Every finding on record at Alcoa Pines Health and Rehabilitation

Number of residents sampled: Number of residents cited: Based on record review, interview, and facility policy review, the facility failed to protect a resident's right to be free from misappropriation of resident's property. Specifically, medications were signed out of the Narcotic Book and not given to 12 (Residents #53, #65, #81, #91, #94, #95, #96, #98, #100, #112, #114, and #115) of 23 residents reviewed for misappropriation of property. The findings include: Resident #53 Review of an admission Record revealed the facility admitted Resident #53 on 04/10/2024. The resident had a medical history that included diagnoses of heart failure, polyarthritis (5 or more joints are inflamed and painful) and gastrostomy status (feeding tube). Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/23/2025, revealed Resident #53 had short- and long-term memory problems and was moderately impaired for daily decision making. The MDS revealed Resident #53 received an opioid pain medication. Review of Resident #53's Care Plan Report, indicated the resident was on pain medication therapy initiated on 05/31/2024. Interventions included to administer analgesic medications as ordered by physician. Review of Resident #53's Medication Administration Record (MAR)/Treatment Administration Record (TAR) for both May and June 2025 revealed an order, dated 12/19/2024 for an opioid pain medication (Norco) Oral Tablet 10-325 milligrams give 1 tablet via PEG-tube every 4 hours as needed for pain Review of Narcotic Book page 100 indicated Resident #53's opioid pain medication was signed out 9 times by LPN #9 between 05/16/2025 and 06/14/2025 and was not administered to the resident. Review of Resident #53's MAR/TAR for both May and June 2025 revealed blank boxes for the dates LPN #9 signed out the resident's opioid pain medication.Resident #65 Review of an admission Record revealed the facility admitted Resident #65 on 04/01/2025. The resident had a medical history that included diagnoses of a fracture around an internal prosthetic right hip joint, anxiety, and pain. Review of a quarterly MDS, with an ARD of 03/16/2025, revealed Resident #65 had a Brief Interview for Mental Status (BIMS) of 15, which indicated the resident was cognitively intact. The MDS revealed Resident #65 had pain and received an opioid pain medication. Review of Resident #65's Care Plan Report, indicated the resident was on pain medication therapy initiated on 04/10/2024. Interventions included administering analgesic medications as ordered by the physician. Review of Resident #65's Physician Orders revealed an order, dated 05/28/2025 for an opioid pain medication (Tramadol HCL) Oral Tablet 50 MG give one tablet by mouth every 6 hours as needed for pain. During an interview on 08/26/2026 at 9:50 AM, Resident #65 indicated the facility ensured they received their pain medication and their pain was controlled. Review of Narcotic Book page 103 revealed Resident #65's opioid pain medication was signed out 8 times by LPN #9 between 05/05/2025 and 06/18/2025 and was not administered to the resident. Review of Resident # 65's MAR/TAR for May and June 2025 revealed blank boxes for the dates LPN #9 signed out the resident's opioid pain medication. Resident #81 Review of an admission Record revealed the facility admitted Resident #81 on 02/21/2025. The resident had a medical history that included diagnoses of heart failure, type 2 diabetes mellitus, right hip pain, and chronic pain. Review of discharge MDS, with an ARD of 05/09/2025, revealed Resident #81 had a BIMS of 15, which indicated the resident was cognitively intact. The MDS revealed Resident #81 had pain and received an opioid pain medication. Review of Resident #81's Care Plan Report, indicated the resident was on pain medication therapy initiated on 04/26/2025. Interventions included administering analgesic medications as ordered by the physician. Review of Resident #81's Physician Orders revealed an order, dated 04/25/2025 for an opioid pain medication (Hydrocodone-Acetaminophen) Oral Tablet 10-325 MG Give 1 tablet by mouth every 6 hours as needed for pain During a phone interview on 08/27/2026 at 10:15 AM Resident #81's representative reported they did not have any issues with the resident receiving pain medications. The representative indicated the resident's pain was controlled. Review of Narcotic Book page 18 revealed Resident #81's opioid pain medication was signed out by LPN #9 five times between 05/02/2025 and 05/09/2025 and not administered to the resident. Review of Resident # 81's MAR/TAR for May of 2025 revealed blank boxes for the dates LPN #9 signed out Resident #81's opioid pain medication. Review of a witness statement dated 06/25/2026 revealed LPN #9 confirmed she listed the wrong date for the medication Resident #91Review of an admission Record revealed the facility admitted Resident #91 on 07/11/2025. The resident had a medical history that included diagnoses of Alzheimer's disease, dementia with anxiety, malignant neoplasm of prostate, pain and migraines. Review of a discharge MDS, with an ARD of 06/02/2025, revealed Resident #91 had a BIMS of 00, which indicated the resident was severely impaired cognitively. The MDS revealed Resident #91's high risk medications included antianxiety medication. Review of Resident #91's Care Plan Report, indicated the resident had diagnoses that included depression and anxiety initiated on 07/15/2025. Interventions included to administer medications as ordered by physician. Review of Resident #91's Physician Orders revealed an order, dated 07/11/2025 for an antianxiety medication (Ativan) oral tablet 0.5 mg give one tablet by mouth every 4 hours as needed for anxiety, restlessness. Review of Narcotic Book page 47 revealed Resident #91's antianxiety medication was signed out by LPN #9 two times between 05/29/2025 and 05/30/2025 and not administered to the resident. Review of LPN #9's clock in times revealed the LPN was not working on 05/29/2025 and 05/30/2025. Review of Resident # 81's MAR/TAR for May of 2025 revealed blank boxes for the dates LPN #9 signed out Resident #91's opioid pain medication. Resident #95 Review of an admission Record revealed the facility admitted Resident #95 on 05/21/2025. The resident had a medical history that included diagnoses of pain in the left ankle and joints of the left foot, anxiety, depression, pain and gout Review of the admission MDS, with an ARD of 05/27/2025, revealed Resident #95 had a BIMS of 14, which indicated the resident was cognitively intact. The MDS revealed Resident #95 had pain and received opioid pain medication as well as an antianxiety medication. Review of Resident #95's Care Plan Report, indicated the resident was on pain medication therapy initiated on 05/21/2025. Interventions included to administer analgesic medications as ordered by the physician. The Care Plan also indicated the resident had diagnoses of depression, anxiety initiated on 05/23/2025 with an intervention to administer medications as ordered. Review of Resident #95's Physician Orders revealed an order, dated 05/26/2025 for a benzodiazepine antianxiety medication (Ativan) oral tablet 0.5 MG give one tablet by mouth every 2 hours as needed related to anxiety disorder. The Physician's Orders also revealed an order dated 05/22/2025 for an opioid pain medication (Hydrocodone-Acetaminophen) 10-325 MG give one tablet by mouth every 4 hours as needed for pain. Review of Narcotic Book page 110 revealed Resident #95's opioid pain medication was signed out by LPN #9 seventeen times between 05/30/2025 and 06/14/2025 and not administered to the resident. Review of Resident # 95's MAR TAR 2025 and MAR TAR JUNE 2025 revealed blank boxes for the dates LPN #9 signed out Resident #95's opioid pain medication. Review of Narcotic Book page 79 revealed Resident #95's benzodiazepine antianxiety medication was signed out by LPN #9 four times between 05/28/2025 and 05/29/2025 and not administered to the resident. Review of Resident #95's MAR TAR MAY 2025 revealed blank boxes for the dates LPN #9 signed out Resident #95's benzodiazepine antianxiety medication. Resident #96 Review of an admission Record revealed the facility admitted Resident #96 on 04/30/2025. The resident had a medical history that included diagnoses of stage 3 pressure injury, emphysema, chronic obstructive pulmonary disease, cirrhosis of liver, dependence on renal dialysis, wedge compression fracture of T9-T10 vertebra and pain. Review of an admission MDS, with an ARD of 05/06/2025, revealed Resident #96 had a BIMS of 11, which indicated the resident had moderate cognitive impairment. The MDS revealed Resident #96 had pain and received an opioid pain medication. Review of Resident #96's Care Plan Report, indicated the resident was on pain medication therapy initiated on 05/01/2025. Interventions included to administer analgesic medications as ordered by the physician. Review of Resident #96's Physician Orders revealed an order, dated 05/09/2025 for an opioid pain medication (Hydromorphone HCL) oral liquid 1 mg/ml give one ml by mouth every 2 hours as needed for pain. During a phone interview on 08/27/2026 at 10:50 AM, Resident #96's representative indicated there were no issues with the resident receiving pain medications while in the facility. The representative reported the resident's pain was controlled. Review of Narcotic Book page 30 revealed Resident #96's opioid pain medication was signed out by LPN #9 one time on 05/09/2025 and not administered to the resident. Review of Resident # 96's MAR/TAR for May 2025 revealed a blank box for the date LPN #9 signed out Resident #96's opioid pain medication. Resident #97 Review of an admission Record revealed the facility re-admitted Resident # 97 on 05/15/2026. The resident had a medical history that included diagnoses of pain in the left and right hip, repeated falls, and malignant neoplasm of upper lobe, right bronchus or lung, and nondisplaced fracture of pubic. Review of a 5-Day MDS, with an ARD of 05/20/2025, revealed Resident #97 had a BIMS score of 06, which indicated the resident had severe cognitive impairment. The MDS revealed Resident #97 rarely or never experienced pain. Review of Resident #97's Care Plan Report, included the resident was on pain medication therapy as needed for pain, revised on 05/16/2025. Interventions included administering analgesic medications as ordered by the physician. Review of Resident #97's Physician Orders revealed an order, dated 05/15/2025 for Oxycodone HCl Oral Tablet 15 MG give 1 tablet by mouth every 8 hours as needed for pain. Review of the narcotic sign out pages 96,61,57, 75, and 39 for Resident #97 revealed Oxycodone 15 mg was signed out 5/23/2025, 5/24/2025, 5/25/2025, 6/05/2025, and 6/17/2025 while LPN #9 was not at work. Review of a witness statement dated 06/25/2025 revealed LPN #9 confirmed she listed the wrong dates for Oxycodone 15mg for Resident #97. Review of an admission Record revealed the facility admitted Resident #98 on 06/06/2025. The resident had a medical history that included diagnoses of malignant neoplasm of lower lung lobe, vascular dementia, depression and pain. Review of admission MDS, with an ARD of 06/12/2025, revealed Resident #98 had a BIMS of 12, which indicated the resident had moderate cognitive impairment. The MDS also revealed Resident #98 had pain and received opioid pain medication. Review of Resident #98's Care Plan Report, indicated the resident was on pain medication therapy initiated on 06/08/2025. Interventions included to administer analgesic medications as ordered by the physician. Review of Resident #98's Physician Orders revealed an order, dated 06/06/2025 for an opioid pain medication (Tramadol HCL) oral tablet 50 mg give one tablet by mouth every 6 hours as needed for moderate and severe pain. Review of Narcotic Book page 64 revealed Resident #98's opioid pain medication was signed out by LPN #9 seven times between 06/07/2025 and 06/13/2025 and not administered to the resident. Review of Resident # 98's MAR/TAR for June of 2025revealed blank boxes for the dates LPN #9 signed out Resident #98's opioid pain medication. Resident #99 Review of an admission Record revealed the facility admitted Resident #99 on 06/10/2026. The resident had a medical history that included diagnoses of pain, polyarthritis and ulcerative colitis. Review of a discharge MDS, with an ARD of 06/26/2025, revealed Resident #99 had a BIMS score of 15, which indicated the resident was cognitively intact. The MDS revealed Resident #99 did not have any pain. Review of Resident #99's Care Plan Report, included the resident was on pain medication therapy as needed for pain, revised on 06/26/2025. Interventions included administering analgesic medications as ordered by the physician. Review of Resident #99's Physician Orders revealed an order, dated 06/10/2025 for Hydrocodone-Acetaminophen 10-325 milligrams give 1 tablet by mouth every 6 hours as needed for pain related to displaced transverse fracture of left patella. Review of Narcotic Book page 69 for Resident #99revealed Norco 10/325 mg was signed out by LPN #9 on 06/21/2026 when LPN #9 was not at work. Review of a witness statement dated 06/25/2026 revealed LPN #9 confirmed she listed the wrong date for the medication. Resident #100 Review of an admission Record revealed the facility re-admitted Resident #100 on 05/20/2025. The resident had a medical history that included diagnoses of pain, and unspecified fractures to left femur. Review of admission MDS, with an ARD of 05/24/2025, revealed Resident #100 had a BIMS score of 15 which indicated the resident was cognitively intact. Review of Resident #100's Care Plan Report, included the resident was on pain medication therapy as needed for pain, revised on 06/03/2025. Interventions included administering analgesic medications as ordered by the physician. Review of Resident #100's Physician Orders revealed an order, dated 5/27/2025 for Hydrocodone-Acetaminophen 5-325mg oxycodone HCl Oral Tablet give 1 tablet by mouth every 8 hours as needed for pain. Review of Narcotic Book page 54for Resident #100 revealed Hydrocodone was administered by LPN #9 when she was not at work Review of a witness statement dated 06/25/2026 revealed LPN #9 confirmed she listed the wrong date for the medication. Resident #108 Review of an admission Record revealed the facility re-admitted Resident #108 on 07/26/2024 The resident had a medical history that included diagnoses of chronic pain syndrome. Review of a significant change MDS, with an ARD of 05/01/2025, revealed Resident #108 had a BIMS score of 14, which indicated the resident was cognitive intact. The MDS also revealed Resident #108 rarely or never experienced pain. Review of Resident # 108's Care Plan Report, included the resident uses antidepressant medications related to insomnia with a revision date of 05/29/2026. The care plan also indicated that the resident was on pain medication therapy. Interventions included to ensure accuracy when prescribing, dispensing, and administering [medications], with a revision date of 03/17/2025 Review of Resident #108's Physician Orders revealed an order, dated 05/02/2025 for Lorazepam 0.5mg give 1 tablet by mouth every 4 hours as needed for anxiety for 14 days. Morphine 0.25 milliliters by mouth every 3 hours as needed for pain/shortness of breath. Review of the narcotic sign out page 12 for Resident #108 revealed Ativan 0.5 milligrams was administered by LPN #9 when she was not at work Review of a witness statement dated 06/25/2026 revealed LPN #9 confirmed she listed the wrong date for the medication. Resident #111 Review of an admission Record revealed the facility re-admitted Resident #111 on 05/15/2026. The resident had a medical history that included diagnoses of pain in the left and right hand, ocular pain, and chest pain. Review of a discharge MDS, with an ARD of 05/07/2025, revealed Resident #111 had modified independence for daily decision making. Review of Resident 111's Care Plan Report, included the resident was on pain medication therapy. Interventions included to review for pain medication efficiency. Review of Resident 111's Physician Orders revealed an order, dated 04/01/2025 for Clonazepam 1mg give 1 tablet by mouth at bedtime related to bipolar disorder. Review of Resident #111's narcotic sign out page 71 revealed clonazepam 1 mg was signed out with the same date and time on 04/22/2025, 04/23/2025, 04/25/2025, 05/01/2025, 05/06/2025, 05/20/2025, and 05/30/2025 Review of a witness statement dated 06/25/2025 revealed LPN #9 confirmed she listed the wrong date for the medication when she signed the clonazepam out of the narcotic book. Resident #112 Review of an admission Record revealed the facility admitted Resident #112 on 05/23/2025. The resident had a medical history that included diagnoses of stage 4 pressure injury of right hip and sacral region, paraplegia, heart failure and pain. Review of a discharge MDS, with an ARD of 06/05/2025, revealed Resident #112 had a BIMS of 15, which indicated the resident was cognitively intact. The MDS also revealed Resident #112 had pain and received an opioid pain medication. Review of Resident #112's Care Plan Report, indicated the resident was on pain medication therapy initiated on 05/24/2025. Interventions included to administer analgesic medications as ordered by the physician. The Care Plan Report also included the resident was on a pain medication therapy as needed for pain with an initiated date of06/06/2025. Review of Resident #112's Physician Orders revealed an order, dated 05/23/2025 for an opioid pain medication (Hydrocodone-Acetaminophen) oral tablet 5-325 MG give one tablet by mouth every 6 hours as needed for pain. Review of Narcotic Book page 52 revealed Resident #112's opioid pain medication was signed out by LPN #9 five times between 05/26/2025 and 06/22/2025 and not administered to the resident. Review of Resident #112's MAR/TAR for May of 2025revealed no documentation for the dates LPN #9 signed out Resident #112's opioid pain medication. Review of a witness statement revealed LPN #9 confirmed she listed the wrong date for the medication. Resident #115 Review of an admission Record revealed the facility admitted Resident #115 on 06/19/2025. The resident had a medical history that included diagnoses of fibromyalgia, depression, headache and stroke. Review of a discharge MDS, with an ARD of 06/25/2025, revealed Resident #115 was independent for daily decision making. The MDS also revealed Resident #115 received an opioid pain medication. Review of Resident #115's Physician Orders revealed an order, dated 06/22/2025 for an opioid pain medication (oxycodone) 5 MG give one tablet by mouth every 12 hours as needed for pain. Review of Narcotic Book page 77 revealed Resident #115's opioid pain medication was signed out by LPN #9 twelve times between 06/20/2025 and 06/24/2025 and not administered to the resident. Review of Resident #115's MAR/TAR for June of 2025 revealed blank boxes for the dates LPN #9 signed out Resident #115's opioid pain medication. Review of LPN #9's employee file revealed that the LPN was hired on 04/08/2025 as a Charge Nurse/Shift Supervisor. Review of facility Job Description indicated that the LPN would be responsible to ensure that narcotic records are accurate for your shift and notify the Director of Nursing Services of all drug and narcotic discrepancies. LPN #9 signed the job description on 04/08/2025. Review of a facility policy titled Code of Conduct revealed in bullet 2 for employees documenting in clinical records, they are certifying that the documentation accurately reflects the information for the resident and that they collect or coordinate collection of the information on the dates specified. Review of Departmental Orientation Nursing indicated LPN #9 was in orientation at the facility from 04/09/2025 through 04/11/2025. Multiple items were completed during the orientation process including patient abuse/neglect-definitions, mandatory reporting and mandatory reporting other included reporting crime was initialed as completed and the form was signed by LPN #9 on 05/01/2025 and signed by the Assistant Director of Nursing (ADON). Review of Termination of Employment indicated LPN #9 was terminated on 06/24/2025 for violation of policies and procedures, additional details included misappropriation of resident drugs. During an interview on 08/27/2026 at 11:44 AM, The ADON indicated he provided orientation and supervised LPN #9. He reported he did not have any concerns with the LPN during orientation. He indicated he found out about the possible misappropriation the same day he was leaving for vacation. He indicated the staff were pulling narcotic books and looking for any signs of diversion and some medications were found missing. He reported that he did not recall any residents' complaining of uncontrolled pain at that time. He indicated that LPN #9 did not raise any red flags. During an interview on 08/27/2026 at 12:26 PM, the Director of Nursing (DON) reported a resident was being discharged and mentioned to the DON that they did not take as much pain medication that was missing from their pain medications. DON reported the resident's family backed up the resident reporting the resident does not like to take pain medication. DON indicated she investigated and LPN #9's name kept showing up as signing out the narcotic medications. She indicated she did remember LPN #9 and nothing was different with her. She indicated misappropriation was taking away from a resident. During an interview on 08/28/2026 at 2:48 PM Medical Director reported she was in the facility every week. She reported DON informed her about narcotic drugs being signed out and not given by a facility nurse. She indicated that she did not recall any residents complaining about uncontrolled pain. She reported that the DON and unit managers check the Narcotic books and that the facility has a nurse practitioner in the facility 5 days a week and she reported that helps deter drug diversion. Medical Director indicated she was very involved with the facility.

