Every finding on record at Apache Junction Health Center

Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that an incident involving staff to resident abuse was documented completely in the clinical record for 1 of 4 sampled residents (#2), and that medical records were maintained for the regulated timeframe for 3 out of 4 residents (#450, #451, #16). The deficient practice could result in incomplete documentation in resident medical records. Findings Include: -Regarding Resident #2 Resident #2 was admitted to the facility on [DATE] with diagnoses that included hypertension, multiple sclerosis, anxiety disorder, and paraplegia. A Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. An allegation of staff to resident abuse that occurred on November 19, 2022 was investigated by the facility on November 24, 2022. However, review of the resident ' s clinical record dated November 19, 2022 through February 21, 2025 revealed no evidence of the incident occurring. A care plan initiated on March 1, 2017 revealed no evidence regarding the allegation of verbal abuse on February 21, 2025. An interview was conducted on February 20, 2025 at 12:53 p.m. with the Director of Nursing (DON/Staff#189) who stated that allegations of abuse should be noted in the progress notes and would have to be a part of the clinical record. An interview was conducted on February 20, 2025 at 1:06 p.m. with a Licensed Practical Nurse (LPN/Staff#114) who stated that allegations of abuse needed to be documented in the progress notes and that it was the facility ' s expectation to document anything and everything in the notes. Staff # stated that the note would need to include the allegation, chain of command notified, interventions, and outcome. -Regarding Resident #450 Resident #450 was admitted to the facility on [DATE] with diagnoses that included fracture of the right femur, subsequent encounter for closed fracture with routine healing, a need for assistance with personal care, and the presence of a cardiac pacemaker. A Quarterly MDS assessment dated [DATE], revealed a stage 3 pressure ulcer and a BIMS score of 14, which indicated intact cognition. A request was made for Resident #450 ' s December 2020 shower sheets to reveal skin integrity and the facility was unable to provide them. -Regarding Resident #451 Resident #451 was admitted to the facility on [DATE] with diagnoses that included hemiplegia, hemiparesis, dysphagia, and atrial fibrillation. A Quarterly MDS assessment dated [DATE] revealed a BIMS score of 14, which indicated intact cognition. A request was made for Resident #451 ' s shower sheets from July 2022 to reveal skin integrity and the facility was unable to provide them. -Regarding Resident #16 Resident #16 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis, type 2 diabetes, edema, and hyperlipidemia. A Quarterly MDS assessment dated [DATE] revealed a BIMS score that was 15, which indicated intact cognition. A request was made for Resident #16 ' s shower sheets from December 2022 to reveal skin integrity and the facility was unable to provide them. An interview was conducted on February 20, 2025 at 11:55 a.m. with the Executive Director (ED/Staff#69) who stated that they did not have shower sheets from 2020-2022 and that they had looked through the off-site boxes in an attempt to find them. The initial request was submitted to Staff #69 on February 20, 2025 at 8:40 a.m. and was unable to be completely fulfilled. Staff #69 signed the submitted request stating that shower sheets were unavailable for the requested years. An interview was conducted on February 21, 2025 at 10:14 a.m. with the Medical Records Director (MRD/Staff#18) who stated that the requirement for maintaining medical records was 6 years for the state. Staff #18 stated that if they did have medical records from 2020-2022 they would be off site, and that shower sheets should be a part of those records. Staff #18 stated that if there were not shower sheets, then those would be incomplete medical records. Staff #18 stated that she had only been working at the facility for a few months and that she did not know if they had the shower sheets from 2020-2022. A follow-up interview was conducted on February 21, 2025 at 10:32 a.m. with the DON (Staff #189) who stated that her rule of thumb for maintaining medical records was [AGE] years, and shower sheets were a part of the medical record. Staff #189 stated that it was her expectation that medical records be maintained for the timeframe required by the regulation and statutes. Review of a policy titled, Retention of Medical Records, revealed that the medical records of discharged residents should be retained by the facility for a period of 6 years. Review of a policy titled, Charting and Documentation, revealed that the medical record must contain events, incidents, or accidents involving the resident. The policy also revealed that documentation must be objective, complete, and accurate.

Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure one of 2 sampled residents (#2) were not verbally abused by a Licensed Practical Nurse (LPN/Staff#207). The deficient practice could result in residents being emotionally harmed. Findings include: Resident #2 was admitted to the facility on [DATE] with diagnoses that included hypertension, multiple sclerosis, anxiety disorder, and paraplegia. There was no evidence in the clinical record that the care plan had been updated regarding an allegation of abuse that occurred on November 19, 2022. A Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The assessment also indicated no behaviors were exhibited. Further review of the resident ' s clinical record from November 19, 2022 through February 21, 2022 revealed no evidence of the verbal abuse allegation that occurred on November 19, 2022. Review of a facility investigation dated November 24, 2022, revealed that a verbal altercation occurred on November 19, 2022 between a LPN (Staff #207) and Resident #2. The allegation was reported by Resident #2 on November 19, 2022. The investigation revealed that the LPN told the facility she felt mocked by Resident #2 for her medication delivery and that the resident made her feel like she was not a nurse and during the investigation the LPN resigned. The facility investigation also revealed that another resident across the hall stated that he heard the nurse say you are not human, you are a monkey multiple times to Resident #2. The facility substantiated the investigation. An interview was conducted on February 20, 2025 at 10:16 a.m. with the previous Executive Director and Abuse Coordinator (Previous ED/Staff#209), who stated that he recalled that the LPN had assaulted Resident #2 verbally, and stated the resident was a monkey and less than human. Staff #209 stated that Resident #2' s roommate corroborated the story and when he confronted the perpetrator, she did not deny that she had said it, and told him I may have said something like that. Staff #209 stated that he did substantiate the allegation because the facility identified that the nurse was inappropriate toward the resident. An attempt was made to contact the Certified Nursing Assistant (CNA/Staff#208) who was named as a witness in the investigation on February 20, 2025 at 10:23 a.m., and there was no response. An attempt was made to call the perpetrator (LPN/staff #207), on February 20, 2025 at 10:24 a.m., however, there was no response. An interview was conducted on February 20, 2025 at 10:59 a.m. with Resident #2 who stated that the nurse LPN (staff #207), entered her room to administer pain medication, and when the resident declined to take the medication the LPN went into a rage and called the resident a monkey and less than a human being. Resident #2 stated that her roommate overheard the incident, as well as several other residents in the hall, and her roommate thought the nurse stated don't mock me. Resident #2 stated that when the roommate said that, Staff #207 overheard, and came back into the room to clarify to both residents that she did actually say monkey and that Resident #2 was less than human, before repeating it 5-6 more times. Resident #2 stated that she immediately called the previous Executive Director (staff #209), and the nurse was immediately taken off the floor and terminated. Resident #2 stated that she ultimately felt she was supported and protected by the facility, but she did feel violated and unsafe following the incident. An interview was conducted on February 20, 2025 at 12:50 p.m. with the Director of Nursing (DON/Staff#189) who stated that abuse was considered anything that made a patient feel unsafe, abuse was not allowed to occur in the facility, and staff should never yell at residents or call them names. The DON stated that if an abuse allegation were made, they would need to report and investigate immediately, and remove the employee to protect the patient from harm. Staff #189 stated that an allegation of abuse would need to be documented in the clinical record in the form of a progress note. Review of a policy titled, Abuse, Neglect, Exploitation or Misappropriation revealed that residents have the right to be free from abuse, which includes verbal abuse. The policy revealed that the facility needed to develop and implement policies to prevent and identify abuse and ensure adequate staffing to prevent burnout, stressful working situations, and high turnover rates. Review of a policy titled, Charting and Documentation, revealed that any changes to the resident ' s medical, physical, functional, or psychosocial condition should have been documented in the resident ' s medical record including incidents and events regarding the resident.

Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure controlled narcotic medications of one resident (#449) were not diverted and misappropriated by a Licensed Practical Nurse (LPN/Staff#210). The deficient practice could result in residents not receiving pain medication as ordered, and pain not being controlled. Findings include: Resident #449 was admitted to the facility on [DATE] with diagnoses that included artificial hip joint, diabetic neuropathy, depression, and anxiety A Discharge Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score was 15, which indicated intact cognition. Review of medication orders revealed that oxycodone 10 MG tablets were initiated on the following dates: -April 13, 2023 -April 17, 2023 -April 23, 2023 Further review of the medication orders revealed no evidence of stopped/discontinued/completed dates for oxycodone on the above dates. Review of medication administration records revealed that the resident was administered oxycodone from April 13, 2023 until her discharge on April 26, 2023. The clinical record revealed that the resident was discharged from the facility on April 26, 2023. A facility investigation dated May 16, 2023, regarding an allegation of narcotic diversion by an LPN (staff #210), revealed video footage with timestamps showing that the LPN arrived late for her shift, ingested pills from her personal bag in a prescription container, removed two bubble pack medication cards that had been discontinued from the cart, popped a large amount of pink medications from the controlled medicine card in her hand, ingested one of the pink pills, and placed the rest of the pills in a pill crushing bag with a rubber band around the top to seal it. The investigation also revealed that the LPN placed the bag into her right pocket and removed the labels from a minimum of 2 cards before placing them in her pocket and discarding the bubble pack in the garbage. The investigation further indicated that in the footage, the LPN took the controlled medication count-down sheet out of the controlled medicine book and folded them into her left pocket. The report revealed that the LPN spent most of her time at the cart in the controlled substance drawer, even though records show she only dispensed one narcotic during her shift. The report identified that the medications that were diverted were the same color as the missing medications, and the nurse marked the two cards as being discharged or destroyed. An interview was conducted on February 20, 2025 at 10:16 a.m. with the previous Executive Director (Previous ED/Staff#209), who stated that on May 2nd, 2023, an unidentified nurse reported to him that the LPN was acting funny. The previous ED stated that when he reviewed the video footage of the LPN, he observed her popping nearly 20 oxycodone pills into a cup and taking it around the nurse ' s station, looking around, and grabbing a pill crusher bag to store the pills in before placing the bag into her pocket. The previous ED stated that the LPN took 17-20 oxycodone pills and 4 antipsychotic pills of some sort that he was unable to identify, and in the video footage he observed the LPN remove one of the 20 pills and take it while standing on the unit. The previous ED stated that the LPN took the medication cart and went to the end of the hallway underneath another camera to remove the count sheets in the narcotics book and the blister pack label, and she put them in her pocket before leaving her shift. The previous ED stated that he notified the police, Adult Protective Services, Arizona State Board of Nursing, ombudsman, and the Arizona Department of Health Services. The previous ED stated that the resident who had their medications diverted was discharged the day prior to the incident, and their protocol was to not purge the medications until later that day. An attempt was made to have a phone interview with the Licensed Practical Nurse (LPN/Staff #210) named in the investigation as the perpetrator on February 20, 2025 at 10:27 a.m., and there was no response. An interview was conducted on February 20, 2025 at 11:45 a.m. with a Licensed Practical Nurse (LPN/Staff#114) who stated that it was not acceptable for nurses to steal or use medications from the medication cart because it would endanger the safety of their patients. The LPN stated that nurses were there to protect residents, and the action of stealing medications or ingesting them while on duty would not protect patients because the nurse would be intoxicated which could cause them to have poor judgement and assessment skills. An interview was conducted on February 20, 2025 at 12:47 p.m. with the Director of Nursing (DON/Staff#189) who stated that staff were not allowed to take controlled medications from the medication cart for personal use and that it would be unacceptable and inappropriate. The DON stated that if this were to be identified in the facility they would need to confront it immediately by investigating and reporting to the police, Arizona Department of Health Services, Arizona State Board of Nursing, and the Drug Enforcement Administration. The DON stated that the risk of staff taking medications from the medication cart for personal use could result in harm to the resident ' s due to the nurse having altered mentality and ability to provide care. The DON also stated that the risk could be that it could lead to medication errors and an impaired nurse might not provide care as it was ordered by the physician. Review of a policy titled, Controlled Substances, revealed that the facility should comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. The policy revealed that the controlled substance inventory should be monitored and reconciled to identity loss or potential diversion in a manner that minimizes the time between diversion and detection. The policy also revealed that the waste or disposal of controlled medications should be done in the presence of a nurse and a witness who both sign the disposition sheet. The policy indicated that controlled substances remaining in the facility after a resident had been discharged should be securely locked in an area with restricted access until destroyed. Review of a policy titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, revealed that the facility should develop and implement policies and protocols to prevent and identify theft, and misappropriation of resident property. The policy revealed that residents have the right to be free from misappropriation of resident property.

Based on clinical record review, policy review, resident and staff interviews, the facility failed to ensure abuse policies were followed regarding one of 2 sampled residents (#2) who was verbally abused by a Licensed Practical Nurse (LPN/Staff#207). The deficient practice could result in abuse policies not being followed, which could result in residents being harmed. Findings include: Resident #2 was admitted to the facility on [DATE] with diagnoses that included hypertension, multiple sclerosis, anxiety disorder, and paraplegia. A Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The assessment also indicated no behaviors were exhibited. Review of a facility investigation dated November 24, 2022, revealed a substantiated allegation that a verbal altercation occurred on November 19, 2022, between an LPN (staff #207) and Resident #2. The investigation revealed that the LPN resigned from the facility. An interview was conducted on February 20, 2025 at 10:16 a.m. with the previous Executive Director and Abuse Coordinator (Previous ED/Staff#209) who stated that he substantiated the staff to resident abuse allegation because the facility protocol was to substantiate if there was truth to the scenario, and from what he understood, the perpetrator (LPN/staff #207) was verbally inappropriate to with Resident #2. An interview was conducted on February 20, 2025 at 10:59 a.m. with Resident #2, who stated that the LPN (staff #207), entered her room to administer pain medication, and when the resident declined to take the medication the LPN went into a rage and called the resident a monkey and less than a human being. Resident #2 stated that her roommate overheard the incident, as well as several other residents in the hall, and her roommate thought the nurse stated don ' t mock me. Resident #2 stated that when the roommate said that, Staff #207 overheard, and came back into the room to clarify to both residents that she did actually say monkey and that Resident #2 was less than human, before repeating it 5-6 more times. Resident #2 stated that she immediately called the previous Executive Director (staff #209), and the nurse was immediately taken off the floor and terminated. Resident #2 stated that she ultimately felt she was supported and protected by the facility, but she did feel violated and unsafe following the incident. An interview was conducted on February 20, 2025 at 12:50 p.m. with the Director of Nursing (DON/Staff#189), who stated that abuse was considered anything that made a patient feel unsafe, abuse was not allowed to occur in the facility as per their policy, and staff should never yell at residents or call them names. The DON stated that if an abuse allegation were made, the protocol would be to report and investigate it immediately, and remove the employee to protect the patient from harm. Staff #189 stated that the process following an allegation of abuse would be to document in the clinical record in the form of a progress note as per the facility ' s policy. Review of a policy titled, Abuse, Neglect, Exploitation or Misappropriation revealed that residents have the right to be free from abuse, which includes verbal abuse. The policy revealed that the facility needed to develop and implement policies to prevent and identify abuse and ensure adequate staffing to prevent burnout, stressful working situations, and high turnover rates.

