Every finding on record at Archbold Living Thomasville

Based on interview, record review, and policy review, the facility failed to review and update the facility assessment annually. This failed practice had the potential to affect all 59 residents to ensure every resident received necessary care and services. Findings include:Review of the facility's Facility Assessment Tool, dated, 06/30/25, revealed, .current population as of 06/30/24.During an interview on 03/12/26 at 1:30 PM, the Administrator confirmed the facility assessment was dated 06/30/25, the report is based on the past 12 months and the current population was dated as of 06/30/24. He stated it was an error that all the dates were not updated when the assessment was completed. He confirmed the facility assessment should be reviewed and updated at least annually.During an interview on 03/12/26 at 1:55 PM, the Long Term Care Director (LTCD) confirmed the facility annual assessment was not updated. She stated the previous administrator changed the date without updating the assessment and did not realize it until the assessment was compared to the previous year's assessment. Review of the undated facility's policy titled, Facility Assessment, revealed, .A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations.

Based on observations, record review, and interviews, the facility failed to ensure one two of two sample residents (Resident (R) 14) reviewed for Pre-admission Screen and Resident Review (PASRR), an evaluation for serious mental illness and/or intellectual disability, received an updated Level I (preliminary assessment) identifying the resident's psychiatric diagnoses. The failure to update the Level I PASRR created the potential for R14 not to be assessed to receive specialized or rehabilitative services as needed.Finding Include:Review of R14's Face Sheet, provided by the facility, revealed R14 was admitted to the facility on [DATE] diagnosis included hemiplegia and hemiparesis following cerebral infarction (stroke).Review of R14's Behavioral Health Assessment, provided by the facility and dated 03/11/25, indicated R14 was diagnosed with major depressive disorder, recurrent, severe with psychotic symptoms effective 11/08/24.Review of R14's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/18/25, revealed R14 had a Brief Interview for Mental Status (BIMS) score of nine out of 15, indicating R14 w was moderately cognitively impaired. The MDS revealed R14 had diagnosis of depression and did not have a Level II PASRR.Review of R14's Care Plan, provided by the facility and dated 11/20/25, revealed, .depressed.provide me with a mental health referral.receives behavioral management services.Review of R14's PASRR Level I Assessment, provided by the facility and dated 01/16/19, revealed R14 did not have a diagnosis of serious mental illness. During an interview on 03/13/26 at 11:20 AM, the Social Services Director (SSD) stated she did not work at the facility when R14 received the new diagnosis of major depressive disorder, recurrent, severe with psychotic symptoms. She confirmed R14 should have been referred for a Level II PASSAR assessment when a new diagnosis of mental illness was identified. Review of the facility's policy titled, admission Criteria, updated 07/2020, provided by the MDSC, noted the following:Our facility admits only residents whose medical and nursing care needs can be met.All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) [PASRR] process.a. The facility conducts a Level I PASARR [PASRR] screen for all potential admissions, regardless of payor source, to determine if the individual meets the criteria for a MD, ID, or RD.b. If the Level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR [PASRR] representative for the Level II (evaluation and determination) screening process.(1) The admitting nurse notifies the social services department when a resident is identified as having a possible (or evident) MD, ID, or RD.(2) The social worker is responsible for making referrals to the appropriate state-designated authority.c. Upon completion of the Level II evaluation, the State PASARR [PASRR] representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate.