Based on record review, observation, and interview the facility failed to ensure the medication error rate was not greater than 5% during the medication pass of two (Resident #6, Resident #20) of five resident reviewed. This surveyor observed 27 opportunities for medication administration and two of the 27 medications were not administered in accordance with the Physician's Orders, and administration guidelines resulting in a medication error rate of 7.41%. The findings include: Resident #20Review of an admission Record revealed the facility admitted Resident #20 on 01/05/2024. The resident had a medical history that included a diagnosis of anemia Review of a significant Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/03/2025, revealed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. Review of Resident #20's Care Plan Report, indicated the resident had anemia. Care Plan Interventions included to give medications as ordered with an initiated date of 04/21/2024. Review of Resident #20's Physician Orders revealed an order, dated 08/06/2026 for Epogen. The order indicated to inject 1 ml (Milliliters) subcutaneously one time every Wednesday related to anemia. During an observation on 08/26/2026 at 8:26 AM, Licensed Practical Nurse (LPN)#12 drew up Epogen 1 ml (milliliter) with a 23-gauge needle into a syringe. LPN #12 gave the injection in Resident #20's right lower abdomen. Resident #20 frowned when LPN #12 administered the injection. LPN #12 indicated that the facility only had one size needle. It is important to use the correct needle size for subcutaneous injections to ensure the medication was delivered safely into the fatty tissue just below the skin rather than into muscle or skin layers. Using the right size needle reduces bruising, bleeding, and scarring. During an interview on 08/26/2026 at 9:06 AM, the Director of Nursing (DON) indicated that the 23-gauge needles were used for intramuscular injections. The DON confirmed that there were only 23-gauge needles in the medication storage room. During an interview on 08/27/2026 at 9:27 AM, the Advanced Practice Registered Nurse (APRN) indicated that there was not a physician order for an intramuscular needle to be used instead of a subcutaneous needle when administering Epogen for Resident #20. During an interview on 08/28/2026 at 11:12 AM Licensed Practical Nurse (LPN) #11 indicated that an intramuscular needle would not be used for a subcutaneous injection. LPN #11 indicated that it's important to use a subcutaneous needle to ensure the needle would only reach the subcutaneous fat. During an interview on 08/28/2026 at 11:33 AM, LPN #10 indicated that an intramuscular needle should not be used for a subcutaneous injection. LPN #10 indicated an intramuscular needle would extend into the muscle. During an interview on 08/28/2026 at 11:54 AM, LPN #7 indicated that an intramuscular needle should not be used for a subcutaneous injection. LPN #7 indicated that a subcutaneous injection was closer to skin and if an intramuscular needle were used it could reach to the muscle instead of the fatty tissue. During an interview on 08/28/2026 at 12:14 PM, LPN #3 indicated an intramuscular needle was much bigger than a subcutaneous needle. LPN #3 indicated that if the needle size was not correct the resident may receive the wrong dose of medication. During an interview on 08/28/2026 at 12:44 PM, the Pharmacy Consultant indicated that a needle used to administer a subcutaneous injection was much smaller than an intramuscular needle. Review of an in-service dated 04/22/2026 revealed LPN #12's signature indicating that LPN #12 was in- serviced on subcutaneous and intramuscular injections. Review of an article title What Syringe is Used for Epogen? A Guide to Administration documented, The needle's gauge and length are selected to ensure the medication reaches the correct tissue layer. For subcutaneous injections, a short, thin needle is needed to deliver the medication into the fatty tissue just beneath the skin. Common recommendations for Epogen and similar medications include a 25-gauge, 5/8-inch needle. The gauge refers to the thickness of the needle. A higher gauge number indicates a thinner needle. The 25-gauge needle is thin enough to minimize discomfort during injection. Resident #6 Review of a Medical Diagnosis Report revealed Resident #6 had diagnoses which included stroke, urinary tract infection and vitamin deficiency. Review of the admission MDS with an ARD of 06/25/2026 revealed Resident #6 had a BIMS score of 15, which indicated the resident was cognitively intact. Review of Resident #6's Order Summary, revealed an order dated 08/17/2026 for Potassium 20 meq, give 2 tablets daily related to hypokalemia with food and a full glass of water due to GI upset. A second order dated 08/25/2026 revealed a BMP was ordered one time due to hypokalemia. During an observation on 08/26/2026 at 8:11 AM, this surveyor observed LPN #3 on medication pass for Resident #6. LPN #3 stated that 11 pills were pulled for Resident #6. LPN #3 then recounted pills for Resident #6 and confirmed she was ready to administer 11 pills to Resident #6. LPN #3 looked at the electronic record when asked to confirm the order for Potassium and stated oh, they changed it, [Resident #6] was getting one potassium tablet. LPN #3 confirmed Resident #6 should get 2 potassium tablets. LPN #3 revealed she was supposed to go by the physician orders when administering medication. During an interview on 08/27/2026 at 1:59 PM, LPN #5 stated she was trained to administer medication an hour before or an hour after a medication was due, and to follow the Medication Administration Record [MAR]. During an interview on 08/28/2026 at 9:33 AM, the Director of Nursing [DON] stated the physician notifies nursing of medication changes, and the new order would be reflected on the Medication Administration Record [MAR].The DON confirmed her expectation was for nursing to go by the MAR when administering medication. Review of a facility policy titled Administering Medications, dated 2001, indicated medications are administered in a safe and timely manner as prescribed to the resident and according to the doctor orders and timeframe. Medications are administered within one hour of prescribed times. The staff administering medications verifies the resident identity, label to verify the person, medication, dosage, time and method of administration. The policy also indicated that the DON supervises and directs all personnel who administer medications.