Based on review of clinical records, policy, and staff interviews the facility failed to ensure an order for pain medication was followed as prescribed for one of eight sampled residents (#46) by failing to administer medication following physician ordered parameters. The deficient practice could result in undesirable medication-induced harm and uncontrolled pain. Finding Includes: Resident #46 was admitted into the facility on [DATE] with diagnoses that included type 2 diabetes, depression and obstructive uropathy. A physician order dated January 18, 2025 was written for tylenol oral tablet 325 milligram (acetaminophen) to give 2 tablets by mouth every 6 hours, as needed for pain 1-3. A Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE], included a Brief Interview for Mental Status (BIMS) score of 12, which indicated intact cognition. It further revealed that the resident had pain occasionally effected her sleep and therapy activities. A care plan initiated on February 12, 2025, revealed that the resident was at risk for pain or discomfort due to immobility, and interventions included to administer medication as prescribed. A February 2025 Medication Administration Records (MAR) revealed that tylenol oral tablet 325 milligram was administered outside of physician ordered parameters on the following dates: -February 2, 2025 at 1:28 p.m.: for a pain level of 5. -February 5, 2025 at 8:32 a.m.: for a pain level of 9. -February 16, 2025 at 8:08 a.m.: for a pain level of 5. Progress notes dated February 2, February 5, and February 16, 2025 revealed no evidence that the physician was notified that the medications were administered outside of parameters. An interview was conducted on February 20, 2025 at 11:39 a.m., with a Licensed Practical Nurse (LPN/ staff # 250), who stated that the resident was alert and occasionally confused. The LPN also stated that the resident has orders for oxycodone prn (as needed) for a pain level of 4-10 and tylenol for a pain level of 1-3. The LPN reviewed the clinical record and stated that tylenol had been administered for a pain level of 5 on two occasions and for a pain level of 9 once, and that this did not follow the physician order. The LPN also stated that the risk could result in unnecessary pain, and a risk of falling from agitated behaviors due to uncontrolled pain. An interview was conducted with the Director of Nursing (DON/ staff # 189) on February 20, 2025 at 12:02 p.m., who stated that the resident had orders for prn pain medication oxycodone and tylenol. The DON reviewed the MAR and stated that she expected nursing to follow physician orders, as written including parameters. She also stated that the risk of not administrating pain medication follow physician order could result in uncontrolled pain. A review of the policy titled, Administering Medication, revealed that medications are administered in accordance with prescriber orders, including any required time frame.