Based on observation, record review, interview, and policy review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the condition and needs for one of 18 residents (Resident (R) 60) reviewed for MDS accuracy. This failure had the potential to contribute to unmet care needs related to contractures and upper mobility limitations.Findings include: Review of R60's Face Sheet located in the electronic medical record (EMR) under the admission Diagnosis tab, revealed R60 admitted on [DATE] with diagnoses including cerebral arteritis (stroke), hemiplegia (right side effected), and aphasia.Review of R60's annual MDS, located in the EMR under the MDS tab, with an Assessment Reference Date (ARD) of 08/19/25, revealed R60 was coded as having no upper extremity impairment. Review of R60's quarterly MDS with an ARD of 11/04/25 revealed R60 was coded as having no upper extremity impairment Review of R60's MDS with an ARD of 02/04/26, revealed R60 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R60 was cognitively intact. Further review of the MDS revealed R60 was coded as having no upper extremity impairment. Review of R60's Occupational Therapy (OT) orders provided by the facility, dated 09/08/25, indicated R60 had a right-hand contracture. During an observation and interview on 03/11/26 at 4:30 PM R60 was lying in bed. He stated he was able to open and close his left hand and provided demonstration. R60 stated he was unable to open right hand.During an interview on 03/11/26 at 4:30 PM with Occupational Therapy Assistant (OT) 1 confirmed R60 does have a right-hand contracture.During an interview on 03/13/26 at 10:27 AM the MDS Coordinator (MDSC) stated R60 did have a contracture. The MDSC reviewed the three MDS dates of 08/19/25, 11/04/25 and 02/04/26, and confirmed the MDS were inaccurate and she would modify them to ensure accuracy.During interview on 03/12/26 at 3:30 PM the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) stated their expectation was for all MDS to be accurate.Review of the facility's undated MDS policy titled, Policy Interpretation and Implementation, indicated, Comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions.

Based on record review, staff and resident interviews, and review of policy titled Falls risk assessment the facility failed to provide care by two staff members, for one resident (R)(R2) of three residents reviewed for falls. Actual harm was identified 4/29/2025 when R2 fell from the bed when rolled away from the Certified Nursing Assistant who was providing care to her. The fall resulted in R2 receiving Fracture of distal end of left femur and Fracture of distal end of right femur. Findings include:Review of the facility policy dated 8/2019, titled, Falls risk assessment, revealed Policy Interpretation and Implementation 6. The staff, with the input of the Attending physician will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility gait, balance, excessive motor activity, Activities of Daily Living (ADL) capabilities', activity tolerance, continence, and cognition. Review of the medical record for R2 revealed the resident was initially admitted to the facility on [DATE] with the following diagnosis's not limited to end stage renal disease, pain in right shoulder, chronic systolic heart failure, type 2 diabetes mellitus with diabetic chronic kidney disease. Review of Quarterly Minimum Data Set (MDS) dated [DATE] (MDS at time of fall) revealed that the resident had a Brief Interview for Mental Health Status (BIMS) of 15, indicating no cognitive impairment.Review of a progress note dated 4/29/2025 at 6:18 am revealed that R2 rolled too far to the side and rolled off bed during a bed bath. The fall was observed by Certified Nurse Assistant (CNA) BB, the CNA that was assisting the resident with the bed bath. The resident complained of pain, moves all extremities. The resident's daughter and physician was notified, and the resident was transferred to the emergency room by rescue. CNA BB was unavailable for interview due to being on leave. Record review revealed CNA BB's statement sent via text to the Director of Nursing (DON), (not dated) read, it was resident's bath night. I asked the resident around 2:15-2:30 am were they ready for their bath; they agreed and we proceed to take the bath. It was time of the bath to dry, enter, and secure the last part of the diaper. I asked the resident to turn to their side, the resident grabs for the grab bar, lifts their leg and ends up overturning the opposite direction of me. Their legs slips off the bed and then loses grasp of the grab bar and slides onto the ground. I check to see if resident is ok and immediately look for my nurse to notify what happened.Record review of the hospital emergency room report on 4/29/2025 revealed an x-ray report that listed a Fracture of distal end of left femur and Fracture of distal end of right femur. Due to the fractures, the resident was transferred to a Trauma Center in Florida. Interview on 7/15/2025 at 1:15 pm with the resident revealed that on 4/29/2025 she rolled off her bed while CNA BB was bathing and changing her. The resident said she thought prior to this incident, there were usually two staff giving her a bed bath but was unsure. She stated that the CNA asked her to turn the opposite way and when resident went to turn, she had more strength than she thought and rolled off the bed. An interview on 7/15/2025 at 1:45 pm with the DON revealed that once a fall takes place, the staff discuss the fall in the morning meeting with the Interdisciplinary Team. The DON revealed that interventions should be initiated after falls, and if additional interventions are needed. The DON revealed prior to the fall the resident