Based on observation, interview, and facility policy review, the facility failed to ensure dietary staff washed their hands between dirty and clean tasks, and before handling clean equipment for 1 of 1 meal observed. The findings are: 1. During an observation on 05/29/2025 at 11:55 AM, this surveyor observed Dietary Aide (DA) #3 remove cartons of shakes from a cart, by the steam table, and place them on resident trays, with his bare hands. Condiments were also placed on the trays, with DA #3 ' s bare hands, contaminating his hands. Without performing hand hygiene, DA #3 picked up glasses, filled with beverages by the rims, and placed them on the resident ' s trays, to be served for lunch. 2. During an observation on 05/29/2025 at 12:03 PM, this surveyor observed DA #2 picking up cartons of shakes from a cart by the steam table, and place them on resident trays, contaminating his hands. Without washing his hands, DA #2 picked up glasses, that contained beverages, and placed them on the resident trays, to be served for lunch. 3. During an observation on 05/29/2025 at 12:05 PM, this surveyor observed DA #4 remove a bag of cheese slices from the refrigerator and handed it to the Dietary Manager (DM). Without washing his hands, he picked up glasses that contained beverages to be served to the residents for lunch by the rims and placed them on the meal trays. 4. During an observation on 05/29/2025 at 12:34 PM, DA #3 washed his hands, after transporting an unheated food cart to the 300-hall, into the dining room. After drying his hands, he pulled up his pants, contaminating his hands in the process. DA #3 then used the same contaminated hands to pick up glasses by the rims, and placed them on the resident's trays, to be served for lunch. At 12:37 PM, DA #4 picked glasses by the rims and handed them to DA #3, who also held them by the rims, as he placed them on the resident ' s trays, to be served for lunch. 5. During an observation on 05/29/2025 at 2:08 PM, DA #5 was observed sorting tray cards. Without washing her hands, she then picked up plates and placed them on the plate warmer, with her fingers, which had long nails with polish on them, touching the insides of the plates. DA #5 was asked what she should have done after touching dirty objects, and before handling clean dishes. She stated she should have washed her hands. 6. A review of the facility policy titled, Hand Washing indicated employees should wash their hands before the beginning of shift, and any other time deemed necessary.

Based on observations, record review, interviews, and facility policy review, the facility failed to ensure a physician's order for oxygen was in place before administering oxygen to 1 (Resident #59) of 1 sampled resident reviewed for oxygen therapy. The findings are: 1. A review of Resident #59's Admission Record indicated the resident had diagnoses which included asthma, acute and chronic respiratory failure, sleep apnea, and chronic obstructive pulmonary disease. 2. During an observation and interview on 05/27/2025 at 11:49 AM, Resident #59 was observed in their room, receiving oxygen from an oxygen concentrator at 4 liters per minute via nasal canula. Resident #59 stated they used oxygen all the time and also used their BiPap machine (A BiPap machine supplies pressurized air into the lungs). 3. A review of Resident #59's annual Minimum Data Set (MDS) with an Assessment Reference Date of 05/15/2025, indicated Resident #59 had a Brief Interview of Mental Status score of 15, which indicated the resident was cognitively intact. The MDS also indicated Resident #59 had shortness of breath, received oxygen therapy, and used a positive airway pressure machine (BiPap). 4. A review of Resident #59's Physician Orders did not reveal an order for oxygen therapy. A review of discontinued orders indicated Resident #59 ' s oxygen order had been discontinued on 02/27/2025. 5. A review of Resident #59's Medication Administration Record did not indicate the resident was receiving oxygen. There was no indication the facility was performing ongoing assessment of the resident ' s respiratory status or response to oxygen therapy. 6. A review of Resident #59's Care Plan, with a revision date of 07/17/2024, indicated the resident had altered respiratory status/difficulty breathing and to use oxygen as ordered. The care plan did not specify the type of oxygen delivery system, when to administer, flow rates, or give instructions on how staff were to monitor oxygen levels. 7. During an interview on 05/29/2025 at 9:40 AM, Licensed Practical Nurse (LPN) #6 stated the nurse on duty for the resident's hall, or the admitting nurse, was responsible for ensuring physician orders were in the electronic health record (EHR). LPN #6 also revealed she puts orders in at times, and the unit manager checks to ensure orders are in place. LPN #6 reviewed Resident #59's EHR and stated she did not see an order for oxygen. 8. During an interview on 05/30/2025 at 11:16 AM, LPN #7 indicated it was important to ensure orders were in the chart, so residents received the care the physicians wanted. She also revealed the nurse who received the order was responsible to ensure the orders were put in the EHR. 9. During an interview on 05/30/2025 at 11:20 AM, the Director of Nursing confirmed the nurse was responsible for ensuring orders were put into the EHR, and to notify the family of any new orders. She stated it was important to ensure orders were put into the EHR to ensure the residents received the care that was ordered. 10. A review of the facility's policy titled, Oxygen Administration, indicated staff were to verify there is a physician ' s order and to review the order prior to administering oxygen, monitor the resident before and while receiving oxygen and to document the rate of oxygen flow, route and the rationale for resident receiving oxygen.

Based on observation, record review, interview, and facility policy review, the facility failed to provide appropriate handling and placement, to prevent possible contamination and complications, from an indwelling urinary catheter for 1 (Resident #59) of 1 sampled resident reviewed for urinary catheter. The findings are: 1. A review of Resident #59's Physicians Orders revealed diagnoses which included chronic kidney disease, urinary retention, urinary tract infection, and dysuria (painful or uncomfortable urination). Listed were orders for cranberry tablets for a urinary tract infection, dated 05/15/2025, and a medication that relaxed the muscles in the prostate/bladder for painful urination, dated 04/21/2025. 2. A review of Resident #59's May 2025 Medication Administration Record (MAR) revealed an order, dated 05/28/2025, for a urinary catheter to be inserted for two days. The MAR indicated the urinary catheter was inserted on 05/28/2025 at 1:10pm. 3. During an observation on 05/29/2025 at 7:25 AM, Resident #59 was observed sitting up in a recliner at bedside while Licensed Practical Nurse (LPN) #8 was providing urinary catheter care. Resident #59 had an indwelling urinary catheter, that the resident said had been placed during the previous night. The tubing was secured in place and attached to a urinary catheter bag, that was hung on a trashcan that had trash inside, at the resident ' s chairside. The urinary catheter bag was touching the floor, with no barrier under it to prevent contamination. 4. A review of Resident #59's annual Minimum Data Set (MDS) with an Assessment Reference Date of 05/15/2025, indicated Resident #59 had a Brief Interview of Mental Status score of 15, which indicated the resident was cognitively intact. The MDS also indicated Resident #59 was independent with toileting and was continent of bowel and bladder, transferred self to commode, and had a urinary tract infection in the past 30 days. 5. A review of Antibiotic Stewardship Notes indicated Resident #59 received antibiotics for a urinary tract infection on 09/16/2024, 09/18/2024, 10/10/2024, 03/20/2025, and 04/18/2025. 6. During an interview on 05/29/2025 at 7:28 AM, LPN #8 indicated an indwelling catheter bag should not be hung on a trash can, nor be touching the floor, due to the potential to cause an infection. LPN #8 specified that clean items should not touch dirty items. 7. During an interview on 05/30/2025 at 11:05 AM, Certified Nursing Assistant (CNA) #9 said an indwelling catheter bag should be below the bladder, so it flows, and not hanging on a trash can or the floor. 8. During an interview on 05/30/2025 at 11:12 AM, CNA #10 stated they had been trained to care for someone with an indwelling catheter, and not to hang catheter bags on a trash can or allow the bag or tubing to touch the floor. CNA #10 also stated practicing good infection control helps to prevent infections. 9. During an interview on 05/30/2025 at 11:16 AM, LPN #7 indicated indwelling catheter bags should be hung to encourage drainage, and not touch a dirty surface or the floor, to prevent a possible infection. 10. During an interview on 05/30/2025 at 11:20 AM, the Director of Nursing confirmed to prevent infection and reduce the risk of a urinary tract infection, a urinary drainage bag should be hung below the bladder and not touch the floor. 11. A review of the facility's policy, Catheter Care, with a revision date of 09/2014, indicated to prevent catheter-associated urinary tract infections, staff were to ensure the catheter tubing and drainage bag are kept off the floor.