Based on observation, staff interviews, clinical record review and facility documentation and policy review, the facility failed to ensure that a medication was administered as ordered for 3 sampled residents (#6, #32 and #25). This deficient practice could result in residents not receiving the necessary treatment to address their medical issues/problems. Findings include: -Resident #6 was admitted on [DATE] with diagnoses of urinary tract infection, dysphagia, and neurogenic bladder. A care plan dated [DATE] for altered skin integrity included and intervention to notify the Physician or Nurse Practitioner as needed. The admission notes dated [DATE] revealed the resident was readmitted with diagnosis of MDR (multi-drug resistant) UTI (urinary tract infection); and was at the facility for IV (intravenous antibiotic). A care plan dated [DATE] revealed the resident had fluid overload. Interventions include to administer medications as ordered. A physician order dated [DATE] included for Ertapenem Sodium (antibiotic) injection solution reconstituted 1 GM (gram) intravenously one time a day for UTI for 14 Days. The start date was [DATE] at 12:00 P.M. This order was transcribed onto the medication administration record (MAR) for [DATE]. The MAR revealed that the resident received one dose of ertapenem on [DATE]. Continued review of the MAR revealed that ertapenem was not documented as administered on [DATE] and [DATE]. An eMAR (electronic MAR) note dated [DATE] revealed that included that there was no IV medication. The clinical record revealed no evidence of a reason why ertapenem was not administered to the resident on [DATE] and [DATE]; and that, the physician was notified. The physician progress note dated [DATE] included that the resident was tolerating ertapenem sodium 1 gram. The 5-day MDS (Minimum Data Set) assessment dated [DATE] revealed that the resident was not taking antibiotic during the last 7 days. -Resident #32 was admitted on [DATE] with diagnoses of rheumatoid arthritis, sepsis and metabolic encephalopathy. The physician progress note dated [DATE] revealed the resident was alert and oriented x3, had chronic pain, chronic bilateral hip pain and sciatica. Assessment included chronic bilateral hip pain; and that, hip x-rays showed severe degenerative changes. Plan included pain control. An admission MDS dated [DATE] included the resident was moderately cognitively impaired, and that the resident occasionally experienced pain and the worst pain in the last 5 days was a 4. A physician order dated [DATE] included for oxycodone (narcotic opioid) ER (extended release) tablet 12 Hour Abuse-Deterrent 10 mg (milligram), give 1 tablet by mouth two times a day for pain. This medication had a trade name of oxycontin. This order was transcribed onto the MAR (medication administration record) for [DATE]. The MAR revealed that oxycodone was documented as administered from [DATE] through [DATE]; and, the total number of tablets given from [DATE] through [DATE] was 6 tablets. The clinical record revealed documentation that oxycodone was discontinued on [DATE]. However, the controlled substance countdown sheet included that Oxycodone was continued to be administered 9 instances after [DATE]. A physician order dated [DATE] included for oxycodone 5 mg give one tablet every 4 hours as needed for pain. This order was transcribed onto the MAR for August and [DATE] and revealed that oxycodone was documented as administered ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] and [DATE]. A physician order dated [DATE] revealed an order for oxycodone 5 mg by mouth every 4 hours as needed for pain ,d+[DATE] related to rheumatoid arthritis. However, a medication cart observation conducted on [DATE] revealed that the oxycontin medication card for resident #32 had twenty 10 mg tablets of oxycontin (trade name for oxycodone). An interview was conducted on [DATE] at 5:23 P.M. with the registered nurse (RN/staff #11) who said that she administered oxycontin to the resident; and, she was using the 10 mg oxycontin in the medication card that was found in the medication to administer to the resident. She said that there were narcotics that were no longer used, or, when a medication was completed, the nurse would take the paper out and sign it as completed with another nurse to witness. She said she had always had someone available to give the narcotic cards to; and that, she was not sure what to do if there was no one. In an interview conducted on [DATE] at 5:25 P.M with another RN (staff #99) who reviewed the resident clinical record, the RN said that the resident had an order for oxycodone HCL ER from [DATE] - [DATE]. The RN also said that the staff should have used 8 tabs; and that, there were more tablets missing in the medication card than what should have been used, considering the time prescribed. -Resident #25 was admitted on [DATE] with diagnoses of elevated white blood cell count, myocardial infarction (MI) and UTI. A care plan dated [DATE] revealed the resident was at risk for impaired cardiac function and complications related to history of myocardial infarction. Interventions included to administer medications as ordered and to observe, document and notify MD of adverse side effects. A physician progress note dated [DATE] included that urine culture report showed sensitivity to meropenem. It also included that PICC (peripherally inserted central catheter) line was ordered and to start IV meropenem soon after PICC line insertion. Assessment included UTI. A physician order dated [DATE] for meropenem IV solution reconstituted 1 gram intravenously every 8 hours for UTI for 7 Days. This order was transcribed onto the MAR for August and revealed that IV meropenem was not documented as administered on at the 10:00 p.m. schedule on [DATE] There was no evidence found in the clinical record of a reason why this medication was not administered as ordered; and that, the physician was notified. A physician progress note dated [DATE] revealed that the resident was receiving antibiotic as scheduled and was tolerating it well. An interview was conducted on [DATE] at 5:30 p.m. with the unit manager/licensed practical nurse (LPN/staff #21) who said that nurses take the medication cards out periodically; and that, when the medication cards were still in the narcotics drawer in the medication cart, they do not have a way of knowing if the medications were discontinued. The LPN said that the nurses were usually good on knowing what medications were discontinued for a resident. She said that if IV medication was not available, the nurse should the pharmacy, inform the provider, then get the medication from the pyxis system if possible and document in the progress note. A review of the clinical record for resident #6 was conducted with the LPN who stated that she did not see any notes or any new orders that say it was ok to hold ertapenem on the [DATE]. The LPN further stated that the unmarked boxes in the MAR meant that medication was not given; and that, if it was not charted, it did not happen. In an interview with another LPN (staff #117) conducted on [DATE] at 1:30 p.m., the LPN stated that when doing medication administration, she checks the time, route and the medication, and, would look at the electronic MAR. She stated that it was absolutely not ok to give an extended release instead of an immediate release medication. She said that she just leaves medications in a cart if it is expired until it can be removed. The LPN said that if she was out of a medication she needed, she would reorder the medication, would document in the nursing note that the medication was pending pharm delivery and would notify the provider. During an interview with the Director of Nursing (DON/staff #56) conducted on [DATE] at 3:09 p.m., the DON stated that the expectation was that the unit manager or herself would collect the narcotics that were not in use twice a week. The DON also said that if medication go out of use before time of collection, the expectation was for staff to let management know sooner than our scheduled days. She said disposing of expired/unusable narcotic medication was just their standard practice and not a policy. The DON said that giving a narcotic without an order does not meet the expectation. The DON also said that she expected that all nurses follow the 5 rights: right medication, route, dose, patient and frequency. Regarding antibiotic administration, the DON stated that the expectation was for staff to notify the pharmacy, try to pull the medication from the Pyxis system when the antibiotic was not available. The DON said that if the staff could not the medication from the Pyxis, staff were expected to document that the medication was not given; and that, staff would notify the physician of any missed doses. Further, the DON stated that any missed doses would be provided at the end and the stop date would be extended. She said that there was a standing order that staff may administer the medication when available from the pharmacy. She said that if 3 standard doses were missed, then we notify them and that the Medical Director was aware of this policy. An interview was conducted on [DATE] at 1:37 P.M. with the Medical Director (staff #100) who said that if residents miss a dose, he will extend the treatment if missed a dose was at the beginning of a treatment because of delayed/pending pharmacy delivery. He said that there cannot be a standing order for missing doses in the middle of the treatment. He said that he would definitely want to be informed of any missed dosed. A policy titled Charting and Documentation revised ,d+[DATE] included all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident ' s medical record. This document included that the medical record should facilitate communication between the interdisciplinary team regarding the resident ' s condition and response to care. This policy included documentation of procedures and treatments will include care-specific details, including notification of family, physician or other staff, if indicated. A policy titled Administering Medication dated ,d+[DATE] revealed that medications are administered in a safe and timely manner, and as prescribed. This policy included the individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on clinical record review, staff interviews, and facility documentation, policies and procedures, the facility failed to ensure that one resident (#5) was free from neglect by failing to ensure oxygen was administered when needed and the provider was notified of decreased oxygen saturation. The deficient practice resulted in cardiopulmonary arrest and hospitalization for resident #5. Findings include: Resident #5 was admitted on [DATE] with diagnoses of multiple sclerosis (MS), epilepsy, and hypertension. The care plan dated [DATE] revealed the resident was admitted due to decreased activities of daily living (ADLs) ability related to MS exacerbation/flare with seizure disorder. Another care plan initiated on [DATE] indicated that the resident had potential for pain/discomfort related to MS flare, neuropath, and decreased mobility. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating the resident was cognitively intact. The assessment also included the resident was not coded for shortness of breath, was not on oxygen therapy and did not have a condition or chronic disease that may result in a life expectancy of less than 6-months. The active physician order summary revealed no orders for supplemental oxygen use. The weights and vitals summary report from [DATE] through 29, 2023 revealed resident had oxygen saturation (O2 sat) rate reading ranging ,d+[DATE]%. The skilled note dated [DATE] revealed the resident was alert and oriented to person, place and time, had no shortness of breath and had O2 sat rate of 95% on [DATE] at 6:46 a.m. The weight and vitals summary report revealed the resident's O2 sat rate were as follows on [DATE]: -At 3:07 p.m. - 87% in room air; and, -At 10:57 p.m. - 81% room air. A late entry physician progress note dated [DATE] included that the resident's O2 sat was 71% on room air based on vitals taken on [DATE] at 5:15 a.m. Per the documentation, the resident was not in great pain, was working on a bike machine, did not have cyanosis and bilateral lung sounds were clear to auscultation. A skilled note dated [DATE] at 3:17 a.m. included the resident's O2 sat was 81% on room air based on vital taken on [DATE] at 10:57 p.m. The note also indicated that the resident was not experiencing shortness of breath and was not on oxygen therapy. The documentation did not indicate any actions taken to address the resident's low O2 sat; and that, the physician was notified. Despite documentation of low oxygen saturation rates, the clinical record revealed no evidence that interventions were put in place to address the resident's oxygen saturation; and that, the physician was notified from [DATE] at 3:07 p.m. through [DATE] before 5:04 a.m. A general note dated [DATE] at 5:04 a.m. revealed resident #5 was alert and oriented was having respiratory difficulty and was cool and clammy. The documentation the note indicated that 911 was called and that the medical doctor was notified. The weight and vitals summary report for [DATE] 5:15 a.m. revealed the resident had an oxygen saturation rate of 71% via nasal cannula A progress note dated [DATE] at 5:15 a.m. included the resident had moderate emesis of brown liquid substance, was breathing and was unresponsive. Per the documentation, CPR (cardiopulmonary resuscitation) was initiated for 15 minutes by paramedics, and that the resident left the facility at 5:35 a.m. A progress note dated [DATE] at 5:25 a.m. revealed that the ambulance arrived at 5:15 a.m.; and that, CPR was initiated. The transfer/discharge summary note dated [DATE] at 7:37 a.m. included that resident #5 left the facility at 5:35 a.m. with mechanical CPR device delivering chest compressions; and that, the resident was taken to the hospital. Per the documentation, staff spoke with the ER (emergency room ) nurse; and that, the resident expired in the hospital. A review of a written statement by staff #117 dated [DATE] revealed that on [DATE], the CNA took the resident's vital signs on or about approximately between the time of 12 midnoc (midnight) and 1:00 a.m. indicated that a CNA informed her that resident #5's O2 sat was 91%. Per the statement, staff #117 noticed the documentation in the electronic record upon entering the patient's room on or about approximately 5:15 a.m. was 81% the O2 sat. At approximately on or about before 5:15 a.m., two CNAs and the nurse (staff #117) entered resident's room. Per the documentation, the resident's family reported that the resident had been like this during the night, the resident needed oxygen and the physician saw the resident today. The statement also included that the resident was awake, responsive and breathing, had an O2 saturation of 71%; and that, staff #117 placed the resident on oxygen at ,d+[DATE] LPM (liters per minute) continuously, exited the room, called 911 and notified the physician. The statement also included that the paramedics arrived at or approximately before or after 5:15 a.m. and the resident was placed on cardiac monitor. It also included that the resident had large emesis of brown liquidy substance; and, the paramedics immediately started mechanical chest compressions and that, the resident was still breathing. The statement also included that the resident left the facility at or about approximately before or after 5:30 a.m. and was transported to the hospital; and that, later on that morning of [DATE], staff #117 called the hospital and was informed that the resident expired. The facility 5-day report submitted on [DATE] revealed that a certified nurse assistant (CNA/staff #47) reported that when she took the resident's vital signs on [DATE] at 10:30 a.m. the resident's oxygen saturation was 81%; and that, she immediately reported the reading to the nurse (staff #117). The report also included that the CNA reported that oxygen was not initiated until the resident was found in distress at 4:45 a.m. on [DATE]. The documentation also included that interviews conducted with staff who worked with staff #117 revealed that staff #117 had problems with time management and follow through; and that, staff #117 seemed to be behind in her work and in a rush and there were instances when the staff had to finish up for staff #117 and follow through on work. The investigative report also included that on [DATE] the director of nursing (DON) spoke with staff #117 who said that the CNA (staff #47) informed her at 10:30 p.m. of [DATE] that the resident had low oxygen saturation but she did not enter the resident's room until 4:45 a.m. the next morning ([DATE]) when the resident was found to be slow to respond and had an oxygen saturation of 45%. Continued review of the report included that there were no progress notes written by staff #117 regarding the resident's health status or any action taken to address the resident's oxygen saturation of 81% at 10:30 p.m. on [DATE] and there was nothing in the medical record that indicated the resident was started on oxygen. Further, the investigative report included that the allegation neglect was substantiated. A phone interview was conducted on [DATE] at 12:44 pm. with the CNA (staff #47) who reported the incident. The CNA stated that she provides direct care for residents including responding to call lights and checking on issues or concerns the resident have; and that, if she notices a change of condition or something outside of the resident's baseline, she will immediately inform the nurse. The CNA stated that it was neglect if someone fails to act or provide a service that the resident needs; and that, instances of abuse/neglect are reported to the administrator or the DON. Regarding resident #5, the CNA stated that she was familiar with resident #5 and she had taken care of the resident for a few weeks. The CNA said that she was working double that day the incident with resident #5 occurred. She stated that the resident's oxygen saturation (O2 sat) normally range between ,d+[DATE]%; and that, at around 2:30 p.m. on [DATE], the resident's O2 sat was low at 87%. The CNA said that she informed the nurse about the low O2 sat and the resident's family concern about the resident having a fever despite the resident having no high temperature. temperature. The CNA stated that at around 10:30 p.m. on [DATE], she took the resident's vitals again and the resident's O2 sat would not go above 81%. She stated that she informed the LPN (staff #117) who told her that they will give the resident oxygen; and that, she thought the LPN (staff #117) went to check on the resident. However, the CNA said that at around 4:45 a.m. the next morning ([DATE]), she got done with her rounds, went to check on resident #5 and when she turned on the light, the resident had a dead stare and was blue. The CNA said that she placed a pulse oximeter on the resident and the O2 sat reading was 45% and the resident did not have oxygen on. The CNA said she reported the reading to the LPN who then called 911 and the doctor; and that, when the paramedics arrived, the resident still had a pulse but was not very alert or oriented. She said that about 5 minutes later, the paramedics started CPR and then transported her to the next-door hospital. Further, the CNA stated that later on that day she found out that the resident had passed away. The CNA stated that she was under the impression that the LPN (staff #117) would have given oxygen to the resident after she informed the LPN that the resident's O2 sat was low; and that, he did not know that the nurse did not check on the resident. Furthermore, the CNA stated that she would have expected the LPN (staff #117) contacted the doctor regarding the resident's low O2 sat but she was not sure if that happened that night. During a phone interview with the medical doctor (MD/staff #116) conducted on [DATE] at 1:36 p.m. the MD stated that he normally sees the residents every other day, which amounts to three times a week; and, he was supposed to be notified by the nurse if a resident has a change of condition or a change in their baseline. The MD said that he would not necessarily say it was neglect if staff fail to act or provide a service which includes notifying him so he can formulate a course of action/treatment. However, he does expect to be notified in those situations. Regarding resident #5, the MD stated that resident #5 was a really nice resident who was in the pre-end stage of MS (multiple sclerosis) and came to the facility to become stronger and was on rehab but was not making much progress. The MD said that he first found out about the resident's low O2 stat in the early morning of [DATE] and he ordered for the nurse to call 911 and to send the resident to the hospital. Further, the MD stated that the resident became hypoxic and this led to the resident's hospital transfer. However, the MD said that he was not sure why she became hypoxic and all he could remembered was that he got a call from a nurse really early in the morning. The MD stated that CPR was initiated but the resident was not resuscitated. Further, the MD said that he was the one who signed off on the resident's cause of death which was acute hypoxic respiratory failure. An interview was conducted on [DATE] at 2:16 p.m. with the DON (staff #31) who stated that the expectation was for staff to notify the doctor and the family when a change of condition occurs or if there was something out of the resident's baseline. The DON stated that it was neglect if the staff failed to provide a service that a resident medically need. Regarding resident #5, the DON stated that she was not familiar with resident #5 but she knows the resident was admitted to the facility with MS flare up. The DON said that it was a concern that resident #5's O2 sat was low; and that, the nurse (staff #117) should have called the doctor, administered oxygen to the resident as an emergency, re-checked the O2 sat and started treatment. The DON also said that the resident was transferred to the hospital because the resident coded and vomited while the paramedics were in the facility. Further, the DON stated that the facility investigation concluded that oxygen was not initiated or administered to resident #5. Regarding the alleged LPN (staff #117), the DON stated that the only complaint she had heard was that the LPN (staff #117) worked slow due to her being older. The DON said that the LPN (staff #117) did not have a history or pattern of behavior against the LPN regarding resident care. Further, the DON stated that the LPN (staff #117) after the incident, the LPN never came back for work and had since resigned. The facility policy on Change of Resident Condition with an effective date of [DATE] revealed that in order to minimize unplanned hospital transfers and ensure that residents do not experience preventable declines in condition, the facility will use a consistent approach in identifying, managing and communicating changes in resident condition. It also included that the nurse will assess the resident's symptoms and physical function and document detailed descriptions of observations and findings; and that, the physician should be notified of all changes in a resident's condition. Furthermore, the policy included that the nurse will document in the nurse's notes, the date, time and parties notified. Documentation will include enough information to describe the situation and indicate how it is being handled. Condition changes that may require physician intervention included tachypnea and dyspnea with a pulse oximetry of lower than 90%. The facility's undated policy on Documentation included that it was their policy that nursing personnel complete documentation requirements each shift and as soon as possible after a resident event. It also included that LPN documentation requirements included complete documentation for any change in resident condition, interventions and resident response; and, to continue documentation as often as the condition warrants and at minimum of every shift times 72 hours or until condition stabilizes or resolves. The facility's undated guide on Oxygen Administration included a purpose to deliver oxygen to the resident when insufficient oxygen is being carried by the blood to the tissues; and that, oxygen administration is the basic responsibility of a licensed nurse. Assessment guidelines may include but are not limited to respiratory distress and pulse oximetry and to document the condition of the resident before procedure and effectiveness of oxygen therapy, vital signs before oxygen was started and periodically after initiation of therapy. Review of a facility policy titled Abuse Prevention Policy & Procedure revised [DATE] revealed that it is the responsibility of all employees to immediately report any suspected or alleged violation of abuse, neglect, injuries of unknown origin, and misappropriation of resident property. Additionally, the policy noted that the facility takes appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown origin, exploitation, and misappropriation of resident property. The policy also defined neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure that one resident (#7) was free from staff physical abuse. The deficient practice could result in further incidents of staff to resident abuse. Findings Include: Resident #7 was admitted on [DATE] with diagnoses of malnutrition, bipolar disorder, depression, anxiety, chronic obstructive uropathy, and dorsalgia. A behavioral care plan with a start date of July 13, 2023 revealed the resident self-directed her own care, routines and decisions with potential for harm to self and others and that the resident confabulated and deflected conversation when confronted regarding behaviors when boundaries were discussed. The goal was that the resident would not be harmed. Interventions included to discuss safety reasons for rules and boundaries with resident as needed. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident had intact cognition. A care plan dated October 24, 2022 included resident exhibited repetitive anxious behaviors, was impatient with staff and demanded to have her requests attended to immediately. Interventions included to assist with adjustment by allowing the resident time to express feelings, listen to concerns, provide emotional support, attempt to resolve concerns in a timely manner, use calm and consistent approach, and calmly explain to resident behavior boundaries and reasons for staff actions. The health status note dated August 7, 2023 revealed that the resident came to the nursing station and wanted her medication. Per the documentation, the staff gave the medication but the resident wanted her PRN (as needed) medications too; and that, the staff told the resident that the PRN medications were not due until the next shift. The documentation included that the resident told staff that she would keep her medications; and, the staff had to get the medications from the resident's hands and another staff had to block the resident's hand so the resident would not hit the staff. Further, the note revealed that the resident then grabbed the other staff's forearm and cause fingernail indentation on the other staff's forearm; and that, the resident ran after the other staff to hit her more but the other staff ran to the activity room to avoid further confrontation. The facility Reportable Event Record revealed that on the evening of August 7, 2023, resident #7 was in the hallway and was approached by the nurse with two medications in a cup. Resident #7 then asked about her other meds and the licensed practical nurse (LPN/staff #1) told the resident that it was too early for the other medications. Per the report, the LPN (staff #1) asked the cup back from the resident who replied no. The report further included that two LPNs (staffs #1 and #2) then grabbed the resident's hands and forcibly removed the medication cup from her possession. The facility investigation dated August 8, 2023 included that resident #7 reported that the night nurses (staffs #1 and #2) grabbed both her hands and removed medications that they already had given to her from her hands. Per the report, the resident informed the local police officer that she had a small red area on her left hand and another discolored area on her left wrist from the incident; and that, her back hurts from the twisting motion of her torso while the 2 nurses (staff #1 and #2) were removing the medications from her hands. The facility concluded that the resident was improperly touched by the nurse (staff #1); and had substantiated the allegation. A review of the personnel file for the alleged LPN (staff #1) revealed the LPN had documentation of having discourteous conduct towards a resident which was heard by a staff in October 12, 2022. Further, the personnel file revealed that on April 28, 2023, the LPN received and in-service training on how to handle situations and the proper responses. The termination record for the LPN (staff #1) signed and dated August 10, 2023 revealed that the LPN (staff #1) was discharged for violation of known rule or policy and mistreatment of patients or residents. An attempt to conduct a phone interview with both LPNs (staffs #1 and #2) was made on August 10, 2023 but was unsuccessful. Both LPNs did not return the call. An interview was conducted on August 10, at 1:40 p.m. with the social services director (SSD/staff #89) who stated that the resident #7 identified the staff members by name; and, the LPN (staff #1) reported that the LPN refused to give resident #7 her PRN medications because they were not due yet. The SSD said that it was a poor decision on the LPN's part; and that, the LPN should have never laid her hands on resident #7. In an interview conducted with the administrator (staff #55) on August 10 at 4:15 p.m., the administrator stated that the camera footage verified the incident and showed that one nurse grabbed the hand of resident #7 and forced the medications in the cup out of her hand while the second nurse distracted the resident. The administrator stated that the LPN (staff #1) had been working in the facility for a long time and had multiple disciplinary issues while employed at the facility. Review of the facility's policy on Abuse Prevention Policy and Procedure revised September of 2022 revealed that it is their policy to take appropriate steps to prevent the occurrence of abuse. The policy also revealed abuse must be willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