required one staff member to assist her during bathing. After the fall, the care plan was updated for a two person assist with bathing. The DON revealed that the resident always turned on her own but this time overcompensated, which led the resident to roll onto the floor. When asked if rolling a resident away from you is best practice, she stated she knew what this surveyor wanted her to say but she can only say that the CNA asked the resident to turn away from her during care, and the resident fell on the floor because she had too much power by swinging her leg giving her too much momentum causing her to roll off bed. The DON stated that after the fall, the Assistant Director of Nursing (ADON) provided an inservice to all CNA's on bed mobility on 5/7/2025. The DON provided training to CNA BB on turning and repositioning and rolling in bed on May 2, 2025. The ADON conducted monitoring rounds 5/5/2025-7/92025. Interview on 7/15/2025 at 4:35 pm with Registered Nurse (RN) CC revealed that she did not remember getting any training on bed mobility but if she were by herself providing care to a resident, she would stand on the side of the bed and make sure the railing on the other side was pulled up. She would then roll the resident toward the rail. She stated that there are usually two staff assisting with bed baths and changing. Interview on 7/15/2025 at 4:41 pm revealed CNA DD revealed the facility gives bed baths with two staff. If she were to do a bed bath or change a resident by herself the best practice would be to have the resident roll towards her and not in the other direction. Interview on 7/15/2025 at 4:39 pm with CNA EE revealed the facility usually has two people assisting with bed baths. If she were by herself providing a bath, the best practice would be to use a lift sheet and roll the resident towards her, never away from her. Interview on 7/17/2025 at 1:33 pm with ADON revealed that she conducted an inservice training on bed mobility with all CNA's on 5/7/2025. She stated that the incident with R2 could have been prevented. She stated the CNA should not have had the resident roll away from her.It was confirmed that the facility implemented the following:Inservice on 5/2/2025 to CNA BB on turning, repositioning and rolling in bed. Inservice to all CNAs on 5/7/2025 on bed mobility.Monitoring rounds from 5/5/2025 through 7/9/2025.Discussed during QAPI meeting on 5/2/2025.

Based on record review, staff interviews, and review of the facility's Abuse Prohibition Policy and Procedures, it was determined that the facility failed to report an allegation of abuse within two hours for one resident (R) (R1) of three sampled residents, after R1 reported another resident exposed his genitals to her. Findings include:Review of the facility's undated policy titled Abuse Prohibition Policy and Procedures, revealed under Reporting: A. Once a complaint or situation is identified involving alleged mistreatment, neglect, or abuse, the incident will be reported immediately, but no later than 2 hours after the allegation is made. Review of the annual Minimum Data Set (MDS), dated [DATE], revealed R1 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition.Record review revealed a progress note dated 6/19/2025 at 10:33 am written by the Therapy Manager that revealed On Tuesday, 06/16/25, resident self-propelled w/c to therapy gym and asked to speak with this writer regarding an issue she had. Resident reports that she was [NAME] herself down the hallway and when she got to the resident's room, that resident was standing in his hallway and exposed his genitals to her. Interview on 7/17/2025 at 9:46 am with Therapy Assistant AA, confirmed R1 approached her on 6/16/2025 with the allegation that another resident exposed himself to R1. She stated she immediately contacted the Social Worker to notify her of the allegation. She stated she documented the incident in the health record. Record review revealed a document titled [Named Organization] Long Term Care Facilities Complaint Form written on 6/19/2025 by the facility's Social Worker. It listed the date of the complaint as 6/16/2025, with R1 making the complaint. The document revealed that the coordinator (Social Worker) received the complaint on 6/16/2025, and the date of the complaint was referred to the appropriate department on 6/16/2025 (Social Services). The document was signed by the Social Worker.Review of the Facility Incident Report Form verified the facility reported the allegation on 6/19/2025 and not on 6/16/2025 when the allegation was first reported. There were no other incidents between the initial incident and the time the facility reported to the State Agency.Interview on 7/17/2025 at 9:52 am with the Director of Nursing (DON) and the Administrator revealed that the DON was made aware of the allegation of abuse on 6/19/2025 by Social Services. She stated she reported it to the state, notified family, law enforcement, and did an investigation. She revealed she is the abuse coordinator and when she's not at the facility the Assistant Director of Nursing (ADON) is her back up, however staff know if there is an allegation of abuse that they can call her 24/7. She confirmed that the allegation should have been reported on 6/16/2025 within 2 hours of the resident making the allegation and not days later on 6/19/2025. The Administrator thought that she was made aware of the allegation on 6/19/2025 and confirmed that DON is the abuse coordinator and that the DON should have been notified on 6/16/2025 so that the allegation could have been reported to the state. R1 refused to be interviewed on 7/17/2025. The Social Worker was on leave at the time of the survey and was unavailable for interview.