Surveyor: [NAME], [NAME] Based on observation and interview, the facility failed to ensure dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen, and that the refrigerator temperature was maintained at 41 degrees Fahrenheit or below to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 79 residents who received meals from the kitchen. The findings are: 1. On 03/17/2024 at 10:33 AM, the following observations were made in the kitchen: a. A step on trash can was leaning against the grill and against the hand washing sink. b. The can opened attached at the end of the food preparation counter had mixture of food, shaving metal and paper on the blade. 2. On 03/17/2024 at 10:35 AM, there was paper and various types of debris throughout the kitchen area. The storage room had a pile of debris left in the middle of the room. 3. On 03/17/2024 at 01:02 PM, the following observation was made in the 2-door refrigerator. a. An opened carton of nectar cranberry juice was on a shelf in the refrigerator; there was date on the box when it was opened. b. An opened carton of lemon favored nectar water was on a shelf in the refrigerator with no open on the box. c. An opened spout to a pitcher that contained tea was on a shelf in the refrigerator, exposing it to cross contamination. d. An opened spout to a pitcher that contained cranberry juice was on a shelf in the refrigerator, exposing it to cross contamination. 3. On 03/17/2024 at 01:27 PM, in the meat freezer there was an opened box of bacon on a shelf with no open date on the box. 4. On 03/17/2024 at 01:35 PM, Dietary Employee (DE) #2 opened the oven door and placed pans of muffins in the oven. Without washing her hands, she picked up individual paper muffin cups and placed them inside each individual muffin cup with her thumb inside the paper muffin cups. 5. On 03/17/2024 at 01:37 PM, the refrigerator temperature in the dining room on 100 Hall that contained a box of liquid coffee was 49 degrees Fahrenheit, instead of 41 degrees Fahrenheit. The box was on the shelf in the refrigerator. The manufacturer specification on the box documented, Frozen concentrated liquid coffee handling instructions: 1. Rotate stock, first in first out. 2. Store in freezer at 0 degrees Fahrenheit.3. Prior to use, separate the cartons and thaw in refrigerator while still in plastic film wrap 41 degrees Fahrenheit. 6. On 03/17/2024 at 02:03 PM, DE #3 touched her mask, then without washing her hands, she picked clean bowls to be used in serving meal at supper and placed them on the counter with her fingers inside the bowls. The Surveyor asked what she should have done after touching dirty objects, before handling clean equipment. DE #3 stated, I should have washed my hands. 7. On 03/17/2024 at 02:29 PM, DE #3 used tissue paper to dry the clean area of the dish washing machine. Without washing her hands, she removed napkins from a container under the counter and placed them on the cart beside a rack that contains clean utensils stationed by the steam table. Contaminating the napkins. The napkins are for the residents to use to wipe their mouth when eating supper meal. 8. On 03/17/2024 at 02:38 PM, DE #2 removed a bag of lettuce leaf and a bag of shredded cheese from the refrigerator and placed them on the counter. She picked up scissors and cut the bags open. She emptied lettuce leaf and shredded cheese into a pan. At 02:39 PM, DE #2 turned on the food preparation sink and rinsed tomatoes that were in a container. After raising tomatoes, she used her bare hand to turn off the faucet. Without washing her hands, she placed tomatoes on the cutting board, sliced the tomatoes, and placed them on top of the lettuce and cheese to be served to the residents at supper meal. The Surveyor asked what she should have done after touching dirty objects, before handling clean equipment. DE #2 stated, I should have washed my hands. 9. On 03/17/2024 at 02:40 PM, DE #4 picked up a metal basket and placed it on the cart that contained a rack with clean utensils, contaminating his hands. Without washing his hands, he picked up utensils by the areas that went into the mouth and placed them on the napkin and wrapped them for the residents to use to wipe their mouth as they eat their supper meal. The Surveyor asked DE #4 what he should have done after touching dirty objects, before handling clean equipment. He stated, I should have washed my hands. 10. A Facility policy on hand washing titled Employee Cleanliness and Handwashing Technique provided by the Dietary Supervisor on 03/18/2024 at 03:01 PM documented Dietary Department Employees are required to wash their hands on the occasions listed below . Before beginning shift . After handling dirty dishes . Any other time deemed necessary.

Based on observation, interview, and record review, the facility failed to provide maintenance to oxygen equipment in accordance with the facility policy for 1 (Resident #29) of 12 sampled residents who received oxygen therapy. The findings are: 1. Resident #29 had diagnoses of Chronic obstructive pulmonary Disease (COPD) and Asthma. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/15/2023 documented the use of oxygen. a. On 03/17/2024 at 11:53 AM, Resident #29 was receiving oxygen per concentrator via nasal cannula (NC) at 2 liters/minute (2L/M). The filter on the oxygen concentrator was visibly dusty with greyish white debris stuck on it. On 03/18/2024 at 09:22 AM, and 03/19/2024 at 03:40 PM the filter on the oxygen concentrator remained visibly dusty. b. Resident #29's Physician Order dated 10/13/2023 documented, .Oxygen 2L [liters] via NC as needed for shortness of breath/decreased O2 [oxygen] SATS [saturation] PT [patient] .Remove o2 Concentrator filter wash with mild detergent and rinse thoroughly, allow to air dry and replace Q [every] week every night shift every Wed [Wednesday] . c. Resident #29's March 2024 Medication Administration Record (MAR) documented that the oxygen concentrator filter had been cleaned on March 6th and 13th. d. On 03/20/2024 at 10:30 AM, Assistant Director of Nursing (ADON) #1 was asked to explain the procedure for oxygen use maintenance. They explained that oxygen equipment maintenance was preformed every Wednesday on night shift (11 PM to 7 AM) and included changing and dating tubing, bags, nebulizers, masks, CPAP (continuous positive airway pressure) equipment, and filters (which are cleaned with mild detergent). ADON #1 then accompanied this Surveyor to Resident #29's room and was asked to describe the filter on the oxygen concentrator. ADON #2 responded, It definitely needs to be cleaned, if not replaced, it ' s so dusty. It will be addressed. ADON #1 then removed the filter and took it to be cleaned. The facility Oxygen Administration policy received from the Nurse Consultant on 03/20/2024 at 02:14 PM documented, .Make sure they (oxygen delivery equipment) are in working order . The facility did not have a policy on oxygen equipment maintenance. 49413

Based on interview and record review, the facility failed to ensure a psychotropic medication, used on an as needed (PRN) basis for more than 14 days, had a duration for the order, to promote or maintain the highest practicable mental, physical, and psychosocial well-being for 1 (Resident #71) of 6 sampled residents who had physician's orders for psychotropic medications on a PRN basis. The findings are: Resident #71 had a diagnosis of Depression. There was no diagnosis for Anxiety documented on the diagnoses section of the Order Summary. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/23/2024 documented the Resident had a diagnosis of Depression but the box for Anxiety was not checked. a. A Physician's order dated 12/27/2023 documented, . LORazepam Tablet 0.5 [half] MG [milligrams] Give 1 tablet by mouth every 24 hours as needed for Anxiety . and there was no duration for the order. b. A Care Plan last completed on 02/02/2024 documented, .The resident uses anti-anxiety medications . c. A Pharmacy MRR (Medication Regimen Review) -PRN (as needed) Psychotropic Meds (medications) > (greater than) 14 days form dated 1/23/24 documented, .If the attending MD (Medical Doctor) or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she MUST .indicate the duration for the PRN order . Attending Physician / Prescribing Practitioner Response: . Continue current medication regimen with no changes . d. On 03/20/2024 at 12:02 PM, Assistant Director of Nursing (ADON) #1 was asked, Who reviews the Pharmacy MRRs? He stated, The DON [Director of Nursing] and myself review them when they come. He was asked, Who reviews the provider's response to the recommendations? He stated, The same [DON and ADON #1]. He was asked, Do you know how long a PRN Psychotropic can be administered? He stated, Generally 14 days unless indicated by the doctor. He was asked, Are you familiar with the facility's policy on Psychotropic medications? He stated, Yes I am. He was asked, If the provider does not accept the pharmacist's recommendations to add a duration to a PRN psychotropic, who follows up with the provider to ensure he/she is aware that a duration is needed to be in compliance with CMS [Centers for Medicare and Medicaid Services] guidelines? He stated, [Advanced Practice Registered Nurse (APRN) name] checks them as they come in as well. She's our APRN. She reviews them and makes the determination as well. e. A Medication Regimen Reviews policy provided by the Nurse Consultant on 03/20/2024 documented, The primary purpose of this review is to help the facility maintain each resident's highest practicable level of functioning . f. An Antipsychotic Medication Use policy provided by the Nurse Consultant on 03/20/2024 documented, .Policy Statement .Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and review .PRN orders for antipsychotic medications will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident . The duration of the PRN order will be indicated in the order .

Based on observation, interview, and record review, the facility failed to ensure meals were served in a method that maintained the appearance of cold product and at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. This failed practice had the potential to affect 16 residents who receive meal trays in their rooms on the 100 Hall, 19 residents who receive meal trays on the 200 Hall, 19 residents who receive meal trays in their room on the 300 hall, 25 residents who receive meal trays in their room on 400 Hall. The findings are: 1. Resident # 24 had diagnoses of Obesity and Type 2 diabetes mellitus with diabetic neuropathy. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/31/2023 documented the resident had a Brief Interview of Mental Status (BIMS) score of 15 (13-15 indicates cognitively intact). a. A Physician's order dated 09/25/2023 documented a diet of Mechanical Soft texture, regular consistency. b. On 03/17/2024 at 11:45 AM, Resident #24 was asked, How are things going for you? Resident #24 stated, I know you're looking at my plate, but I did not eat my breakfast because I like fried eggs, and they brought me scrambled eggs and it was cold. I've told them I don't eat scrambled eggs. When I eat in the dining room, it comes right to you and it's hot, but when they bring it here, it's cold. 2. On 03/18/2024 at 08:01 AM, an unheated food cart that contained 25 trays for breakfast was delivered to 400 Hall by the Certified Nursing Assistant #4. At 08:21 AM, immediately after the last resident was served in their room on 400 hall, temperature of the food items on the tray used as test trays were taken and read by the Dietary Supervisor were with the following results: a. Milk - 45.3 degrees Fahrenheit. b. Ground sausage links - 91.4 degrees Fahrenheit. c. Scrambled eggs - 107 degrees Fahrenheit. d. Regular sausage links - 103 degrees Fahrenheit. 3. On 03/18/2024 at 08:04 AM, an unheated food cart that contained 16 trays for breakfast was delivered to 100 Hall by the Certified Nursing Assistant #5. At 08:25 AM, immediately after the last resident was served in their room on 100 Hall, temperature of the food items on the tray used as test trays were taken and read by the Dietary Supervisor were with the following result: a. Sausage links - 99.5 degrees Fahrenheit. 4. On 03/18/2024 at 08:26 AM, an unheated food cart that contained 19 trays for breakfast was delivered to 200 Hall by the Certified Nursing Assistant #6. At 08:35 AM, immediately after the last resident was served in their room on 200 Hall, temperature of the food items on the tray used as test trays were taken and read by the Dietary Supervisor with the following results: a. Milk - 45 degrees Fahrenheit. b. Sausage links - 112 degrees Fahrenheit. c. Scrambled eggs - 106.8 degrees Fahrenheit. d. Ground sausage links - 107 degrees Fahrenheit. e. Oatmeal - 140 degrees Fahrenheit. 5. On 03/18/2024 at 08:29 AM, an unheated food cart that contained 19 trays for breakfast was delivered to 300 Hall by the Certified Nursing Assistant #7. At 08:46 AM, immediately after the last resident was served in their room on 300 Hall, temperature of the food items on the tray used as test trays were taken and read by the Dietary Supervisor were with the following results: a. Milk - 54.8 degrees Fahrenheit. b. Sausage links - 91.4 degrees Fahrenheit.