Based on clinical record reviews, staff and resident interviews, facility documentation, review of policies, procedures, and police investigation report, the facility failed to ensure two residents (#1 and #2) were free from staff sexual abuse. The deficient practice could result in abuse of other residents at the facility. Findings include: Review of a facility document titled, Associate Disciplinary Action dated January 24, 2020 revealed that a resident complained that staff #100 made her feel uncomfortable when he hugged and kissed her on the cheek. A similar document dated February 3, 2020 revealed staff #100 had been given disciplinary action; and that, staff #100 needed to learn people's personal space and not hug, kiss, and touch patients and their family members even to show care. Further, the document included that if there was any other incident in the future it will lead to termination. -Regarding incident between resident #1 and staff #100 -Resident #1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of post-traumatic stress disorder, and unspecified complication of internal orthopedic prosthetic device, implant, and graft, sequela. The MDS (Minimum Data Set) assessment dated [DATE] included a BIMS (Brief Interview of Mental Status) score of 15, indicating the resident was cognitively intact. The assessment included the resident required one-person physical assist for toilet use, dressing, personal hygiene; and, was always incontinent of bowel and bladder. A progress note dated March 8, 2023 revealed resident was oriented x 3, thought process was appropriate, and memory was normal. A progress note dated April 16, 2023 revealed the resident spoke with staff about an incident with CNA (certified nursing assistant/staff #100); and that, it made her feel disgusted that his inappropriateness went on for one to two months. The note also included that the resident felt better that actions were being taken. A facility investigation report dated April 20, 2023 revealed staff #100 admitted to putting his hands on her shoulders and kissing her while his mask was on. A termination record dated April 20, 2023 revealed staff #100 was terminated due to violation of known rule or policy and his last day worked was April 16, 2023. Review of a police report dated April 21, 2023 revealed a written statement from staff #100 who admitted to kissing resident #1 on the lips with his mask on; and, playing and pinching her vaginal area because he was bored. The report also revealed that staff #100 admitted to cleaning resident #1 and should have finished by placing a new adult diaper but first played with vaginal area prior to putting the diaper back on. The documentation included that staff #100 was arrested for committing sexual abuse by intentionally or knowingly engaging in sexual contact with resident #1. An interview with resident #1 was conducted on July 12, 2023 at 2:35 p.m. resident #1 stated that on the first incident, the AP (alleged perpetrator/staff #100) slid his hand up to her vaginal area without using gloves while cleaning her with the other hand. She alleged that the AP began to play with her vulva for about 2-3 minutes. Resident #1 stated that during the third incident, the AP told her that she had been a bad girl and he was going to punish her; then, the AP went to her bed and put both arms on her shoulders and kissed her on the lips. Resident #1 stated that after this incident, she reported the AP and the incidents to staff. A phone interview was conducted on July 13, 2023 with the AP (staff #100) who stated he did kiss resident #1on the cheeks and not the lips. The AP stated that he and resident #1 had been joking and laughing which gave him confidence to jokingly say he was going to punish her and then grabbed her face to kiss kiss kiss her cheeks. Staff #100 also stated that in 2020 he received verbal warning for kissing a resident on the cheek. Staff #100 stated he did not believe his actions were bad because they were taken the wrong way. Further, the AP denied touching resident #1 inappropriately on her vagina. -Regarding incident between resident #2 and staff #100 -Resident #2 was admitted on [DATE] with diagnoses of hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, and major depressive disorder. The care plan initiated on January 29, 2021 revealed the resident was incontinent with bowel. Intervention included checking and toileting when in room giving care and as needed, and provide good incontinent care. The MDS assessment dated [DATE] included a BIMS score of 15, indicating the resident was cognitively intact. The assessment included the resident required one-person physical assist for toilet use; and, was always incontinent of bowel. A progress note dated June 20, 2023 revealed resident was awake and alert x3 with no altered level of consciousness, thought process was appropriate, thought content was future oriented, memory was normal, judgement was fair and intellectual functioning was good. The progress note dated July 9, 2023 revealed resident reported to social services director that a male CNA who no longer worked at the facility was inappropriate with her. An interview was conducted on July 12, 2023 at approximately 11:15 a.m. with the administrator (staff #3) who stated that during their investigation over the weekend of an unrelated incident, resident #2 made an allegation of abuse against CNA (#100) around the same time or before the allegation made by resident #1. An interview was conducted on July 12, 2023 at 2:51 p.m. with resident #2 who stated she had issues moving her bowels and one day (date unknown) she attempted to pass stool while in bed but with difficulty. The resident said she called for assistance and staff #100 went to her room. She stated that staff #100 asked her to turn to her left side, facing the wall, away from him and told her he was able to see the stool coming out of her anus. Resident #2 stated that staff #100 then put his finger in her rectum and inserted another finger in her vagina which caused her pain. Resident #2 stated that was when she asked for another staff to assist her. However, she never reported the incident until she spoke with her sister who advised her to report the incident. A phone interview was conducted on July 13, 2023 at 8:45 a.m. with the AP (staff #100) who recalled an incident where he assisted resident #2 when she was having painful constipation. The AP said that he described saw the resident's stool stuck in the opening; and he did not want resident #2 to be in pain so he dug a little bit of stool from the anus with his finger and with another finger in the vagina, hook down to help push the stool out. The AP said that he put a finger inside the resident's vagina to help get the stool out. After making this statement, the AP then asked if he can get in trouble for that. The AP then retracted his statement and said that he did not put his finger inside resident #2's vagina. The AP then said he used his pointer finger inside the anus, about one inch, because the stool was coming out. An interview was conducted on July 13, 2023 at 10:45 a.m. with a CNA (staff #50) who stated CNAs are not allowed to insert their finger in the anus to dig stool out because it is connected with the heart and can cause a heart attack. She stated that if a resident was constipated, they were to report it to the nurse. In an interview with a licensed practical nurse (LPN, staff #75) conducted on July 13, 2023 at 10:59 a.m., the LPN stated digital disimpaction was within the scope of an LPN but not a CNAs. The LPN also said that digital disimpaction required a physician order; and that, the potential risk associated with digital disimpaction was tear with finger nails. During an interview with the director of nursing (DON/staff #30) conducted on July 13, 2023 at 11:20 a.m., the DON stated that staff were not allowed to insert their finger in residents' anus to assist in moving their bowels because they can cause vagal stimulation. The DON said that it was considered abuse if fingers are inserted in the vagina. The DON also stated digital disimpaction required a physician order and it was out of the scope of a CNA because it can cause bleeding and inserting a finger in the vagina was not part of the process. Review of facility's policy on resident rights revealed residents have the right to dignity, respect, and freedom to include freedom from abuse. The facility policy on Abuse Prevention Policy and Procedure revealed it is the facility's responsibility of all employees to immediately report any suspected or alleged violation of abuse, neglect, injuries of unknown source and/or misappropriation of resident property. It is their policy to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown source, exploitation and misappropriation.

Based on observations, staff interviews, and review of policy, the facility failed to ensure that an account of all controlled drugs was maintained and reconciled. The deficient practice could result in misappropriation of residents' medications. Findings include: During an observation conducted on June 14, 2023 at 10:53 AM with a Licensed Practical Nurse (LPN/staff #6), of the Station B medication cart. Review of the Controlled Substance Card Inventory form revealed that two cards had been added to the cart, but did not have a two-nurse reconciliation. She stated that both nurses would initial the form that the reconciliation had been completed. During an observation conducted on June 14, 2023 at 11:07 AM with a Licensed Practical Nurse (LPN/staff #33), of the Station C medication cart. Review of the Controlled Drugs-Count Record dated June 2023, revealed 3 shifts that did not have a two-nurse reconciliation. The LPN stated that she forgot to sign off on the reconciliation form this morning, and the expectation is that it is initialed by both nurses, the on-going and out-going nurses at the time of the reconciliation. She further reviewed the form and stated that there was one nurse initial on June 7, 2023 on the day shift, and no reconciliation completed on the evening shift. She also stated that this did not meet the facility expectation regarding controlled medication reconciliation. During an observation conducted on June 14, 2023 at 11:15 AM with a Licensed Practical Nurse (LPN/staff #15), of the medication cart on Station A, it was found the that Controlled Drugs-Count Record was missing two-person reconciliation initials. The LPN stated that the facility policy is to have a two-nurse initial for reconciliation of controlled medications. She reviewed the Controlled Drugs-Count Record and stated that there are no initials of a completed reconciliation on the evening and night shifts on June 13, 2023. She stated that this did not meet the facility policy. Further review of the Station A Controlled Substance Card Inventory form revealed three occasions that there were not two-nurses reconciliation the inventory. LPN (staff #15) stated that this did not meet the facility policy and that there should be two nurses signing in/out all controlled medications. An interview was conducted on June 14, 2023 at 12:18 PM with the Director of Nursing (ADON/staff #100), who stated that the expectation is to have a two-nurse initial on the Controlled Substance Card Inventory form any time a medication is added or removed. She further stated that the facility expectation is to have a two-nurse reconciliation every shift the on-going/off-going nurses of the controlled substances on the medication carts, that included both initialing the Controlled Drugs-Count Record. She reviewed the Controlled rugs-count Records for stations A, and C and stated that there were multiple shifts that there were not initials from 2 nurses completing the reconciliation. She also reviewed the Controlled Substance Card Inventory Forms for all 3 stations and stated that there were multiple instances that there were not two-nurses initialing that the reconciliation had been completed for outgoing medication cards. Review of the facility policy titled, Medication Management, revealed that narcotics shall be kept in a separate locked drawer inside the medication cart and shall be accounted for at each shift change. Disposal of controlled substances includes that the disposition is documented on the Controlled Substance sign-out sheet with information that included the signatures of witnesses. Review of the facility policy, Controlled Substances, revealed that accurate accountability of the inventory of all controlled drugs is maintained at all times.

Based on observation, clinical record review, resident and staff interviews, and policy and procedures, the facility failed to ensure that one sampled resident (#65) was assessed to determine clinical appropriateness to self-administer medications. The deficient practice could result in medications not being taken as ordered and unsafe storage of medications. Findings include: Resident #65 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician's Order dated April 26, 2022 included [MEDICATION(S)] (opioid analgesic) HCl Tablet 50 MG (milligrams). Give 2 tablets by mouth every 4 hours as needed for PAIN SCALE 1-3. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 15, which indicated no cognitive impairment. An observation was conducted in the resident's room on May 31, 2022 at 9:04 AM. A medication cup was observed with two white pills marked AN627. An interview was conducted immediately after this observation with this resident, who stated that the pills are pain pills. The resident said that no one has spoken to him about self-administration of pain medications. A review of this resident's clinical record did not reveal an assessment of this resident's ability to administer his own medication. An interview was conducted on June 2, 2022 at 9:29 AM with a Licensed Practical Nurse (LPN/staff #119) who said when she is administering medication for pain she would watch the resident take the medication and that it is not ok to leave a medication in a room because someone might take it or the resident might not take it. The LPN said that this resident takes medication whole easily, asks for pain medication, and is alert and oriented. An interview was conducted on June 2, 2022 at 1:27 PM with this LPN (staff #119) who said that this resident cannot administer his own medication. She said that staff should not leave medication on his bedside table. Another interview was conducted on June 2, 2022 at 2:06 PM with this LPN (staff #119) who said that she went into this resident's room and asked if medication was left in the room. The LPN stated that the resident laughed and said that you cannot believe everything you hear. She said that she was concerned because she had watched him take all of his medication without an issue. The LPN stated the resident just downed the whole cup of medications with no problem. She said that she asked if she could look in the resident's drawer and there was a cup of pills in there. The LPN said that she had reported it to the Director of Nursing (DON). An interview was conducted on June 3, 2022 at 10:28 AM with the DON (staff #8) who stated that staff should ensure that the medication is taken before they leave the resident's room. She said that if the resident does not want to take the medication, staff have to take the medication back, document it, and notify the physician. The DON said that it is not her expectation that staff would leave medication in the resident's room. Review of the facility policy Administering Medications revised April 2019 revealed medications are administered in a safe and timely manner, and as prescribed. The policy also revealed residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. A facility policy regarding Medication Administration revealed staff shall not leave medication unattended. Residents choosing to self-administer their own medications may do so only after the completion of the facility's Medication Self-administration Assessment and a written physician's order for self-administration. Medications stored by a resident in the resident's room shall be kept in a locked container or cabinet in the resident's room.