Based on observation, record review, interview, and policy review, the facility failed to utilize the proper personal protective equipment (PPE) for enhanced barrier precautions (EBP) for one of one resident (Resident (R) 14) reviewed for EBP out of a sample of 20 residents. This created a potential for the transmission of infection to staff and other residents. Findings include: Review of R14's Admitting and Discharge Record located in the Facesheet tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses of urinary tract infection and diabetes. Review of R14's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/08/24 and located in the MDS tab of the EMR, revealed R14 had short- and long-term memory problems on the Staff Assessment for Mental Status. She had a diagnosis of oral phase dysphagia (difficulty swallowing), had a feeding tube, and received >51% or her total calories through a tube feeding. Review of R14's EMR tab labelled Physician Orders Medispan revealed an order dated 11/11/24 for Enhanced Barrier Precautions (EBP). Review of R14's Care Plan, located in the Care Plans tab of the EMR, revealed a problem, dated 11/11/24, of greater potential for infection related to wounds and PEG (feeding tube inserted through the abdomen into the stomach). An intervention included extended [sic] barrier precautions per protocol. During an observation on 01/14/25 at 12:03 PM, Licensed Practical Nurse (LPN) 1 dispensed liquid medication into a medication cup at the medication cart and walked into R14's room. R14 had no EBP sign posted by her name outside of the door. A caddy containing PPE supplies of gloves and gowns hung on R14's door. LPN1 washed her hands at the sink in the room and prepared cups of water for R14's PEG tube flush. LPN1 walked to the door, grabbed gloves from the caddy, and put the gloves on. LPN1 did not put on a gown. When LPN1 was unable to flush the feeding tube utilizing water in a syringe, she tried to massage the tubing with gloved hands. At 12:12 PM, LPN disposed of the water in the syringe into the sink and changed gloves. LPN1 walked around the bed and hit the button on the wall to page for assistance. At 12:15 PM, LPN1 removed her gloves and left the room to get a pipe cleaner [feeding tube declogger] for the feeding tube. LPN1 washed her hands at the sink upon return to the room and used the pipe cleaner inserted into the feeding tube to attempt to unclog it. LPN1 re-attempted the flush, and after massaging the tube again, the water flowed from the syringe into the feeding tube. LPN1 administered the liquid medication and flushed the tube with water. At 12:20 PM, LPN1 finished administering medication, removed her gloves, and washed her hands at the sink. LPN1 did not wear a gown throughout the medication administration. During an interview on 01/14/25 at 4:20 PM, when asked what residents were on EBP, Certified Nursing Assistant (CNA) 1 stated residents with foley catheters or colostomies. When asked what precautions staff were to take when working with a resident with a catheter, CNA1 responded that if she changed or emptied the bag, she wore gloves and washed her hands. When asked if residents with feeding tubes needed EBP, CNA1 stated, Yes. CNA1 then stated residents with wounds also required EBP. When asked if staff wore gowns when assisting residents on EBP with cares such as dressing or toileting, CNA1 responded, I feel they should wear a gown at any point of contact for infection purposes. CNA1 stated she knew which residents were on EBP because there was a sign by their name outside their door. During an interview on 01/14/25 at 4:25 PM, interview with Registered Nurse (RN) 2 reported residents who were on EBP had an infection such as MRSA (methicillin-resistant enterococcus) in a wound and were on contact precautions. RN2 further stated a resident was on droplet precautions for influenza. When prompted to look at an EBP sign outside a resident's door, RN2 stated a resident was on EBP with wounds, even if the resident did not have an infection. When asked what PPE staff were to utilize when caring for a resident with EBP, RN2 said nurses wore a gown and gloves when treating wounds. When asked if activities such as toileting or dressing would warrant a gown, RN2 stated a gown was not needed. When asked if people with feeding tubes were on EBP, RN2 stated no and that staff wore gloves and did hand hygiene when caring for them. During an interview on 01/14/25 at 4:45 PM, LPN1 stated EBPs were used when someone tested positive for