Based on observation, interview, and record review, the facility failed to ensure expired medication was removed from a medication cart to decrease the potential for harm and or misappropriation of property for 1 (Resident #11) of 10 sampled residents who resided on the 400 Hall. The findings are: 1. On [DATE] at 10:17 AM, Licensed Practical Nurse (LPN) #2 unlocked the medication cart for the 400 Hall. In the bottom right small drawer, there was a card that was labeled Furosemide (a diuretic given to help treat fluid retention and swelling) and there were 16 pills remaining on the card. The label documented, (expiration date) [DATE]. 2. On [DATE] at 10:26 AM, LPN #2 was asked, Can you tell me what the expiration date is for this medication? He looked at the card and stated, [DATE]. He was asked, Who checks the medication cards for expiration dates? He stated, All of us. He was asked, What is the facility's process for removing expired medication cards? He stated, We're supposed to write down the amount that's on the card on the refill tag and take it off and place the tag in a book in the med room. He was asked, Is this resident still here? He stated, Yes. 3. The [DATE] electronic Medication Administration Record (eMAR) for Resident #11 had no current order for Furosemide. 4. An Order Review Report for [DATE] to [DATE] documented, on page 5, the last order for Furosemide was on [DATE] and discontinued on [DATE]. 5. An Inservice with the Topic: Medication Cart and dated [DATE] documented, . Remove meds [medications] once discontinued . 6. A Storage of Medications policy provided by the Nurse Consultant on [DATE] documented, .Policy Interpretation and Implementation .The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed .

Based on interview and record review, the facility failed to ensure an Antibiotic Stewardship Program was consistently implemented, as evidenced by an antibiotic was prescribed without a duration or end date, to decrease the potential for harm and/or antibiotic resistance for 1 (Resident #35) of 3 sampled residents who were prescribed an antibiotic. The findings are: Resident #35 had a diagnosis of Urinary tract infection (UTI). a. A Physician's order dated 03/13/2024 documented, Macrobid Oral . Give 1 capsule by mouth two times a day for Urinary Tract Infection . There was no duration or end date included in this order. b. A Nursing Order Note dated 03/13/2024 at 15:30 (3:30 PM) documented, .This dose fails a general dose range check based on drug inputs and/or the patient information provided . c. A Pharmacy MRR (Medication Regimen Review)- Antibiotic Stewardship form dated 3/14/24 documented, .Antibiotic stop date not specified .Please clarify a stop date and/or # (number) of doses. If this medication is being used chronically, please ensure that a care plan is initiated and reviewed regularly . Attending Physician / Prescribing Practitioner Response: a. Antibiotic Stewardship information has been reviewed. Continue current antibiotic as ordered . d. A Care Plan, revised 03/14/2024, documented, .03/13/2024 sent to ER (Emergency Department) - UA (urinalysis) obtained - started on abxs (antibiotics) for UTI . e. An Access Medical Clinic note dated 03/14/2024 documented, .Assessment/Plan . 2. Urinary tract infectious disease .Cont (continue) Macrobid as ordered BID (twice a day) x (times) 5 days . Resident #35 was to only receive 10 doses. f. The March 2024 electronic Medication Administration Record (eMAR) documented Resident #35 had 1 dose of Macrobid 100 mg on 03/13/2024 and 03/20/2024 and 2 doses on 03/14-03/19 for a total of 14 doses as of 03/20/2024. Resident #35 was administered 4 extra doses according to the documented plan on the Access Medical Clinic note dated 03/14/2024. g. On 03/20/2024 at 12:29 PM, the Assistant Director of Nursing (ADON) #2 was asked, Who reviews the antibiotic order for all components, such as dose, route, frequency and duration? She stated, It will be our MD (Doctor of Medicine) or APN (Advanced Practice Nurse). Our pharmacy consult will start our Antibiotic (ABT) Stewardship. She was asked, Who reviews the ABT Stewardship from the pharmacist? She stated, Me, the DON [Director of Nursing] and the Doctor. She was asked, When were you made aware of no end date to [Resident #35]'s ABT order for Macrobid? She stated, The next day. I check my dashboard daily. She added, I had reached out to [local hospital name] to get clarification, but I haven' been able to get in contact with the person who prescribe it. My second step is [APN name]. h. The facility's Antibiotic Stewardship Policy provided by the Administrator on 03/17/2024 documented, .If an antibiotic is indicated, prescribers will provide complete antibiotic orders including the following elements .Duration of treatment; (1) Start and stop date, or (2) Number of days of therapy .

Based on observation, interview, and record review, the facility failed to ensure a wander management device was in place to decrease the potential for elopement and safety hazards for 1 (Resident #35) of 5 sampled residents who had devices in place. The findings are: 1. Resident #35 had diagnoses of Unspecified dementia and Anxiety. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/19/2023 documented a Brief Interview for Mental Status (BIMS) score of 03 (00-07 indicates severely impaired). a. A note in the Electronic Health Record (EHR) dated 03/13/2024 at 17:40 (5:40 PM) documented, .Primary Care Provider Feedback .Send to ED [Emergency Department] for UA [urinalysis] and evaluate . An EHR note dated 3/14/24 at 01:24 (1:14 AM) documented, .Resting in bed with eyes closed . b. A Care Plan revised 03/14/2024 documented, .The resident is an elopement risk/wanderer related to: DEMENTIA . CHECK WANDERGUARD PLACEMENT Q [every] SHIFT WANDERGUARD TO LEFT LEG . c. A Nsg (nursing) Elopement Risk with Care Plan form documented Resident #35 had a score of 9 (9-10 indicates at risk to wander). d. On 03/18/2024 at 02:35 PM, Resident #35 was sitting in a wheelchair (w/c) in the common area with other residents. There was no wander management device visible on the resident's left or right leg or ankle. e. On 03/19/2024 at 09:15 AM, Resident #35 was sitting up in a w/c in the common area with other residents. There was no wander management device visible to left leg or ankle at this time. f. On 03/19/2024 at 11:51 AM, Resident #35 had propelled self to the front entrance in front of the door, and a staff member came and propelled the resident away from the door. There was no wander management device visible to the resident's left leg or ankle at this time. g. On 03/20/2024 at 08:41 AM, Resident #35 was lying in bed with eyes closed. There was no wander management device visible to left or right leg or ankle. h. The March 2024 electronic Medication Administration Record (eMAR) documented, .CHECK WANDERGUARD PLACEMENT Q SHIFT WANDERGUARD TO LEFT LEG . There were initials in the boxes for the day and night sections on 3/14/24 through 3/19/24. i. On 03/20/2024 at 08:43 AM, Certified Nursing Assistant (CNA) #3 entered Resident #35's room with this surveyor and was asked to look at the resident's left leg to see if there was a wander management device in place. She pulled the non-skid sock below the ankle and there was no wander guard visible. The resident's left pants leg was up, and the lower leg, from below the knee to the ankle, was visible and there was no wander management device in place. She was asked, Do you see a [named brand of wander management device] on either leg? and she stated, [Resident #35] used to have a [named brand of wander management device], but I've been off for a week, and I don't know what's happened, but no, I don't see one. j. On 03/20/2024 at 11:44 AM, Licensed Practical Nurse (LPN) #3 was asked, Were you made aware that [Resident #35] did not have a [wander management device] on [Resident #35]'s left lower leg this morning? She stated, Yes. They cut it off when [Resident #35] went to the hospital and the DON [Director of Nursing] and the ADON [Assistant Director of Nursing], [Name ADON #1], were aware because I gave it to them when they cut it off. [Resident #35] went out to the hospital last Thursday [03/14/2024]. She was asked, Who is responsible for checking this [wander management device]? She stated, We are. She was asked, Who is we? She stated, The nurses. She was asked, Do you know who put it on [Resident #35] this morning? She stated, [ADON #1 or ADON #2] because they are the ADONs and they take of those type of things. LPN #3's initials were noted on the eMAR for 03/13/2024 and 03/14/2024. k. On 03/20/24 at 12:11 PM, ADON #1 was asked, There was no [wander management device] on [Resident #35]. Where you made aware of this? He stated, That was brought to my attention this morning, and it was put on [Resident #35] this morning. He was asked, Do you know who put it on [Resident #35]? He stated, I put it on [Resident #35] myself. He was asked, Who is responsible for daily checks to ensure it's on? He stated, There is an order for nurses to check placement daily. He was asked, What could have happened with [Resident #35] since there was no [wander management device] in place? He stated, [Resident #35] could have attempted to get out of the door. He was asked, What is the purpose of a [wander management device]? He stated, It alerts us if someone attempts to open the door. The door will not open if it's close by. l. A Wandering, Unsafe Resident Policy provided by the Administrator on 03/20/2024 documented, .The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement .Interventions to try to maintain safety, such as a detailed monitoring plan will be included . m. A Secure Care Installation Manual provided by the Administrator on 03/20/2024 documented, .Section 7 Standard Features . The standard mode of operations for the Exit System allows free access of the door by staff members and visitors but quietly locks the door when an infant wearing a monitored transmitter approaches the door. When the infant leaves the monitored area, the door unlocks and access is again available for staff and visitors .