Based on resident, resident family, and staff interviews, clinical record review, the Centers for Medicare & Medicaid Services (CMS), and policies and procedures, the facility failed to ensure one sampled resident (#44) had the right to receive visitors of their choosing and at the time of their choosing. The deficient practice could result in residents' rights regarding visitation not being honored. Findings include: Resident #44 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Care Plan dated July 1, 2021 revealed the resident has psychosocial needs as evidenced by restricted visitation due to COVID-19 mandatory measures. Interventions included assisting the resident with alternate ways to communicate with family/loved ones and providing alternate activities as available such as courtyard fresh air as possible. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 14, which indicated no cognitive impairment. An interview was conducted on May 31, 2022 at 12:30 PM with the resident who said that the facility has not let his spouse visit in a week. The resident said that they were both fully vaccinated and he misses her very much. An interview was conducted on June 1, 2022 at 12:01 PM with this resident's spouse who said that she has been calling every morning and speaking with dietary (staff #93). This spouse said that she spoke to staff #93 this morning who said it could be a long time before they allow visitation, she does not know when. She said that she does everything the facility asks of her. She said that the resident said that he feels like a prisoner of war. The spouse said that she had selected this facility because it is close and convenient for visitation. Another interview was conducted on June 1, 2022 at 12:57 PM with this resident's spouse who said that the last time she saw the resident was last Thursday (May 26, 2022). She stated on May 29, 2022 the facility was on restrictions. She said it was the receptionist who was at the front counter who told her she could not visit, it was on a Sunday. This spouse said that staff #93 reaches out to people to give them a daily update, and the update said that the facility was suspending visitation. An interview was conducted on June 1, 2022 at 1:41 PM with the Infection Preventionist (IP/staff #102) who said that right now visitation is on hold due to recommendations from the county for the outbreak. She said that they argued that there was a CMS QSO memo that required visitation, but the county stated that the facility needed to close down visitation and admissions because they have multiple cases of COVID. She said that the outbreak happened just this Saturday (May 28, 2022) and that they informed families by making calls and leaving messages. She said that the calls were placed by staff #93 or social services (staff #95). The IP stated they do have iPads and they can do window visitations. An interview was conducted on June 2, 2022 at 1:32 PM with a Restorative Nursing Assistant (RNA/staff #112) who said that some of the residents want to go outside and some of the families are asking when they are going to have visitation again. He said that this resident's spouse is here every day bringing breakfast and things. He said that it is harder without the spouse being here because this resident is on the call light a lot. An interview was conducted on June 3, 2022 at 9:09 AM with a Licensed Practical Nurse (LPN/staff #47) who said that when she started the residents had visitors and family in the room. She said that recently when she engages with this resident, he talks about his wife and grandson. She said that she thinks the reason the resident has been talking more about his family is because he is not getting to visit them. The LPN said that sometimes the resident puts the call light on so he can talk to someone about his wife. She stated that he is very heart-achy about his wife, and sometimes calls out about his wife. The LPN said that pressing the call light and calling out translates to the resident needing his family. Review of the CMS QSO-20-39-NH Nursing Home Visitation - COVID-19 revised March 10, 2022 revealed that while CMS guidance has focused on protecting nursing home residents from COVID-19, they recognize that physical separation from family and other loved ones has taken a physical and emotional toll on residents and their loved ones. The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident. Facilities must allow indoor visitation at all times and for all residents as permitted under the regulations. Facilities can no longer limit the frequency and length of visits for residents, the number of visitors, or require advance scheduling of visits. Visits should be conducted in a manner that adheres to the core principles of COVID-19 infection prevention and does not increase risk to other residents. While it is safer for visitors not to enter the facility during an outbreak investigation, visitors must still be allowed in the facility. Visitors should be made aware of the potential risk of visiting during an outbreak investigation and adhere to the core principles of infection prevention. If residents or their representative would like to have a visit during an outbreak investigation, they should wear face coverings or masks during visits, regardless of vaccination status, and visits should ideally occur in the resident's room. Facilities may contact their local health authorities for guidance or direction on how to structure their visitation to reduce the risk of COVID-19 transmission during an outbreak investigation. A facility policy titled Resident Self Determination and Participation revealed that the facility respects and promotes the right of each resident to exercise his or her autonomy regarding what the resident considers to be important facets of his or her life. A facility policy titled Visitation Policy revealed, While (this facility) has focused on protecting nursing home residents from COVID-19, we recognize that physical separation from family and other loved ones has taken a physical and emotional toll on residents and their loved ones. Residents may feel socially isolated, leading to increased risk for depression, anxiety, and expressions of distress. Residents living with cognitive impairment or other disabilities may find visitor restrictions and other ongoing changes related to COVID-19 confusing or upsetting. The facility understands that nursing home residents derive value from the physical, emotional, and spiritual support they receive through visitation from family and friends. The facility will follow all guidance from the County, State, and Federal Health Departments.

Based on observation, clinical record review, staff interviews, and policy reviews, the facility failed to ensure medication was administered in accordance with professional standards for one resident (#95). The deficient practice could result in residents not receiving the total dose of ordered medication. Findings include: Resident #95 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the admission MDS assessment dated [DATE] revealed a BIMS score of 08, indicating the resident had moderate impaired cognition. During a medication administration observation conducted on 06/02/22 in the [MEDICATION(S)] 7:58 AM with a Registered Nurse (RN/staff #30), the RN was observed to prepare resident #95's medication which included a [MEDICATION(S)] drink for bowel care and a [MEDICATION(S)]-salmeterol inhaler for breathing. The resident was presented with a cup of [MEDICATION(S)] and drank approximately a quarter of the medication. The inhaler was then administered to the resident. Following the administration of the inhaler, staff #30 educated the resident to swish with fluid and spit into a cup. Resident #95 reached for the cup of [MEDICATION(S)] in front of her. There was a cup of water a bit off to the right of the [MEDICATION(S)] cup. Staff #30 handed resident #95 the cup of [MEDICATION(S)] and the resident sucked with the straw a mouthful of [MEDICATION(S)] and spit into an empty cup offered by staff #30. Staff #30 left the cup of [MEDICATION(S)] with resident #95 and educated the resident to drink the rest of the medication while she was gone. An interview was conducted on 06/02/22 at 10:20 AM with an LPN (staff #127). The LPN stated that when administering oral liquid medication to a resident, providing a straw and following the medicine with water helps a resident to increase intake. Staff #127 stated that when swishing and spitting is required following the administration of a medication, the resident should be provided with a glass of water, a spit cup, and a tissue. The LPN stated that liquid medications should not be used to swish and spit with. The LPN stated that if the resident does use an oral liquid medication to swish and spit, then the resident should be educated on not using the oral medication for swishing and spitting. She stated if the resident does not finish the medication, the quantity of medication should be charted and the physician informed. The LPN stated medication should not be left in the room with the resident. She stated any leftover medication should be taken back with the nurse to be charted on and disposed of properly. An interview was conducted on 06/02/22 at 12:03 PM with the Director of Nursing (DON/staff #8). The DON stated that bowel care medication should never be used to swish and spit following medication administration. Staff #8 stated medication should not be left at the resident's bedside. The DON indicated that this did not meet her expectations. Review of the facility policy Administering Medications revised April 2019 revealed medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. A facility policy titled, Medication Management, revealed that staff shall not leave medication unattended. A medication error or a resident's unexpected reaction to a medication shall be documented in the resident's medical record and immediately reported to the Director of Nursing (DON) and the medical practitioner who ordered the medication. A Medication Error/Omission Report shall be completed and sent to the Director of Nursing for Quality Management review.

Based on observations, clinical record reviews, resident and staff interviews, and policy reviews, the facility failed to ensure that one resident (#76) had orders for oxygen, and one resident (#404) had orders for use of a [CONDITION(S)] (continuous positive airway pressure) unit. The sample size was 2 residents. The deficient practice could result in residents receiving respiratory care without orders. Findings include: -Resident #404 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation and interview with the resident were conducted on May 31, 2022 at 9:43 AM. A [CONDITION(S)] unit was observed sitting on the bedside table, with the tubing attached. During the interview the resident stated that she had not been reminded by staff to use the [CONDITION(S)] the last two nights. The resident further stated that she has not yet cleaned the unit, but would need assistance. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The assessment also revealed the resident used [CONDITION(S)]/[CONDITION(S)] (bilevel positive airway pressure) while a resident. Review of the Medication Administration Records (MARs) dated May 2022 and June 2022, revealed no documentation that a [CONDITION(S)] use was initiated. Review of the Treatment Administration Records (TAR) dated May 2022 and June 2022, revealed no documentation that use of a [CONDITION(S)] unit was initiated. Review of the physician's initial history and physical dated May 30, 2022, included obstructive sleep apnea, continue [CONDITION(S)]. Review of Nurse practitioner's (NP) progress notes dated May 31, 2022 and June 1, 2022, included documentation of obstructive sleep apnea, continue [CONDITION(S)]. However, review of physician's orders revealed no oxygen or [CONDITION(S)] orders. Review of the care plan initiated on May 28, 2022, revealed no goals or interventions related to oxygen or [CONDITION(S)] use. Further review of the care plan on June 3, 2022, revealed that a care plan for the use of [CONDITION(S)] was initiated on June 3, 2022. An interview was conducted on June 2, 2022 at 2:55 PM with a Registered Nurse (RN/staff #128), who stated they would need a physician's order for use of oxygen, to change the tubing, and for use/care of a [CONDITION(S)] unit. She also stated that it is the facility policy to have a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She further stated that documentation of use would be on the TAR. The RN stated that if a physician's order is not written, the information is not placed on the MAR or TAR for nursing staff to document use, monitoring and care. She also stated that the risk of not having a physician's order could result in an infection control issue, if the tubing is not cleaned. Another interview was conducted on June 3, 2022 at 8:10 AM with the resident, who stated that staff have not been assisting her with placing on the [CONDITION(S)] at night, but she is getting better at remembering. She also stated that the tubing had not been cleaned since she had been in the facility. An interview was conducted on June 3, 2022 at 8:17 AM with a Certified Nursing Assistant (CNA/staff #50), who stated that she had the last week off, but she assisted with the resident's care last week. She also stated that she had not cleaned the resident's [CONDITION(S)] tubing. She further stated that the facility policy is to clean [CONDITION(S)] tubing and cannula with warm water daily. She also stated that they do not document that this is completed but tell the nurses verbally. An interview was conducted on June 3, 2022 at 8:30 AM with a RN (staff #88), who stated that the facility policy for use of any type of oxygen, including [CONDITION(S)], is to obtain a physician order. She also stated that use/care would be documented in the MAR. She further stated that they would not need an order to clean [CONDITION(S)] tubing, but the facility policy is to clean daily with soap and water, and document it in the CNA charting. She reviewed the physician's orders, and stated that there were no orders for use of a [CONDITION(S)] unit for this resident. She also stated that she did observe a [CONDITION(S)] unit in the resident's room, at this time. The RN also stated that this does not follow facility policy, and the risk could include that the physician is not aware of any respiratory issues. She also stated that she will notify the physician today for [CONDITION(S)] orders. An observation and interview were conducted on June 3, 2022 at 8:47 AM with the Director of Nursing (DON/staff #8), who entered the resident's room and stated that she had observed the [CONDITION(S)] unit in the resident's room and that nursing staff should have requested an order from the physician prior to it being brought to their attention. The DON stated that the facility policy is to obtain a physician's order for oxygen/[CONDITION(S)], especially coming from the hospital. She reviewed the medical record and stated that there were no physician's orders for [CONDITION(S)] use. She also stated that the tubing should be cleaned weekly, and it would be included in the [CONDITION(S)] order. She further stated that cleaning of a [CONDITION(S)] unit would be scheduled on the TAR, usually on Sunday night. She stated that if no documentation was on the TAR, then it was not done. She stated that the [CONDITION(S)] equipment was used, and not cleaned, and the risk could be infection. The DON further reviewed the medical record and stated that there would not be any progress notes of cleaning because it would be documented on the TAR. She reviewed the progress notes and stated that there were no notes related to cleaning the [CONDITION(S)] tubing and no documentation on the TAR. The DON stated that the risk of using a [CONDITION(S)] unit without a physician's order could include the risk that nurses would not know that the resident needed it for a diagnosed condition. An interview was conducted on June 3, 2022 at 9:45 AM with the Infection Preventionist (IP/staff #102), who stated that she had been made aware of the [CONDITION(S)] use for resident #404, and stated that her greatest concern is the infection control issues, that the tubing had not been cleaned. Another interview was conducted on June 3, 2022 at 10:22 AM with the DON (staff #8), who stated that she had further reviewed the progress notes and the NP (nurse practitioner) was aware of the [CONDITION(S)] at the time of admission, but did not write the order, and that this did not meet the facility policy or expectations. She also stated that the NP should have written an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility policy titled, Physician Orders, included the facility must have physician orders for the resident's immediate care. Medication and treatment orders shall be transcribed directly from the medical practitioner's order to the MAR and/or TAR. Review of the facility policy titled, Oxygen Administration, revealed to check physician's order for method of administration, and document the method of delivery as ordered. Review of the facility policy titled, [CONDITION(S)]/[CONDITION(S)] Equipment Cleaning & Disinfecting schedule and instructions, included the cleaning and disinfection schedule should be followed diligently. Daily cleaning removes dirt and oils that may harbor germs, disinfection kills germs that may lead to infection. -Resident #76 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A skilled nursing note dated 5/2/22 revealed that the resident was receiving oxygen via nasal cannula and the resident's oxygen saturation at that time was 95%. A review of the admission Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental status score of 15, indicating the resident was cognitively intact. The assessment also revealed the resident received oxygen therapy while a resident at the facility. An observation was conducted on 05/31/2022 at 12:06 PM in resident #76's room. Resident #76 was observed to be receiving oxygen at 2 Liters per minute via nasal cannula via concentrator. However, a review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted on 06/03/22 at 9:03 AM with a Licensed Practical Nurse (LPN/staff #63). Staff #63 indicated that oxygen can only be administered to a resident with an order. The LPN stated oxygen levels must be monitored and the resident's oxygen delivering device must be maintained. The LPN also stated that oxygen may only be administered without an order during an emergency. An interview was conducted on 06/03/2022 at 10:28 AM with the DON (staff #8). Staff #8 stated that a resident receiving oxygen without an order for [MEDICAL RECORD OR PHYSICIAN ORDER] A review of a facility policy titled, Oxygen Administration, revealed that a physician's order must be checked for flow and method of administration of oxygen.

Based on observation, staff interview, and policy review, the facility failed to ensure medications were secured and not left unattended on top of the medication cart. The deficient practice could result in misappropriation of medications. Findings include: During a medication administration observation conducted on 06/02/22 in the [MEDICATION(S)] 7:58 AM with a Registered Nurse (RN/staff #30), the RN was observed to prepare the medications for a resident, which included aspirin, [MEDICATION(S)] (antidepressant), [MEDICATION(S)] sodium (stool softener), and [MEDICATION(S)] (medication for dementia). Staff #30 then realized she needed another medication that was not in the medication cart, so she locked the medication cart but left the cup of prepared medications on top of the locked medication cart. Staff #30 then went down the hall to another medication cart. The RN's back was to the unattended cart, which was facing the resident's room. An interview was conducted on 06/02/22 at 12:03 PM with the Director of Nursing (DON/staff #8). The DON stated medication should not be left on top of a medication cart unattended. The DON indicated that the situation described during medication administration did not meet her expectations. Review of the facility policy Administering Medications revised April 2019 revealed that during administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by.

