Notifying a physician of a change in condition, Proper documentation of Blood Glucose levels, will be provided to all nursing staff by the Inservice Director/Infection Preventionist, Nursing Management, Director of Nursing and Administrator/Designee. Beginning on 12/18/20 education regarding proper documentation of a change in Hospital Medication Orders will be provided to all facility physicians and physician extenders by the Medical Director/Designee. Beginning week of 1/2/21 and monthly the Director of Nursing will complete an audit of Medical records, including Resident's Hospital admission orders [REDACTED]. Findings to be reviewed in QA. Beginning week of 1/2/21 and monthly the Director of Nursing will complete and audit of all residents receiving Insulin's POC to ensure treatment plan is effective and appropriate for resident. Findings to be reviewed in QA. Beginning week of 1/2/21 and monthly the Director of Nursing will meet with Nurses and Nurse Manager to discuss all residents receiving Insulin and the need for addition to or modification of Treatment plans for residents. Residents were assessed and none were identified to be at risk, Nurses and Nurse Managers will continue to be reeducated on a monthly basis to ensure that all resident needs are met. An audit of Insulin dependent residents will be conducted monthly to ensure proper assessment and treatment plans are appropriate for individual residents on a monthly basis and brought to QA until substantial compliance is achieved.

This citation pertains to intake MI 921. Based on interviews and record reviews the facility failed to provide any form of pain relief, or order 'timely' radiology diagnostic tests (X-rays) for one of five residents (#234) reviewed for falls, resulting in R#234 having 'severe' pain after a fall and not receiving any form of pain relief, and not having an X-ray until approximately nine hours after the fall, ultimately delaying R#234's transfer to the hospital and obtaining pain relief and treatment for [REDACTED]. Findings include: According to the complaint intake, the resident's Responsible Party (RP) said she was notified on 8/5/20 at approximately 6:30 AM that R#234 had a fall and he was OK. The RP said, I asked the nurse to please get a X-ray order from the doctor to be sure he hadn't broken anything. The nurse said she would get a order for a X-ray. I called and talked to the day shift nurse several times throughout the day, and he (the nurse) kept telling me that he (R#234) was 'OK' and they were still waiting for X-ray. At about 4:00 PM that day another nurse called me back and told me he (R#234) had broke his hip and was being sent out to the hospital. I'm upset that he (R#234) had to suffer like that for so long. I don't understand why the X-ray took so long, and why they just didn't send him to the hospital so he could get treated faster. A closed medical record review indicated that R#234 admitted to the facility on [DATE] for [DIAGNOSES REDACTED]. According to the progress note dated 8/5/20 at 6:45 AM, the resident was found seated upright on the floor with his back against the wall in his room. The resident was assisted back into his wheelchair and denied having pain. The family and physician were notified, no orders were received from the physician at this time. A progress note on 8/5/20 at 9:15 AM, written by the Occupational Therapist reads as follows: patient reports 'unbearable pain' in LLE (left lower extremity) and hip. Nurse and NP (Nurse Practitioner) notified. Order for X-ray of LLE hip ordered and awaiting results. A progress note on 8/5/20 at 9:39 AM, written by the Physical Therapist reads as follows: patient moaned and flinched when writer attempted to put sock on patient's left foot. Patient complains of 'excruciating pain' in his left hip area. Nurse notified of patient's complaint and X-ray ordered. A progress note on 8/5/20 at 10:01 AM, written by nurse D reads as follows: resident complains of severe pain on lower left side of body related to a recent fall. NP notified of resident's status an ordered an X-ray to r/o (rule out) fracture or dislocation. There is no documentation to indicate the nurse, or any nurse staff member administered any pain medication or provided any pain relieving treatments of any kind to the resident. A progress note on 8/5/20 at 3:05 PM, written by Speech Therapist reads as follows: resident complains of pain. Notified nurse staff. A review of the resident's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. A progress note on 8/5/20 at 3:37 PM, written by nurse J reports the following: imaging here to take X-ray of resident's left hip. X-ray tech called writer in the room to say resident had left broken hip. Wife notified of X-ray results. A progress note on 8/5/20 at 4:12 PM, written by nurse D documented that the NP was notified of the X-ray results and the resident was sent out to the ED (emergency department). There is no documentation of pain relieving medication or treatment prescribed or administered at this of any other time. On 8/18/20 at 3:25 PM, nurse D was asked about R#234's pain management. Nurse D reviewed R#234's medical record and confirmed there was no documentation to support that a pain relieving medication or any type of pain relieving therapy was administered to the resident while he was at the facility. Nurse D said, He (R#234) was only ordered to have Tylenol, and that wouldn't have done much for his pain, and he (R#234) didn't really complain of pain unless he moved or put pressure on his left leg. Nurse D confirmed that the X-ray was not ordered STAT (immediately). Nurse D could not explain why he didn't obtain an order for [REDACTED]. A progress note that was actually written on 8/5/20 at 10:10 PM, by the NP was a 'late entry' for 8/5/20 at 9:10 AM documented the following; the resident had a fall and has been having some left hip pain, physical therapy explained that resident was exhibiting pain in left hip and left leg and unable to move his left leg without significant pain and was very tender upon palpation of the left hip area. The NP ordered a X-ray and to continue Tylenol for pain. On 8/18/20 at 10:30 AM, the NP was interviewed regarding the pain management and X-ray order for R#234 on 8/5/20. The NP said, We don't order narcotics to a resident with cognition deficits, because it can make their mental status worse. We don't send residents to the hospital unless there is a fracture. The NP was asked why he did not order the X-ray STAT, or send the resident to the emergency room after his assessment at 9:10 AM, which documented the resident was unable to move his left left without signficant pain. The NP said he thought he did order the X-ray STAT, and he would review his notes. There was no additional interview with the NP prior to the end of the survey. A review of the radiology report dated 8/5/20 at 3:54 PM (approximately nine hours after the resident fell ) revealed the following impression: intertrochanteric fracture left hip.