Based on observation, interview, and record review, the facility failed to update the resident care plan to reflect a diagnosis of Diabetes with insulin usage for one (Resident #11) sampled resident. The findings are: 1. Resident #11 had a diagnosis of Pre-Diabetes upon admission on 02/22/2022. a. Resident #11's Physician Orders dated 2/22/2024 included an order for a fast acting insulin prescribed to treat Diabetes. 1. Resident #11's Plan of Care did not address the resident not having a diagnosis of diabetes, nor the use of insulin by the resident. 2. On 03/19/2024 at 03:10 PM, Licensed Practical Nurse [LPN] #2 was asked, Should a diagnosis of diabetes be on a residents care plan? LPN #2 responded, Yes, in my opinion, so that the staff knows how to care for the resident and be alert to the resident's needs. At 3:15 PM, the Assistant Director of Nursing (ADON) #1 was asked the same question to which they responded, It wouldn't hurt. 3. On 03/20/2024 at 11:30 AM, the Minimum Data Set (MDS) Coordinator was asked, How often should the care plans be updated? The MDS coordinator stated, Quarterly and as needed. When asked how a change is communicated the MDS coordinator responded, There are sheets outside my door that staff fills out and puts under my door, or if I ' m here they come into office and let me know. The MDS Coordinator went on to say she checks the order recap during the day and after being off to ensure nothing is overlooked. When asked if insulin should be on a care plan, the MDS Coordinator confirmed it should be on diabetic care plan. When asked about Resident #11's insulin order the MDS Coordinator confirmed, It should have been caught during recap. I ' m putting it in there right now. 4. The facility ' s Comprehensive Person-Centered Care Plans policy received from the Administrator on 03/20/2024 at 11:37 AM documented, .Incorporate identified problem areas .reflect treatment goals, time tables and objectives . identify problem areas and their cause and developing interventions . assessments of residents are ongoing and care plans are revised as information about the resident and the residents condition changes .

Based on observation, interview, and record review, the facility failed to ensure residents were free from accidents and hazards by leaving the storage room door unsecured allowing residents access to supplies that are not for human consumption. This failed practice had the possibility of affecting 14 residents with 4 (Residents #12, #21, #54, #333) sampled residents with Brief Interview for Mental Status (BIMS) scores of 11 or below; and 1 (Resident #21) sampled resident that ambulated or were self-propelled out of 22 residents the resided on the hall. The findings are: 1.On 03/17/2024 at 11:17 AM, the Surveyor observed the housekeeping door on 300 Hall was left unlocked without staff present to ensure residents did not enter the room. The following items were on shelving units inside the room: a 1 gallon glass cleaner container, a 1 gallon phosphoric bathroom cleaner, a 1 gallon liquid odor counteractant, 1 gallon germicidal detergent container, 5 gallons of floor finish, 1 spray bottle wax-base cleaner and spray-buff compound, and 1 package of 12.5 x 7.5 inch 50 count cleaning wipes. Each container ' s label documented, keep out of reach of children. 2.On 03/17/2024 at 11:21 AM, the Surveyor asked Certified Nursing Assistant (CNA) #1 if the housekeeping door should be left unlocked without staff present. CNA #1 reported they do not mess with that door. 3.On 03/20/2024 at 08:20 AM, the Surveyor asked the Housekeeping Director if the doors to the housekeeping rooms are to be unlocked without staff present. The Housekeeping Director reported the doors are always to be kept locked. The Surveyor asked the Housekeeping Director why the door should be kept locked. The Housekeeping Director confirmed the doors are to be kept locked because there are chemicals inside that residents could get to. The Surveyor asked the Housekeeping Director about the concern of residents getting into the chemicals. The Housekeeping Director confirmed that residents could swallow the chemicals, get the chemicals on their skin or in their eyes, or multiple other things. 4.On 03/20/2024 at 08:59AM, the Administrator provided a policy titled Hazardous Areas, Devices and Equipment which stated Policy Statement: All Hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible . Identification of Hazards: 1. A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include, but are not limited to: Open area or items that should be locked when not in use . Access to toxic chemical . Assessment and Analysis of Hazards: .Any element of the resident environment that has the potential to cause injury and that is accessible to a vulnerable resident is considered hazardous .Resident vulnerability is based on risk factors including the individual resident's functional status, medical condition, cognitive abilities, mood and health treatments (E.g. medications) . 5. On 03/20/2024 at 09:20 AM, the Administrator provided the following Material Safety Data Sheets: a. [named brand] Glass Cleaner: Keep out of reach of children, Section 2 - Hazards Information: CAUTION Do not get in eyes, on skin or on clothing, use personal protective equipment as required. Avoid release to the environment. b. [named brand] Phosphoric Bathroom Cleaner: Keep out of Reach of Children, Section 2 - Hazards Information DANGER! Acute Toxicity Irritant (skin and eye Respiratory Irritant, Corrosive to Metals, Eye Damage, Skin Corrosion/Burns. Chronic prolonged symptoms: Corrosive to eyes. Can cause severe corrosive burns and serious eye damage, Skin Corrosive to skin tissue, can cause severe corrosive burns, Inhalation spray mists are corrosive to respiratory tract ad mucous membranes, Ingestion harmful if swallowed, Ingestion can cause corrosive burns in the throat and stomach and may affect target organs, Ingestion may cause vomiting which may be harmful if it enters airways. c. [named brand] Phosphoric Bathroom Cleaner: Keep out of Reach of Children, Section 2 - Hazards Information WARNING! Irritant skin and eye, causes eye irritation, mild skin irritation, Mist may be harmful if inhaled. Harmful is swallowed do not get in eyes, on skin, or on clothing. Use personal protective equipment as required. d. [named brand] germicidal detergent: Section 2 - Hazards Identification of Eyes: extremely irritating to the eyes and may cause severe damage including blindness, Skin causes corrosive burns, exposures not promptly wash off it may lead to toxic effects similar to ingestion. Harmful if absorbed through the skin. Ingestion: ingestion can cause gastrointestinal irritation, nausea, vomiting and diarrhea and possibly death. Inhalation: mists and vapors can irritate the throat and respiratory tract. High vapor concentrations may cause central nervous system effects. Seek immediate medical attention . Section 7 - Handling and Storage: Storage: Keep out of reach of Children. e. [named brand] floor polish: Section 2 - Hazards Identification Health hazards causes mild skin irritation wash hands and exposed skin thoroughly after handling wear eye protection/face protection. If skin irritation occurs get medical advice/attention, causes serious eye irritation IF IN EYES: rinse cautiously with water for several minutes, continue rinsing. f. [named brand] waxed based cleaner: Section 2 - Hazards Identification Causes severe eye damage. Harmful if inhaled. Causes skin irritation, acutely hazardous to the aquatic environment. Keep out of waterways. Potential Health Effects: Eyes: causes irreversible eye damage. Skin: Slightly toxic and slightly irritating based on toxicity studies. Inhalation: Harmful if inhaled. Overexposure may cause upper respiratory tract irritation and symptoms similar to those from ingestion. Ingestion: Harmful if swallowed. May cause nausea, vomiting, abdominal pain, decreased blood pressure, muscle weakness and muscle spasms. Preexisting Condition: Inhalation of product may aggravate existing chronic respiratory problems such as asthma, emphysema, or bronchitis. Skin contact may aggravate existing skin disease. Chronic Health Effects: Repeated overexposure to phenoxy herbicides may cause effects to liver, kidneys, blood chemistry and gross motor function. Refer to Section 11 - Toxicological Information Eye effect: causes irreversible eye damage. Vapors and mist can cause irritation. Skin Effects: Slight irritant not a skin sensitizer; Specific Target Organ Toxicity: Liver, kidneys. g. Disposable Washcloths with Aloe: Section 2 - Hazardous Identification: Eyes: can cause irritation, Skin: May cause rash/irritation in persons with sensitive skin. Ingestion: It can cause nausea and vomiting if swallowed Inhalation: If inhalation is produced from incorrect use, may be slightly irritating to the nose, throat, and respiratory system.

Based on record review and interview, the facility failed to ensure two staff members were present when transferring a resident who required two-person assistance to prevent accident and injury for 1 (Resident #1) of 4 sampled residents. This failed practice resulted in findings of Past non-compliance. The findings are: 1. Resident #1 was admitted on [DATE]. The Admission/ Medicare 5-Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/23/2023 documented the resident is total dependence of two+ persons for transfer. a. The closet care plan with an admitted [DATE] noted Resident #1 had total dependence on staff with two+ persons physical assist with transfers. b. Review of the nursing progress note dated 07/08/2023 at 3:06 PM revealed .During shift resident complained of lower leg pain. Resident stated during transfer from shower chair to bed that she twisted leg. Mild swelling noted. Placed call to on call. Telehealth visit completed. Xray ordered. Orders carried out. Will continue to monitor . c. Review of the nursing progress note dated 07/08/2023, noted Resident #1 reported to the nurse she was transferred from the shower chair to her bed, and she twisted her leg. The resident noted the incident occurred on 7/7/23. d. Review of the nursing progress note dated 7/8/2023 at 4:54 PM noted Resident #1 was sent to the emergency room for fracture of the tibia and increased pain. e. A review of the Arkansas Department of Health and Human Services Division of Medical Services Office of Long Term Care form (DMS-762) dated 07/09/2023 noted on 7/8/2023 Resident #1 did not want to get out of bed and complained of pain in her left leg. The document noted, the resident told the nurse on 7/7/2023 that the CNA transferred her from the shower chair to the recliner and her leg twisted. On 7/8/2023 x-ray results noted a tibia/fibula fracture of the left leg. f. On 07/26/2023 at 11:24 AM, interview with Occupational Therapy Assistant #1 who stated Resident #1 was an extensive assist of two people. She stated the resident was not stable enough to transfer with one person. g. On 07/27/2023 at 10:43 AM, interview with Resident #1, who stated she was a two person assist to transfer before her injury and stated she is now transferred with a lift. She stated, the CNA stood me up by herself and my legs collapsed, and I broke my leg. h. On 07/27/2023 at 02:36 PM, interview with the Director of Nursing (DON) who confirmed Resident #1 required two people for transfers prior to her injury. i. On 07/27/2023 at 2:55 PM, interview with the Administrator who confirmed Resident #1 required 2 staff to assist her prior to her injury. j. During the investigation the facility found the care plan was not followed and inserviced staff on transfers, and following closet care plans, body audits were conducted on non-cognitive residents, verified all care plans were in place for residents who required 2 person assist with transfers. the DON/designee to monitor 4 transfers weekly for 8 weeks to ensure staff follow the closet care plan, will monitor documentation of transfer. All negative findings will be reported to Quality Assurance. k. Facility Lifting Policy signed by Certified Nursing Assistant (CNA) #1 on 12/14/12, documented, It is the policy of this facility that 2 person lifts, or the use of electronic lifts, by qualified personnel (licensed/ certified staff0 are mandatory at all times. When assisting in the lifting of residents, it is required that the 2 person lift procedure and/ or the electronic lifts be used. Every patient of this facility will be assessed and identified as to which lifting procedure is to be utilized. Licensed/ certified personnel have the responsibility to check that assessment (in the location designated by the D.O.N. or administrator) prior to lifting any patient All staff members have the responsibility of reporting all potential patient abuse/ neglect immediately to the Administrator, which necessarily includes instances where this policy is not followed .