Based on facility documents and staff interviews, the facility failed to ensure that the Daily Staff Postings for nursing staff was accurate for actual hours worked by licensed and unlicensed direct care nursing staff. The deficient practice could result in residents and visitors not being informed of accurate and current staffing information. Findings include: A review of 7 randomly chosen days of staff postings compared with the actual hours worked by staff on those days revealed that none of the staff postings matched the actual hours worked by staff. -May 1, 2022 staff posting indicated 32 Registered Nurse (RN) hours worked, 96 Licensed Practical Nurse (LPN) hours worked, and 177 Certified Nursing Assistant (CNA)/Restorative Nursing Assistant (RNA) hours worked. Review of the total hours worked revealed 29.17 RN hours worked, 76.31 LPN hours worked, and 169.29 CNA hours worked. -May 5, 2022 staff posting indicated 24 RN hours worked, 92 LPN hours worked, and 237.5 CNA/RNA hours worked. Review of the total hours worked revealed 38.67 RN hours worked, 69.96 LPN hours worked, and 218.64 CNA hours worked. -May 11, 2022 staff posting indicated 40 RN hours worked, 72 LPN hours worked, and 181 CNA/RNA hours worked. Review of the total hours worked revealed 60.39 RN hours worked, 55.68 LPN hours worked, and 173.37 CNA hours worked. -May 14, 2022 staff posting indicated 32 RN hours worked, 102 LPN hours worked, and 184.5 CNA/RNA hours worked. Review of the total hours worked revealed 39.86 RN hours worked, 83.08 LPN hours worked, and 186.69 CNA hours worked. -May 19, 2022 staff posting indicated 24 RN hours worked, 84 LPN hours worked, and 189 CNA/RNA hours worked. Review of the total hours worked revealed 40.88 RN hours worked, 66.87 LPN hours worked, and 191.6 CNA hours worked. -May 24, 2022 staff posting indicated 36 RN hours worked, 84 LPN hours worked, and 181 CNA/RNA hours worked. Review of the total hours worked revealed 44.69 RN hours worked, 65.48 LPN hours worked, and 160.91 CNA hours worked. -May 31, 2022 staff posting indicated 36 RN hours worked, 72 LPN hours worked, and 171 CNA/RNA hours worked. Review of the total hours worked revealed 45.29 RN hours worked, 86.33 LPN hours worked, and 157.53 CNA hours worked. An interview was conducted on June 2, 2022 at 11:36 a.m. with the Staffing Coordinator (staff #114). She reviewed the staff posting and actual hours worked for May 1, 2022. She stated the staff posting form documented hours did not match the actual hours worked and that the hours should match. Staff #114 stated that the staff posting should reflect the actual number of staff working and hours worked. An interview was conducted on June 2, 2022 at 12:54 p.m. with the Administrator (staff #11). He acknowledged that the staff posting should be accurate for the actual hours worked.

Based on observations, staff interviews, facility documentation, review of the Centers for Disease Control (CDC) recommendations and policies and procedures, the facility failed to ensure infection control standards were followed, by failing to ensure that screenings of staff for COVID-19 were thoroughly completed. The deficient practice could result in the spread of infection, including COVID-19 to residents and staff. Findings include: Upon entrance into the facility on [DATE] at 8:30 a.m., a staff member who was sitting at the reception desk, directed the surveyors to use hand sanitizer, and individually asked the surveyors to complete the screening questions on the form and then took the surveyors temperatures. She then initialed the form by the documented temperature. Two staff members were observed to enter the facility, find the screening book for their department, and complete the questions. The receptionist took the two staff temperatures which each staff documented on the form. The receptionist then initialed the form for that day. Review of the Employee Surveillance Tool form for Coronavirus Screening (for associates/staff) dated November 23, 2020 to December 3, 2020 revealed the following: -On December 2, 2020, a staff member's temperature was not recorded, the section was left blank. -In the section regarding the 10 screening questions for COVID-19 that required Y/N (yes/no) answers, there were 7 instances where this section was left blank. An interview was conducted on December 3, 2020 at 10:00 a.m. with the receptionist (staff # 47). She stated that if the staff COVID-19 screening form is left blank or questions are incomplete, she will let the nurse know. She stated that she tries to review the screening forms for blanks. Staff #47 also stated that she did not know how often the administration staff reviews the screening forms. After reviewing the forms that had incomplete documentation, staff #47 stated that those areas should be filled in. During an interview with the Administrator (staff #125) conducted on December 3, 2020 at 12:15 p.m., staff #125 stated that before staff start their shift, staff have to stop at the front desk to be screened for COVID-19 which includes asking the COVID-19 screening questions and having their temperature taken. The Administrator also stated that the receptionist has been checking the screening forms and will notify the Infection Preventionist (IP/staff #16) if staff are positive for COVID-19 symptoms. An interview was conducted with the IP (staff #16) on December 3, 2020 at 12:17 p.m., who stated that it has been a long time since she reviewed the COVID-19 screening forms. Staff #16 further stated that she should be reviewing the screening forms, but has not reviewed them lately. The IP stated the expectation is that the receptionist would review the COVID-19 screening forms for completion. She stated that if a form is not complete, the receptionist should ask the staff to complete it. Regarding the COVID-19 unit: Review of the Employee Surveillance Tool form for Coronavirus Screening (for associates/staff) dated December 3, 2020 revealed a Registered Nurse (RN/staff #37) did not complete the form or document her temperature prior to working on the COVID-19 unit. An interview was conducted on the COVID-19 unit with staff #37 on December 3, 2020 at 10:45 a.m. The RN stated that she did not remember checking in for the COVID-19 screening and that she did not know how they did the screening on the COVID unit. The RN stated that she thought there was a book for them to sign in, that contained the COVID-19 screening forms. However, she was unable to locate the book. The RN stated that she did take her temperature that morning. During an interview on the COVID-19 unit conducted with housekeeping (staff # 20), staff #20 stated that she completes the screening for COVID-19 at the front desk in the lobby. Staff #20 stated that she then drives her car to the entrance of the COVID unit. In an interview conducted with the Administrator (staff #125) on December 3, 2020 at 12:15 p.m., staff #125 stated the COVID-19 unit has their own thermometer and the staff are still required to answer the COVID-19 screening questions. An interview was conducted with the IP (staff #16) on December 3, 2020 at 12:17 p.m. The IP stated that there is a COVID-19 screening book on the COVID-19 unit. The IP stated the staff check for completion of the COVID-19 screening forms themselves. She said that she reviews the screening forms when she is on the COVID-19 unit to evaluate the residents. Review of the facility's policy regarding limiting transmission and spread of infectious disease throughout the facility revised November 15, 2020 included all incoming and outgoing staff shall be screened for symptoms of COVID-19. Check temperature, cough, shortness of breath, fever, chills, muscle pain, sore throat, new loss of taste/smell and document. Review of the CDC guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 Pandemic updated November 4, 2020, revealed the CDC recommends using additional infection prevention and control practices during the COVID-19 pandemic, along with standard practices recommended as part of routine healthcare delivery to all patients. Establish a process to ensure everyone (patients, healthcare personnel, and visitors) entering the facility is assessed for symptoms of COVID-19, or exposure to others with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection and that they are [MEDICATION NAME] source control. The CDC guidance titled Preparing for COVID-19 in Nursing Homes updated November 20, 2020 included that given their congregate nature and resident population served (e.g. older adults often with underlying chronic medical conditions) nursing home populations are at high risk of being affected by respiratory pathogens like COVID-19. As demonstrated by the COVID-19 pandemic, a strong infection prevention and control (IPC) program is critical to protect both residents and healthcare personnel (HCP). Screen all HCP at the beginning of their shift for fever and symptoms of COVID-19. HCP who work in multiple locations may pose higher risk and should be encouraged to tell facilities if they have had exposure to other facilities with recognized COVID-19 cases.

Based on clinical record review, staff interviews, and the Form Instructions for the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN), the facility failed to ensure one resident (#56) received the SNFABN when his skilled services ended. The deficient practice could result in residents not being informed of their potential liability for payment. Findings include: Resident #56 was admitted on [DATE] with a [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident scored a 14 on the Brief Interview for Mental Status (BI[CONDITION]) indicating that he was cognitively intact. Review of the clinical record revealed that the resident's stay was being billed to Medicare and that he was receiving skilled therapy to increase his strength. The facility determined that the resident's stay would not longer be billable to Medicare after 1/3/19 as he was to be discharged from skilled therapy. The resident remained in the facility after 1/3/19. There was no documentation that the resident was informed of the liability change or that a SNFABN had been completed. During an interview with the resident on 1/16/20 at 10:00 a.m., he stated he didn't remember getting a form telling him how much services would cost when the funding source changed. In an interview with the interim administrator (staff #158) on 1/16/20 at 11:00 a.m., she stated resident #56 was not given a SNFABN and should have been informed of facility service costs when being discharged from skilled services and remaining in the facility. She further stated that the facility does not have a specific policy for the SNFABN. Review of the form instruction for the SNFABN revealed that Medicare requires skilled nursing facilities to issue the SNFABN to Medicare beneficiaries prior to providing care that Medicare usually covers but may not pay for when the care is not medically necessary. The SNFABN provides information to the beneficiary so that he can decide whether or not to get the care that may not be paid for by Medicare and assume financially responsibility.

Based on clinical record review, staff interview, facility documentation and policy review, the facility failed to ensure that fall safety interventions were consistently documented and implemented for one of three sampled residents (#258), who was identified to be at high risk for falls. The deficient practice resulted in a lack of interventions to prevent falls and the resident sustained [REDACTED]. Findings include: Resident #258 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the admission nursing note dated August 22, 2019 at 2:30 p.m. revealed the resident had arrived from the hospital with left hip pain related to a fall at home. Per the note, the resident was oriented to person only. Review of a fall risk assessment dated [DATE] revealed the resident had intermittent confusion, had 1-2 falls in the past 3 months and had decreased muscular coordination. Per the fall risk assessment, the resident was a high fall risk. A care plan initiated on August 22, 2019 included the resident had decreased abilities with activities of daily living (ADL) related to [MEDICAL CONDITION], anxiety and a previous ground level fall. The goal was that the resident would have participation in performance of ADL's to the greatest potential. Interventions included to encourage the resident to be out of bed as tolerated, encourage independence, allow time for task performance before offering assistance, assist of one person for toileting and a grab bar for bed mobility, repositioning and transfers. A nursing note dated August 23, 2019 included the resident was very confused and unable to follow directions. The resident had refused to go to bed or sleep, had been sitting in her wheelchair the entire night shift, and had required 1:1 supervision, as she would attempt to stand and ambulate every minute. Per the note, the resident was unsteady, was unable to be redirected and displayed moods ranging from tearful to pleasantly confused within minutes. The note included that the next shift was made aware of the resident's behavior and fall risk. Further review of the clinical record revealed there was no documentation of the rationale for discontinuing the 1:1 supervision or when it was discontinued, nor was there documentation of any additional safety interventions which were implemented to prevent falls after discontinuing the 1:1 supervision, despite the resident being at high risk for falls. A nursing note dated August 24, 2019 at 1:20 a.m., included that a loud noise was heard and the resident was found in her room on the floor, near the right side of her bed. The note included that the resident was asked what happened and replied I got up to get a glass of water, but I fell . Per the note, the resident was alert and oriented x 3; however; it also included that the resident was able to answer simple questions, but thought she was at home. The note further included the resident was sent out to the hospital for complaints of severe pain to the left hip. The note did not include a description of any fall interventions which were in place, prior to the fall. Another nursing note dated August 24 2019, included the resident was admitted to the hospital for a left femoral neck fracture. Review of an interdisciplinary fall note dated August 29, 2019, which was five days after the fall incident revealed that on the first night in the facility, the resident had been agitated/restless and needed close supervision from staff. The fall note included that per staff interviews, the resident had been calm and cooperative on the evening prior to the fall, and the resident had been educated to use the call light and wait for assistance. The note included that around 9:00 p.m., the nurse had administered medication to the resident while she was watching television, and around 10:30 p.m. the resident was in bed sleeping, with the bed in a low position at about knee level. At midnight the resident was observed to be sleeping, while the nurse aide changed the resident's pitcher of ice water and placed it on the bedside table. The bedside table, water pitcher and call light were all noted to be within the resident's reach. The note included that the floor was free of clutter with adequate lighting, and at the time of the fall the resident was wearing non-skid socks. The facility's fall investigation report was requested on January 14, 2020 at 11:00 a.m., however the fall investigation report was not provided. An interview was conducted with the Director of Nursing (DON/staff #98) on January 15, 2020 at 12:00 p.m. She said that some factors, such as a fall at home or a [DIAGNOSES REDACTED]. She said typical interventions for new resident's who are at risk for falls would include a low bed position, a fall mat and instructions/re-education to use the call light. She said a baseline care plan would be initiated for residents on admission, and additional care areas and interventions would be added to the baseline care plan until the comprehensive care plans were created. She stated that if a resident had a fall, either she or the charge nurse would conduct an investigation. She said the fall review progress note contained the details of the fall investigation, however the actual fall investigation report was an internal document and would not be provided. She said that her understanding of the situation for this resident was that on the first night the resident was adjusting to the facility, but by the next afternoon the resident was calm. She said the resident went to bed early and did not need one on one supervision. She said the reason there was not specific documentation of supervision or interventions on the night the resident fell was because the resident had been so calm. During a follow-up interview on January 15, 2020 at 1:16 p.m., staff #98 stated the resident did not have a care plan for fall risk. Review of the Fall Prevention policy revealed that a fall prevention program will be maintained that provides ongoing assessment of each resident's risk potential for falls. The goal of a fall prevention program is to identify and eliminate or modify risk factors and thereby, reduce the likelihood of an accident occurring or re-occurring. Per the policy, a fall risk assessment would be completed within 24 hours following admission, and an interim care plan would be instituted for residents determined to be at risk for falls.