Based on record review and interview the facility failed to ensure personal funds were not misappropriated, for 3 (Resident #4, #5, #6) sampled residents with money held in a trust fund by the facility. The failed practice resulted in findings of past non-compliance. The findings are: 1. A review of the Arkansas Department of Health and Human Services Division of Medical Services Office of Long Term Care, form (DMS-762), dated 07/11/2023, noted Resident #6 Trust Fund account had been mishandled. a. The report noted a total of $4,262.00 was mishandled from Resident #6 Trust Fund Account. The mishandled funds were: i. On 9/30/19, check #2758 for $1,020.00 for room and board. ii. On 10/12/19, check # 2770 for $250.00 for shopping. iii. On 12/9/19 check #2814 for $1,015.00 for shopping. iv. On 3/12/20 check #2872 for $1,078.00 for room and board. v. On 8/7/20 check #2999 for $38.00 for room and board. vi. On 3/2/21 check #3166 for $574.00 for room and board. vii. On 9/30/22 check 3632 for $287.00 for room and board. b. The DMS-762 revealed two cash withdrawals totaling $689.36 were deducted from Resident #6 Trust Account, that did not go to the resident. c. The document revealed the previous Business Office Manager (BOM) posted the checks as room and board, and personal shopping, but the checks were endorsed and cashed by the former BOM. c. The document noted the amount of $4,951.36 would be reimbursed to the resident or beneficiary by 7/20/23. The resident discharged from the facility on 5/17/23. 2. A review of the DMS-762 dated 07/11/2023 noted Resident #5 Trust Fund Account had been mishandled. a. The report noted a total of $2,332.00 was mishandled from Resident #5 Trust Fund Account. The mishandled funds were: i. On 3/1/22, check #3470 for $1,350.00 for room and board. ii. On 3/7/22 check #3475 for $982.00 for room and board. b. The DMS-672 noted the two checks were written to cash and signed by the former BOM. The checks were endorsed by the BOM, indicating she received the cash from the bank. The former BOM posted in the accounting software that each of the checks was to pay room and board. c. The document noted on 12/31/2022 the facility wrote off $1,711.24 of an outstanding balance for the months of 9/2021 through 2/2022. d. Resident #5 discharged from the facility on 3/14/22. The facility reimbursed the resident or her estate on 7/14/23 for $620.76 plus interest, which is the amount of the checks minus $1,711.24 that was written off on 12/31/22. 3. A review of DMS-762 dated 07/11/2023 noted Resident #4 Trust Fund Account had been mishandled. a. The DMS-762 noted a total of $1,400.00 was mishandled from Resident #4 Trust Fund Account. The mishandled funds were for check #3232 on 5/4/21 for $1,400.00. b. The DMS-762 noted the check was written to cash and signed and endorsed by the former BOM, indicating that she received cash from the bank. She posted the check in the accounting software as a close out to the resident's account. c. The facility reimbursed the resident or the representative by 7/20/23. The resident discharged from the facility on 2/26/21. 4. The facility implemented segregation of duties which included signing checks, posting accounting transactions, and reconciling the trust account- were no longer completed by the same person. The Business Office Manager was removed from the signature card for the resident trust bank account, and the monthly resident trust reconciliation responsibility was given to the accounting department at the Administrative Service Provider. The former BOM resigned. 4. On 07/27/2023 at 2:55 PM, the Administrator stated, on July 7th the regional office did an audit. The Administrator stated some of the checks looked like they were made payable to the facility but was really made out to cash. The Administrator stated the former BOM would get the check back, white out the word, cash and insert the facility name. She would then copy those and send the copies in for reconciliation. The Administrator stated all the residents that had discrepancies on their accounts have been reimbursed.

Based on interview and record review, the facility failed to ensure 1(Resident #2) of 2 (#2, and #3) sampled residents received their scheduled shower or bath. The findings are: a. On 05/15/23 at 9:34 AM, the Surveyor asked Resident #2, How often do you get a bath or shower? She stated, I suppose to get one on Tuesday, Thursday, and Saturday, but I didn't get one Saturday because there weren't enough folks working. b. On 05/15/23 at 10:11 AM, the Director of Nursing (DON) provided a Bathing Log for Resident #2. It indicated that Resident #2 did not receive a shower on 05/06/23 and 05/13/23. c. On 05/16/23 at 11:25 AM, the Surveyor asked Certified Nursing Assistant (CNA) #1, Did you work with Resident #2 on this past Saturday? CNA #1 stated, Yes. The Surveyor asked, How often does she get a bath or shower? CNA #1 stated, Today is her shower day. The Surveyor asked, Can you tell me why she didn't get a shower or bath on Saturday? CNA #1 stated, I was working by myself with a NA [Nursing Assistant]. The Surveyor asked, Did any of the residents that you had on your hall scheduled for a shower on Saturday get their shower? CNA #1 stated, No ma'am. The Surveyor asked, Did you let the nurse know that you were not able to give any showers? She stated, Yes, she told us to do the best we could do. The nurse is fairly new too. She only works weekends. d. On 05/16/23 at 11:32 AM, the Surveyor asked Nurse Assistant #1, Did you work with Resident #2 this past Saturday? NA #1 stated, Yes ma'am. The Surveyor asked, How often does she get a bath or shower? NA #1 stated, Every other day. The Surveyor asked, Can you tell me why she didn't get a shower or bath on Saturday? NA #1 stated, Well it was only 2 people on there and we didn't know who was supposed to get a shower that day. The Surveyor asked, Did you ask the nurse who was supposed to get a shower? NA #1 stated, When I asked the nurse, she was acting confused. The Surveyor asked, Do you use the computer system to look at the residents ADL's [Activity of Daily Living]? He stated, I don't know how to use the computer system. I'm still learning. e. On 05/16/23 at 12:14 PM, the Surveyor asked NA #2, Did you work this past Saturday? NA #2 stated, Yes ma'am, I worked the 100 Halls with NA #1. He's a NA as well. The Surveyor asked, Were you able to get all your scheduled showers completed this past Saturday? NA #2 stated, No ma'am. We didn't give any showers Saturday. The Surveyor asked, Did you let the nurse know? NA #2 stated, Yes, and she was ok because we were both NAs and there wasn't enough CNAs to go in the shower with us. f. On 05/16/23 at 1:10 PM, the Surveyor asked the DON, Who is responsible for giving showers on the weekends? The DON stated, The CNAs. The Surveyor asked, Are the Nurse Assistants allowed to give showers without a CNA present? The DON stated, Normally the CNA does the shower. The Surveyor asked, Can you tell me why Resident #2 didn't get a shower on Saturday? The DON stated, No ma'am I'll have to look into it. The Surveyor asked, Can you tell me why it's important that the residents get their shower on their assigned shower days? The DON stated, It's good hygiene. It helps reduce infection, and bacteria. g. On 05/16/23 at 1:21 PM, the Surveyor asked the Administrator, Who is responsible for giving showers on the weekends? The Administrator stated, The CNAs. The Surveyor asked, Are the Nurse Assistants allowed to give showers without a CNA present? The Administrator stated, No. The Surveyor asked, Can you tell me how the residents are supposed to get their shower if there are two nurse assistants assigned to the hall, and no CNA? The Administrator stated, Another CNA is to come from another hall. The Surveyor asked, Can you tell me why Resident #2 didn't get a shower on Saturday? She stated, I can't tell you that. The Surveyor asked, Can you tell me why it's important that the residents get their shower on their assigned shower days? She stated, It's a dignity and safety concern. It's their right.

Based on observations, interviews, and record review, the facility failed to ensure staff implemented universal source control by wearing face masks in the facility when the county transmission rate was high and there was a COVID-19 outbreak in the facility to prevent the transmission of COVID-19 and/or other respiratory diseases. This failed practice had the potential to affect 81 residents and staff and visitors. The findings are: a. On 2/26/2023 at 8:58 a.m. the Surveyor entered the facility and Licensed Practical Nurse (LPN) #1 walked toward the nurse's station with face mask below chin. LPN #2 was walked through the facility, then sat down behind the nurse's station with mask below chin. Certified Nursing Assistant (CNA) #1 stood in the hall on 100 Hall with mask below chin. Dietary #1 cleared tables in the dining area with no mask on. There were multiple residents that ambulated in the halls, sitting around the nurse's station, and in the dining area. b. On 2/26/2023 at 9:18 a.m., LPN #2 had mask below the chin administering medications to a resident on the 400 Hall. The Surveyor asked LPN #2, why didn't you have your mask up when the Surveyor entered the facility? LPN #2 replied, I was on the phone. The Surveyor asked LPN #2, why didn't you have your mask up while giving medications? LPN #2 replied, because my glasses keep fogging up. The Surveyor asked LPN #2, are you supposed to be wearing a mask while in the facility? LPN #2 replied, yes. The Surveyor asked LPN #2, why are you wearing masks in the facility? LPN #2 replied, because of COVID-19, I think it's because of the County Positivity Rate. c. On 2/26/2023 at 9:33 a.m., the Surveyor asked CNA #3, are you supposed to be wearing a mask while in the facility? CNA #3 replied, yes. The Surveyor asked CNA #3, why are you wearing masks in the facility? CNA #3 replied, COVID-19 restrictions-the count in the county is high. d. On 2/26/2023 at 9:44 a.m., the Surveyor asked Dietary #1, why weren't you wearing a mask when the Surveyor entered the facility? Dietary #1 replied, I got here at 6:00 a.m., and there weren't any masks. e. On 2/26/2023 at 10:18 a.m., the Surveyor asked LPN #3, why are we wearing masks in the facility? LPN #3 replied, the County Positivity Rate is high, that's why we're wearing masks. f. On 2/26/2023 at 12:01 p.m., a review of the Centers for Disease Control COVID-19 Tracker website documented the county the facility resides in was currently at a High transmission rate. g. On 2/27/2023 at 9:22 a.m., the Surveyor asked the Assistant Director of Nursing (ADON), what is the county COVID-19 transmission rate? The ADON replied, it's high dated on Thursday, I check it on Thursday and confirm before I record the information on Friday? The Surveyor asked the ADON, what was it last Friday 2/24/2023? The ADON replied, it's been high for a while, a couple of weeks, since January. The Surveyor asked the ADON, what precautions did the facility implement to decrease the transmission and the spread of COVID-19. The ADON replied, implemented masks for all staff, visitors and education and signage. The Surveyor asked the ADON, what Personal Protective Equipment (PPE) is supposed to be worn while in the facility now? The ADON replied, a surgical mask at all times, if it's an isolation room, full PPE, depending on the isolation precautions, but all times a mask. The Surveyor asked the ADON, why should face masks be worn at all times while in the facility? The ADON replied, to reduce transmissions of and spread of COVID-19? The Surveyor asked the ADON, how often is the facility testing for COVID-19? The ADON replied, we are in outbreak, so we test Tuesdays and Fridays. h. On 2/27/2023 at 1:16 p.m., the Surveyor asked CNA #4, what PPE is supposed to be worn while in the facility now? CNA #4 replied, masks, due to high community guidelines. i. On 2/27/2023 at 1:40 p.m., the Surveyor asked the Director of Nursing (DON), what is the county COVID-19 transmission rate? The DON replied, we have been in the red for weeks. The Surveyor asked the DON, what precautions did the facility implement to decrease the transmission and the spread of COVID-19? The DON replied, depends on the level .high back to the masks. The Surveyor asked the DON, what PPE is supposed to be worn while in the facility now. The DON replied, masks because that's what our policy says when in outbreak. The Surveyor asked the DON, if there are no masks at the door, where do you get them? The DON replied, at the nurses station. The Surveyor asked the DON, how often is the facility testing for COVID-19? The DON replied, two times a week. The Surveyor asked the DON, what are your expectations from your staff regarding following the facilities policies and procedures and the Centers for Medicare and Medicaid Services (CMS) guidelines? The DON replied, I expect them to follow them. j. On 2/27/2023 at 1:41 p.m., the Surveyor asked the Administrator, what is the county COVID-19 transmission rate? The Administrator replied, high. The Surveyor asked the Administrator, what precautions did the facility implement to decrease the transmission and the spread of COVID-19? The Administrator replied, facemasks. The Surveyor asked the Administrator, what PPE is supposed to be worn while in the facility now? The Administrator replied, masks, because that's what our policy says when in outbreak. The Surveyor asked the Administrator, if there are no masks at the door, where do you get them? The Administrator replied, PPE is available at the kitchen. The Surveyor asked the Administrator, how often is the facility testing for COVID-19? The Administrator replied, two times a week. The Surveyor asked the Administrator, what are your expectations from your staff regarding following the facilities policies and procedures and the CMS guidelines? The Administrator replied, I expect them to follow them. k. A policy provided by the DON on 2/27/2023 at 11:05 a.m. documented, .Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures .This facility follows recommended standard and transmission-based precautions, environmental cleaning and social distancing practices to prevent the transmission of COVID-19 within the facility .to address Asymptomatic and Pre-Symptomatic transmission, universal source control is being implemented when county transmission rate is high or there is a COVID-19 outbreak in the facility .anyone entering the facility is required to have a face covering regardless of symptoms .staff should wear a facemask at all times when in the facility if county transmissibility rate is high or facility is in an outbreak status .

Based on observation, interview, and record review, the facility failed to ensure nebulizer masks and tubing were contained when not in use to prevent the potential spread of infection and infectious diseases for 3 (R #3, R #4, and R #5) of 8 (R #1, R #2, R #3, R #4, R #5, R #6, R #7, R #8) sample mix residents. The findings are: 1. Resident (R#3) had diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Heart Failure, and Respiratory Failure. The 5-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/11/2023 revealed the resident scored 15 (13-15 cognitively intact) on the Brief Interview Mental Status (BIMS) required limited assist of one staff for bed mobility, transfer, dressing, toilet use, and personal hygiene. a. A Physician Order with a start date 2/9/2023 of documented . Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) mg/3 ml 3 [milligrams/milliliters] inhale orally every 6 hours as needed . b. A Care Plan with an initiated date of 9/11/2022 documented .resident has COPD .give Aerosol or Bronchodilators as ordered . c. On 2/26/2023 at 10:39 a.m., R #3 sat on an oxygen contractor in her room. A Nebulizer machine was on top of a mini refrigerator. The Nebulizer mouthpiece and tubing laid across the nebulizer machine and were not contained or bagged. The Surveyor asked R #3, do you take updraft treatments? R #3 replied, I'm supposed to get them three times a day. The Surveyor asked R #3, do you ever refuse your updraft treatments? R #3 replied, no, but I did get it one time today. 2. Resident (R #4) had diagnoses of COPD and Respiratory Failure. The Quarterly MDS with an ARD of 1/31/2023 documented the resident scored 15 (13-15 Cognitively Intact) on the BIMS, required limited assist of one staff for bed mobility, transfer, and toilet use, and extensive assist of one staff for dressing and personal hygiene. a. A Physician Order with a start date of 7/21/2022 documented .Ipratropium-Albuterol Solution 0.5-2.5 (3) mg/3 ml 1vial inhale orally every 4 hours . b. The Care Plan with a revision date of 11/25/2022 documented, . has altered respiratory status/difficulty breathing dx (diagnosis), COPD, Pulmonary Emboli, Acute/Chronic Respiratory Failure, Pulmonary Edema .Administer Medication/puffers as ordered . c. On 2/26/2023 at 10:32 a.m., R#4 laid in bed. A nebulizer machine was on the nightstand with the nebulizer mouthpiece, and the tubing which laid across the nebulizer machine was not contained or bagged. 3. Resident (R #5) had diagnoses of Heart Failure, Respiratory Failure, and Pneumonia. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/14/2023 revealed the resident scored 15 (Cognitively Intact) on the Brief Interview for Mental Status (BIMS), required extensive assist of two staff for bed mobility, transfer, toilet use, and personal hygiene. a. A Physician Order with a start date of 1/21/2023 documented, .Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) mg (milligrams) / ml (milliliters) .1 vial inhale orally four times a day . b. A Physician Order with a start date of 1/31/2023 documented, .Budesonide Inhalation Suspension 0.5 mg/2 ml .2 ml inhale orally two times a day . c. The Care Plan with an initiated date of 2/2/2023 documented, .resident has Emphysema/COPD/Respiratory Failure .give Aerosol or Bronchodilators as ordered . d. On 2/26/2023 at 9:55 a.m., R#5 laid in bed with oxygen running at 2 liters per minute via nasal cannula. A nebulizer was on the nightstand with nebulizer mask and tubing laying in an open compartment of the nebulizer machine and was not contained or bagged. 4. On 2/27/2023 at 9:22 a.m., the Surveyor asked the Assistant Director of Nursing (ADON), where are nebulizer masks and tubing supposed to be stored when not in use? The ADON replied, in a bag. The Surveyor asked the ADON, who is responsible for ensuing nebulizer masks and tubing are contained/in a bag when not in use? The ADON replied, nurses and management, we walk the halls, but not on Sundays. The Surveyor asked the ADON, why should nebulizer masks and tubing be contained/in a bag when not in use? The ADON replied, to reduce exposure to infectious pathogens. The Surveyor asked the ADON, have you/the nurses been trained on administration/storing of nebulizer masks and tubing? The ADON replied, I don't remember one since December, that's when I started. 5. On 2/27/2023 at 1:40 p.m., the Surveyor asked the Director of Nursing (DON), where are nebulizer masks and tubing supposed to be stored when not in use? The DON replied, in a bag with name and date. The Surveyor asked the DON, who is responsible for ensuing Nebulizer masks and tubing are contained/in a bag when not in use? The DON replied, nurses. The Surveyor asked the DON, why should nebulizer masks and tubing be contained/in a bag when not in use? The DON replied, infection control. The Surveyor asked the DON, have you/the nurses been trained on administration/storing of Nebulizer masks and tubing? The DON replied, yes. The Surveyor asked the DON, what are your expectations from your staff regarding following the facilities policies and procedures and the Centers for Medicare and Medicaid Services (CMS) guidelines? The DON replied, I expect them to follow them. 6. On 2/27/2023 at 1:41 p.m., the Surveyor asked the Administrator, where are nebulizer masks and tubing supposed to be stored when not in use? The Administrator replied, in a bag with name and date. The Surveyor asked the Administrator, who is responsible for ensuing nebulizer masks and tubing are contained/in a bag when not in use. The Administrator replied, nurses. The Surveyor asked the Administrator, why should nebulizer masks and tubing be contained/in a bag when not in use? The Administrator replied, infection control. The Surveyor asked the Administrator, have you/the nurses been trained on Administration/storing of Nebulizer masks and tubing? The Administrator replied, yes. The Surveyor asked the Administrator, what are your expectations from your staff regarding following the facilities policies and procedures and the CMS guidelines? The Administrator replied, I expect them to follow them. 7.A policy provided by the DON on 2/27/2023 at 10:46 a.m. documented, .Departmental (Respiratory Therapy) - Prevention of Infection .the purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment .among residents and staff .infection control considerations related to medication nebulizers .obtain equipment (i.e., administration set-up, plastic bag, gauze sponges) .after completion of therapy .removed the nebulizer container .rinse the container with fresh tap water .dry on a clean paper towel or gauze sponge .reconnect to the administration set-up when air dried .take care not to contaminate internal nebulizer tubes .wipe the mouthpiece with damp paper towel or gauze sponge .store the circuit in plastic bag, marked with date and resident's name, between uses .discard the administration set-up every seven (7) days .

Based on interview, and record review the facility failed to sure 1 (Resident #2) of 3 (Resident #1, R #2, R #3) sampled residents that depended on the staff to assist them with a shower were showered on their scheduled shower day. The findings are. Resident #2 had a Diagnosis of Morbid (Severe) Obesity Due to Excess Calories, and TYPE 2 DIABETES MELLITUS WITH HYPOGLYCEMIA WITHOUT COMA. A Medicare 5-Day Minimum Data Set (MDS) had an Assessment Reference Date (ARD) of 1/6/23. The resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS), she required extensive two plus persons physical assistance with personal hygiene, and bed mobility; total dependence with 2 plus persons for transfers. a.The Care Plan with a target completion date of 12/12/22 documented, .BATHING/SHOWERING: The resident requires extensive/dependent assistance by staff with showering @ [at] least 3x/wk [times a week] and as necessary. b. On 2/15/23 at 10:40 AM, the Surveyor asked Certified Nursing Assistant (CNA) #1, how often does Resident #2 get a shower? She stated, she gets it 3 times a week. Her days are Tuesdays, Thursdays, and Saturdays. The Surveyor asked CNA #1, can you tell me why she didn't get her scheduled shower yesterday? She stated, no, ma'am I wasn't here. c. On 2/15/23 at 10:53 AM, the Surveyor asked CNA #2, how often does Resident #2 get a shower? She stated, I was supposed to give her one yesterday, but I didn't have time. The Surveyor asked CNA #2, can you tell me why she didn't get her scheduled shower yesterday? She stated, I got sick yesterday and I had to go home. We had CNA #4, and CNA #5 left on the hall. d. On 2/15/23 at 11:05 AM, the Administrator provided Resident #2's bathing record for February 2023 which documented, .Bathing Tuesday, Thursday, Saturday, and PRN (as needed) . There was no shower or bath documented for 2/2/23, and 2/11/23. e. On 2/15/23 at 11:30 AM, the Surveyor asked CNA #3, how often does Resident #2 get a shower? She stated, it's supposed to be Tuesday, Thursday, and Saturday. That was my next one I was going to get. She stated, the Surveyor asked CNA #3 can you tell me why she didn't get her scheduled shower yesterday? She stated, to my knowledge I thought it was because of the Valentine's Day party, but she's going to get one today. f. On 2/16/23 at 10:46 AM, the Surveyor asked the Director of Nursing (DON), how often does Resident #2 get a shower? She stated, I do not, but everyone is scheduled for 3 times a week. The Surveyor asked the DON, can you tell me why she didn't get her scheduled shower Tuesday? She stated, I'll have to ask CNA #3 I'm not sure. g. On 2/16/23 at 10:55 AM, the Surveyor asked the Administrator, how often does Resident #2 get a shower? She stated, I don't know. The Surveyor asked the Administrator, can you tell me why she didn't get her scheduled shower Tuesday? She stated, no, I didn't know she didn't.