Based on clinical record review, observations, staff interviews and policy and procedure, the facility failed to ensure that a physician's order was obtained for one of two sampled residents (#[AGE]) who was receiving oxygen. The deficient practice could result in adverse clinical outcomes. Findings include: Resident #[AGE] was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the admission physician's orders revealed no evidence of an order for [REDACTED].>A physician's progress note dated December 20, 2019, included that the resident had a history of [REDACTED]. The note included that upon examination, the resident was receiving oxygen at 2 LPM. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BI[CONDITION]) score of 15, which indicated that the resident was cognitively intact. The assessment included that the resident had received oxygen, but not while he was a resident at the facility. The baseline careplan did not include that the resident was receiving oxygen. Review of a skilled nursing note dated January 6, 2020, revealed the resident had an oxygen saturation of 91% while breathing room air. However, the note also included that the resident had received oxygen while in the facility. A care plan initiated January 8, 2020, included for the potential for difficulty breathing related to chronic conditions of [MEDICAL CONDITION], valley fever, cardiac status, and [MEDICAL CONDITION]. The goal included to minimize risks for respiratory distress, with interventions to administer and monitor the effectiveness of drugs affecting respiratory status, remind the resident to breathe slowly and deeply when short of breath, and report changes in respiratory status to the physician. Review of the physician's orders for January 2020, revealed no evidence of an order for [REDACTED].>An observation of the resident was conducted on January 13, 2020 at 10:26 a.m. The resident was receiving oxygen at 3 LPM via nasal cannula. During an observation of the resident on January 15, 2020 at 3:00 p.m., the resident was seated in his bed in his room. He was receiving oxygen at 3 LPM via nasal cannula. An observation was conducted on January 16, 2020 at 9:51 a.m. The resident was receiving oxygen at 3 LPM via nasal cannula. An interview was conducted on January 16, 2020 at 10:49 a.m. with a Licensed Practical Nurse (LPN/staff #110). She stated that in order for a resident to receive oxygen, there should be a physician's order and a care plan created. She said a resident could receive oxygen without an order if the situation was emergent, however the physician would be notified and an order would be obtained as soon as possible. She said residents receiving oxygen would also have documentation in the clinical record every shift of the oxygen rate, method of delivery, and saturation levels. She said she did not know why this resident did not have an order for [REDACTED].>An interview was conducted on January 16, 2020 with the Director of Nursing (DON/staff #98). She stated her expectation is that oxygen would be administered with a physician's order. She said in an emergency the nurse could administer oxygen and then notify the physician as soon as possible. Review of the facility's policy for oxygen administration revealed that the purpose of administering oxygen is to improve tissue oxygenation for the treatment of [REDACTED]. Oxygen would only be administered by physician's order, except in an emergency. The policy included that in an emergency situation, oxygen could be administered without a physician's order, but the order must be obtained immediately after the crisis was under control.

Based on observations, clinical record reviews, hospital documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#41) was provided adequate supervision to help prevent a fall with injuries. The facility also failed to ensure that the resident environment remains as free of accident hazards as is possible, by failing to ensure one resident (#133) with moderate cognitive impairment was provided supervision while smoking, by failing to ensure smoking materials were kept in a secure location for one resident (#107) who was non compliant with the smoking policy regarding the sharing of smoking materials, and by failing to accurately assess two resident's (#s 166 and 303) ability to smoke safely. Findings include: -Resident #41 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a Potential for Fall Care Plan dated June 6, 2012, revealed the resident had a history of [REDACTED]. Interventions included to use appropriate assistance for all cares and transfers. The Minimum Data Set (MDS) assessment dated [DATE], indicated the resident was totally dependent and required the assistance of two people for bed mobility and transfers. The assessment also indicated the resident had short and long term memory problems and had severe cognitive impairment. A review of nursing notes dated November 19, 2014, included that the certified nursing assistant (CNA) called for the nurse to come into the resident's room. The resident was lying on the floor face down, with blood on the floor by her head. The note included that the resident's bed was in the high position. First aid was given and 911 was called. According to the facility's investigation, a CNA was performing personal care and was in the process of changing the resident's brief. The resident was on her left side close to the edge of the bed and the bed was at waist level. The CNA then realized that he did not have a trash can with a liner close by. The CNA let go of the resident to get the trash can which was near the roommates part of the room and the resident rolled off the bed onto the floor. The resident sustained [REDACTED]. The resident was sent to the hospital 911. Review of the hospital emergency room documentation dated November 19, 2014, included that the resident had incurred an intraventricular hemorrhage and a laceration and hematoma to her forehead. During an interview conducted on April 8, 2015 at 10:00 a.m., the CNA stated he was caring for the resident on the night of the incident. The CNA stated that the resident's brief needed to be changed so he raised the bed to waist height, so he would not hurt his back. He said he was in the process of cleaning the resident's buttocks and realized the trash can he needed for the soiled brief was across the room. He said the resident's body was positioned close to the side/edge of the bed so he positioned one of the resident's legs on top of the other so her feet were together. He stated that he then walked across the room to get the trash can that had a liner in it. When he looked back at the resident, he saw one of her legs fall over the side of the bed and she rolled off the bed and landed face first on the floor. An interview was conducted with the DON on April 8, 2015 at 3:00 p.m., who confirmed that the CNA should have assembled all necessary equipment before providing peri care and should not have left the resident unattended. A review of the facility policy titled, Falls/Accident Management System revealed that the goal of this program was to prevent falls, reduce both the incidences of falls and the injuries that may accompany falls. The purpose of the fall prevention program was to improve quality of life and care for residents. Risk factors associated with falls/accidents include cognitive impairment, dementia, and history of falls. Care giver risk factors included improper resident assistance or turning and needs not anticipated. Regarding the smoking issue: -Resident #166 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident resided on the post acute unit. A review of the Initial Resident Smoking assessment dated [DATE], revealed the resident was assessed as a non-smoker. On April 7, 2015 at 9:50 a.m., resident #166 was observed smoking on the smoking patio, unsupervised. Following the observation, the resident was interviewed and stated when he wants to smoke, he goes to the nurse's station and asks for his cigarettes and lighter. During an interview conducted on April 7, 2015 at 10:05 a.m., a RN reviewed the resident's initial smoking assessment. The RN stated that since the resident was assessed to be a non-smoker, this meant the resident's ability to smoke safely was not assessed, nor was he assessed for the need to wear a smoking apron, or be supervised while smoking. She also stated the resident's smoking materials were kept at the nurses station and were given to him when he requested. Another observation was conducted at 9:37 a.m. on April 8, 2015, of resident #166 sitting outside on the smoking patio in a wheelchair. The resident removed a packet of cigarettes and a lighter from his pants pocket and lit the cigarette. The resident was not wearing a smoking apron and no staff were present to supervise the resident. At 9:48 a.m., a staff member was observed walking past the resident, while he smoked. During an interview conducted at 10:10 a.m. on April 8, 2015, a RN stated the resident was an independent smoker and was given his smoking materials earlier that morning, so he could smoke. After reviewing the Initial Resident Smoking Assessment, the nurse stated that a new smoking assessment needed to be completed, because the old assessment indicated that the resident did not smoke. An interview was conducted with the Director of Nursing (DON) on April 8, 2015 at 11:30 a.m., who confirmed per the facility's smoking policy, that the resident should have been identified as a smoker on admission and been assessed for safe smoking. -Resident #303 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident resided on the post acute unit. A review of the Initial Resident Smoking assessment dated [DATE], included the resident was not physically capable of holding a cigarette, matches/lighter, or lighting and extinguishing his own cigarette without assistance. In addition, the Smoking Assessment was incomplete, as the last two questions were unanswered, which asked if the resident had signed a smoking agreement and if the care plan addressed the smoking status. There was also no determination made by the facility on whether the resident was deemed safe to smoke independently, or was required to wear a smoking apron. During a random observation on April 7, 2015 at 9:50 a.m., the resident was observed smoking on the smoking patio, unsupervised. The resident was interviewed following the observation, and stated that the nurse gives him his cigarettes and lighter when he asks for them. During an interview conducted on April 7, 2015 at 1:00 p.m., the nurse confirmed the Initial Smoking Assessment had not been completed and did not indicate whether or not he could smoke independently or required the use of an apron. The nurse stated the resident's smoking material was provided to him upon his request. -Resident #133 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident resided on the long term care unit. Review of the annual MDS assessment dated [DATE], revealed the resident scored a 10 on the Brief Interview for Mental Status, which indicated the resident had moderate cognitive impairment. A quarterly Resident Smoking assessment dated [DATE], revealed the resident was a supervised smoker, who was not required to wear a smoking apron. The assessment also included the resident had no changes in smoking status. The smoking care plan dated February 18, 2015, documented the resident required supervised smoking due to physical impairment, debility, dementia and rheumatoid arthritis. However, one of the approaches included that the resident was required to wear a smoking apron at all times when smoking. Another approach included the resident was able to smoke in designated areas, with family or staff only. During an observation of the smoking patio conducted at 10:20 a.m. on April 8, 2015, resident #133 was observed sitting at a table with resident #107. Resident #133 was observed accepting a cigarette from resident #107, and allowed him to light her cigarette. Also observed was that resident #133 was not wearing a smoking apron and there were no staff or family members out on the patio supervising the resident, while she smoked. During the observation, staff members were observed walking across the patio and none stopped to supervise the resident or ensured that the resident was wearing a smoking apron, as care planned. During an interview conducted at 11:05 a.m. on April 8, 2015, a LPN stated the resident (#133) was a supervised smoker and her smoking materials were kept in the medication cart. The LPN stated the resident often goes outside to smoke with a family member. When asked how she would know when the resident was out smoking the LPN stated that she would have to look in the medication cart to see if the resident's cigarettes were there. Additional observations were conducted between 12:45 p.m. and 3:00 p.m. on April 8, 2015. Resident #133 was observed sitting on the patio smoking, with a family member. The resident smoked several cigarettes while outside; however, the resident did not have an apron on while smoking, as care planned. Staff members walked past the resident several times, without stopping to ensure the resident was wearing a smoking apron. -Resident #107 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident resided on the long term care unit. A review of the Initial Resident Smoking assessment dated [DATE], revealed the resident was a non smoker. The assessment was updated on October 15, 2014, and indicated the resident had a past history of poor judgement regarding safety for himself or others. The assessment also revealed that the resident needed supervision for smoking, but did not indicate whether or not the resident was required to wear a smoking apron. A review of the Quarterly Resident Smoking assessment dated [DATE], revealed the resident was alert and oriented and occasionally went out to the courtyard area to smoke. The assessment also included the resident was aware of the facility smoking protocol and was compliant, and was not required to wear a smoking apron or be supervised while smoking. According to a quarterly Minimum Data Set (MDS) assessment dated [DATE], the resident scored a 13 on the Brief Interview for Mental status, which indicated the resident was cognitively intact. Review of the potential for smoking care plan dated January 15, 2015, revealed will not need to be supervised while smoking, and that the resident will not be required to wear a smoking apron when smoking and will abide by the facility smoking policy. Review of a quarterly Resident Smoking assessment dated [DATE], revealed the resident was an unsupervised smoker, who was not required to wear a smoking apron and was compliant with the facility's smoking policy. During an observation of the smoking patio conducted at 10:20 a.m. on April 8, 2015, resident #107 was observed sitting at a table with resident #133. Resident #107 was observed reaching into his shirt pocket and removing a cigarette and lighter. The resident then handed a cigarette to resident #133, and lit the cigarette for the resident, before lighting his own cigarette. During an interview conducted at 10:25 a.m. on April 8, 2015, resident #107 stated he keeps his own cigarettes and lighter in a hidden location on him and keeps cigarettes and a lighter in his room. During an interview conducted at 11:05 a.m. on April 8, 2015, a licensed practical nurse stated the resident (#107) was able to smoke independently and kept his smoking materials on his person or in his room. Review of the facility's smoking policy revealed that the purpose was to provide maximum safety to all residents at all times and to ensure residents who smoke are able to do so safely, without placing themselves and others at risk. The policy included that residents admitted to the post acute unit who smoke will be assessed for their ability to do so safely. This assessment will be completed by a licensed nurse upon admission, quarterly and as needed to ensure their continued safety. Based upon this assessment a resident may be required to wear a smoking apron or employ other safety precautions. All patients who wish to smoke must agree to sign the smoking consent and release form. Smoking conditions and restrictions are addressed in the residents plan of care. The policy further included that residents who wish to smoke will agree to the following: all residents who smoke who are assessed as needing direct supervision will be directly monitored by staff, the nursing staff will manage and distribute smoking materials for all residents, and smokers are prohibited from sharing smoking materials with other patients. In addition, the policy stated that effective June 1, 2007, the facility does not permit smoking for residents of long term care units. Long term care residents who were residents of the facility prior to June 1, 2007 are permitted to smoke, consistent with the procedure above. The policy also included that any resident who does not comply with this policy constitutes grounds for discharge, due to being a risk to themselves and others.

Based on clinical record reviews, facility and hospital documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#23) was free of significant medication errors. Findings include: Resident #23 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed documentation that the resident was alert and oriented, able to communicate needs, and had the ability to understand others. The documentation also included the resident was allergic to [MEDICATION NAME]. Review of the December 2013 physician orders [REDACTED]. The orders did not include the resident was to receive [MEDICATION NAME]. The current care plans addressed an identified problem related to diabetes. Interventions included the resident would be administered all medications as ordered. In addition, a care plan had been developed that addressed the resident's allergy to [MEDICATION NAME]. The goal was to not administer [MEDICATION NAME] to the resident, with the following interventions: 1) Place allergy sticker in front of chart, 2) Label physician's orders [REDACTED]. A nurse's note dated January 5, 2014 at 7:45 p.m., included that an error in the administration of insulin and an oral medication ([MEDICATION NAME]) had occurred. The NP (nurse practitioner) was notified and new orders were obtained. This entry was signed by a Licensed Practical Nurse (staff #1). Continued in the nurse's note was that immediately following the medication errors, the resident was alert and oriented and regularly scheduled neurological checks, vital signs, and blood sugar levels were initiated. A nurse's note dated January 6 at 5:00 a.m., documented the resident was alert and oriented, aroused easily for cares, and Accuchecks and neurological checks were normal. Later that afternoon at 2:00 p.m., the documentation included that the resident was difficult to arouse, oxygen saturation (O2 sats) were 80 percent, oxygen was initiated and O2 sats increased to 92 percent, resident was afebrile, vital signs were stable and there were no episodes of [DIAGNOSES REDACTED] (low blood sugar). Per the note, the NP was notified and [MEDICATION NAME] 0.4 mg intramuscular was ordered and staff were to notify her of any changes. The next nursing note dated January 6, 2014 at 3:15 p.m., documented the resident was very lethargic, but was able to open his eyes when called by name. The note included the resident was unable to speak, and his tongue was to the left of his mouth and he was drooling a large amount of phlegm. The resident was able to squeeze the nurses's hand, however, was unable to move his extremities. The resident's systolic blood pressure was 82 and the diastolic pressure was unable to be heard. The O2 sats decreased to 80 percent and the oxygen rate was increased. The NP was notified and the resident was transported to the hospital. According to the facility's investigation, staff #1 was performing a medication pass and became distracted, and administered 90 mg of [MEDICATION NAME] and 84 units of [MEDICATION NAME] (40 units of insulin were ordered) to resident #23. The report included the resident was allergic to [MEDICATION NAME]. The report further explained that the nurse also attempted to give the resident a nasal spray, however, the resident told the nurse that he did not get a nasal spray and that is when the nurse realized that she gave the wrong medications to the resident. The resident was admitted to the hospital in ICU (intensive care unit). The report also included that the nurse was terminated. Review of the hospital records dated January 6, 2014, revealed the resident was accidentally overdosed in the evening hours on January 5, 2014, with [MEDICATION NAME] 90 mg and a larger than usual dose of [MEDICATION NAME]. Per the documentation, approximately 12 hours later the resident had an altered level of consciousness and was difficult to arouse and was brought to the emergency department and admitted to ICU. Per the clinical record, the resident was discharged from the hospital on January 7, 2014, and was readmitted to the facility. An interview was conducted with the Director of Nursing (DON) on January 27, 2014. The DON stated that the nurse had been hired in December 2013. She said that at the time of the incident, the nurse was distracted and did not check the resident's arm band and administered the wrong medications. The DON further stated that the nurse notified the NP when the errors occurred, however, she did not inform the NP that the resident was allergic to [MEDICATION NAME]. The DON further stated that the EMT's discovered the documentation that the resident was allergic to [MEDICATION NAME]. An interview was conducted with resident #23 on January 28, 2014 at 8:49 a.m. He stated that several weeks ago a newly hired nurse gave him some medications and did not look at his name band. He said that the nurse also tried to give him some nose spray and when he told her he did not get a nose spray, she seemed to know something was wrong. An interview was conducted with staff #1 on January 29, 2014. She stated she was very distracted on January 5, 2014, when she made the errors and administered [MEDICATION NAME] and insulin to resident #23 by mistake. She stated she called the Nurse Practitioner (NP) immediately following the error, but did not inform the NP of the resident's allergy to [MEDICATION NAME]. Stated she had not noted that the allergy had been documented in numerous locations in the clinical record and on the MAR. According to a facility policy regarding medication administration the following statement was included: Residents are identified before medication is administered by methods of checking the identification band, checking photograph attached to the medical record, calling resident by name, and if necessary, verifying resident identification with other facility personnel. An additional facility policy regarding medication errors included the following: 1) In the event of a medication error immediate action is taken, as necessary to protect the resident's safety and welfare. 2) Attending physician is notified promptly of any error or adverse medication reaction.

Based on closed clinical record review, hospital record review, staff interviews,facility documentation and review of facility policy, the facility failed to adequately monitor and treat one resident (#255) with diabetes, resulting in hyperosmolar [MEDICAL CONDITION] and intensive care unit hospitalization . Findings include: Resident #255 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. A review of the hospital history and physical prior to the resident's admission to the facility revealed that the resident had diet-controlled diabetes, his blood sugars were to be checked before meals and in the evening, and the resident was to be placed on sliding scale insulin. A review of the hospital Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A review of the clinical record revealed physician admission orders [REDACTED]. The admission orders [REDACTED]. Progress notes from January 30 and February 5, 2012, documented the resident was on a consistent carbohydrate (CCHO) diet to control DM type 2. A review of the resident's potential for hyper/hypoglycemic episode care plan from February 15, 2012, documented several approaches to help keep the resident's blood sugar within normal limits. Some of the approaches included: monitor food intake, patient-family teachings on prescribed diet and medications, monitor blood sugar through finger sticks, and for blood sugars over 400 follow physician's orders. Review of the Comprehensive Metabolic Panel fasting laboratory results, revealed that the resident's blood sugar was 134 on January 30, 2012, 161 on February 3, 2012, 157 on February 6, 2012, 202 on February 13, 2012, and 432 on February 27, 2012. The lab results documented that the normal range for a blood sugar was between 74 and 106. Also documented on the laboratory results was that the physician was notified. However, despite the multiple elevated blood sugars, there were no physician's orders to monitor the resident's blood sugar and no orders for medication to treat his elevated blood sugar. A nurse's note on March 4, 2012, and in the speech therapy (ST) notes, it documented the resident was non compliant with diet texture and that the family brought food in for him. Further review of the clinical record revealed there was no documentation that staff were concerned about the food itself, other than the texture of the food that the family brought in. It was documented that the resident would aspirate or choke. Further review of the nurse's note from March 4, 2012, revealed the resident's family wanted the resident to be transferred to the hospital because of their concern that the resident was dehydrated and having tremors. A physician's order dated March 4, 2012, documented to send the resident to the hospital, per family request. A review of the hospital history and physical from March 4, 2012, revealed that the resident was in a hyperosmolar hyperglycemic state with a blood sugar of 1,035. The resident was admitted to the intensive care unit (ICU) and placed on an insulin drip. The hospital discharge summary from March 10, 2012, documented that the resident had uncontrolled DM with a Hemoglobin A1c of 10. Hospital lab results revealed that a normal Hemoglobin A1c was below 5.7. During an interview conducted on November 28, 2012 at 12:20 p.m., the Director of Nursing (DON) stated that the physicians would look at what the hospital was doing and what the resident was doing at home to determine how often the resident's blood sugar needed to be checked. The DON also reported that the dietary manager usually would document whether residents have been compliant with their diets. During an interview conducted on November 29, 2012 at 2:00 p.m., the resident's physician stated that the main factor contributing to the resident's high blood sugars was non-compliance with his diet. He reported that it was documented in ST notes that the resident's family would bring in food from outside and the resident would not follow his diet. The physician stated that they did not treat the resident's blood sugar of 432 because the resident had two different issues going on in late February that he believed were more critical. He stated that he would generally treat a blood sugar that high. When the physician was asked when he would consider placing someone on medication for diabetes, he stated when the resident's fasting blood sugar was consistently above 126 and non-fasting blood sugar was above 200. The physician admitted that he should have put the resident on sliding scale insulin and finger sticks based on the resident's lab results. During an interview conducted on December 3, 2012 at 8:10 a.m., the resident's Nurse Practitioner (NP) stated that they looked to see if the resident was on any medications for diabetes in the hospital and what the resident was taking at home to determine whether the resident needed to be on medication for DM. A review of the facility's policy on resident change of condition documents "resident change in condition will be assessed promptly and follow up action will occur as appropriate and in a timely fashion." The facility listed abnormal lab values as an example of a change in condition.

Based on clinical record review, hospital record review, review of facility policy and procedure the facility failed to ensure that two residents (#s 14 and 67) were transferred safely. Both residents sustained actual harm. Findings include: -Resident #67 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented that the resident was totally dependent for all activities of daily living and required two people to assist the resident with bed mobility and transferring. The care plan dated July 13, 2010, documented that the resident was dependent with all activities of daily living (ADL). The approaches included to maintain a safe and hazard free environment by anticipating the needs of the resident by answering the alarms/lights and by using a Hoyer lift for all transfers. The nursing notes dated September 4, 2010 at 10:00 a.m. documented that the certified nursing assistant (CNA), had informed the nurse that the resident's left arm had no resistance and appeared to be swollen and deformed. The notes documented that the resident sustained [REDACTED]. Nursing notes further revealed that the nurse contacted the resident's physician and an x-ray was ordered. The results of the x-ray confirmed that the resident had sustained a fractured humerus. Review of facility's investigation was conducted. The two CNAs involved in the incident were interviewed on September 7, 2010. It was documented that the CNAs, had used a two person transfer instead of the Hoyer lift. Both CNA's stated they were aware that the resident was to be transferred with a Hoyer lift as specified in the resident's plan of care. An interview was conducted on September 1, 2011 at 10:00 a.m. with the licensed practical nurse (LPN) who cared for resident. The LPN stated that the resident's transfer status was communicated to the CNA's every day in report. She stated that the CNA's and the shower techs would come to the nursing staff if they believed that a resident had a decline in their activities of daily living and request that they be assessed for a Hoyer lift. An interview was conducted on September 2, 2011 at 9:15 a.m. with a CNA who cared for the resident. She stated that the resident needed a Hoyer lift for all transfers. The CNA stated that the facility used two or three staff members for a Hoyer lift. She stated the resident would never be moved without a Hoyer because of her peg tube and feeding bag and fear of dislodging it. -Resident #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment dated [DATE], revealed that the resident required extensive assist of two people for transfers. A review of the care plan for alteration in functional ADL ability r/t (related to) decline of mobility secondary to MS (multiple sclerosis) and alterations in functional mobility R/T MS with decline expected secondary to disease progression, revealed no approaches to address the resident's need for two person assist with transfers. A review of the propensity to fall/injurious falls care plan revealed an approach to "use appropriate assist for all cares and transfers prn (as needed)." Further review of the care plans revealed no approaches that would identify what "appropriate" transfer assistance was to be done for the resident. A review of the nurse's notes dated August 24, 2011, revealed that the resident was "in bed all day due to combativeness - took 3 people to change brief." The documentation also revealed that due to the resident's resistance the resident was not dressed. The nurse further documented, "demeanor is different - does not make eye contact & says very little tonight." A review of the nurses notes dated August 26, 2011, revealed that the resident complained of right hip pain. The nurse practitioner was notified and orders for a right leg, hip and pelvis x-ray was received. The resident was transported to the hospital emergency room . A review of the facility's Investigation Report of the resident's injury of unknown origin dated September 5, 2011, revealed that two CNAs reported that on August 23, 2011, that the resident was lowered to the floor during a two person assist during a transfer from bed to shower chair. The two CNAs also reported that with the help of a third CNA they transferred the resident from the floor into the shower chair. A review of the Interview Summaries revealed that on September 5, 2011, a CNA (staff member #4) stated that she and another CNA transferred the resident from the bed to shower chair and lowered the resident to the floor. She also reported that she did not notify the nurse or inform the nurse of the resident's fall. The Interview Summaries also documented that a second CNA (staff member #5) stated that she helped another CNA transfer the resident from bed to shower chair and they lowered the resident to the floor. She also reported that she did not notify or inform the nurse about the resident's fall. The two CNAs stated that they had a third CNA assist to transfer the resident from the floor into the shower chair and after the resident's shower used three people to transfer the resident from the shower chair onto a wheelchair. During an interview conducted at 2:37 p.m. on September 6, 2011, a CNA stated that at approximately 4:30 p.m. on August 23, 2011, a LPN stated that the resident fell asleep in her wheelchair and asked him to transfer the resident into bed. He also stated that the nurse watched him pivot the resident on her right leg and transfer the resident into bed by himself. The CNA reported that the resident had not expressed any pain when he transferred her. However, the CNA also reported that a couple hours later the resident was resisting care when he assisted the CNA assigned to the resident in getting the ready for bed. He further reported that the resident had never resisted care provided by him before. During an interview conducted at 2:53 p.m. on September 6, 2011, a second CNA who was assigned to care for the resident on 2-10 p.m. shift on August 23, 2011, stated that the resident had already been transferred into bed when she asked a male CNA to assist her in preparing the resident for bed. She stated that the resident was combative and complained of pain. The CNA further stated that she informed the LPN on duty of the resident's combative behavior. The CNA reported that she provided care to the resident on August 24 and 25, 2011, and the resident remained in bed and continued to resist care. She also reported that she had informed the nurse a second time of the resident's behavior. The CNA said that she had cared for the resident for a couple years and the resident had never resisted care in the past. The CNA also said that after the resident was transfer into bed on the 2 to 10 shift on August 23, 2011, the resident remained in bed until she was transferred to the hospital on August 26, 2011. During an interview conducted at 3:07 p.m. on September 6, 2011, a third CNA stated that she had assisted the CNA assigned to care for the resident on August 25, 2011. She stated that she was asked to assist the CNA in changing the resident's brief. She also stated that changing the resident's brief was usually a one person job and the resident usually reached for the side rail to help turn her. She further stated that on that date the resident was resisting care and not assisting in turning onto her side. She also reported that she asked the CNA assigned to care for the resident if the resident's unusual behavior had been reported to the nurse and was told that the resident's unusual behavior had been reported to the nurse. During an interview conducted on September 6, 2011, the DON stated that three LPNs who were responsible to provide care to the resident from August 23 through 26, 2011, were all aware of the changes in the resident's behavior and response to her daily care. She also stated that none of the nurses assessed the resident's sudden changes in the resident's ability to turn, and refusal to get out of bed. The DON said that after she completed her investigation she was unable to positively determine if the resident sustained [REDACTED]. A review of the facility's Fall Prevention policy and procedure revealed "...The fall prevention program is designed to ensure a safe environment for all residents. Each resident will be evaluated upon admission, quarterly and as needed by an RN/LPN to assess his/her individual level of risk. The purpose of the fall prevention program is to identify residents at risk in a timely manner, to gather accurate, objective and consistent data for the purpose of implementing an individualized plan of care designated to meet the resident's needs and to ensure consistency in the implementation of preventive measures to assist with the reduction of falls..."