something and needed contact precautions. When prompted to look at an EBP sign outside a resident's door, LPN1 stated there were contact precautions and droplet precautions. LPN stated, we use standard precautions, but EBP if a resident tested positive for something. When asked how they know who is on EBP, LPN1 stated the infection control nurse verbally let staff know. When asked about the EBP signs by residents' names and if staff used the signs as an indicator, LPN1 stated again that the communication was verbal. When asked if R14 was on EBP, LPN1 stated no. During an interview on 01/15/25 at 8:58 AM, LPN2 stated staff wore gowns and gloves when providing direct care to residents on EBP. Residents were on EBP if they had a feeding tube, catheter, or wounds. LPN2 stated she normally looked for an EBP sign by a resident's name to determine if they were on EBP. During an interview on 01/15/25 at 9:03 AM, the Assistant Director of Nursing (ADON) stated nurses can tell if a resident is on EBPs because they had orders which indicated the reason for EBP in the EMR. The ADON stated that in addition, there were signs posted by their names. During an interview on 01/15/25 at 10:34 AM, the Director of Nursing/Infection Preventionist (DON) stated the signs by residents' names, as well as their orders, indicated the need for EBPs. The DON expected nurses to gown and glove when they administered medications via a PEG tube. Review of the facility's Enhanced Barrier Precautions policy, dated 04/01/24, revealed Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition [e.g. residents with wounds or indwelling medical devices].

Based on interview, record review, and facility policy review, the facility failed to ensure a resident's code status was accurately reflected in the medical record in accordance with his wishes for one resident (Resident (R) 16) out of 24 residents reviewed for advanced directives out of a census of 61 residents. Findings include: Review of R16's Admitting and Discharge Record located in the Facesheet tab of the electronic medical record (EMR) revealed he was admitted to the facility on [DATE]. R16 had diagnoses of hemiplegia and hemiparesis following cerebral infarction (stroke) and protein-calorie malnutrition. Review of R16's EMR tab labeled Physician Orders Medispan revealed an order dated [DATE] for Full Code. Review of R16's scanned in document, Georgia POLST (Physician Orders for Life-Sustaining Treatment) located in the Document Management tab as well as a paper copy in the hard chart, revealed a request for Do Not Attempt Resuscitation (DNR), signed by the physician on [DATE]. Review of R16's Care Plan, located in the Care Plans tab of the EMR, revealed a problem, dated [DATE], of Full Code, Manifested by: Physician Order and a goal to Honor resident wishes for Full Code. The care plan did not reflect the change in code status to DNR on the POLST dated [DATE]. Review of R16's hard chart Orders tab revealed orders for [DATE], to include an order for Full Code, electronically signed by the physician. Review of R16's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] and located in the MDS tab of the EMR, revealed he scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. During an interview on [DATE] at 9:23 AM, R16 did not respond to questions asked. During an interview on [DATE] at 11:21 AM, Registered Nurse (RN) 1 was asked what she would do if a resident was found without a pulse or respirations. RN1 stated she would check the EMR for code status. In addition, someone would check the hard chart for a POLST. If the two conflicted, RN1 went by the POLST. During an interview on [DATE] at 11:23 AM, the Assistant Director of Nursing (ADON) stated she would look at the EMR where the order appeared on the dashboard. The ADON would also look at the POLST. The ADON verified that the order and POLST should match. If they did not match, the ADON followed the code status documented on the POLST. The ADON reported a nurse always went to the POLST during a code. During an interview on [DATE] at 11:30 AM, the ADON verified the conflicting physician's order and POLST for R16 and stated, This is why I look at the [hard] chart first [where the POLST is located]. During an interview on [DATE] at 11:34 AM, the Medical Records Coordinator (MRC) stated she took POLSTs signed by a resident/representative to the doctor to be signed. Once she picked the signed POLST back up from the clinic, the MRC made a copy and gave the original to the social worker. The MRC stated she scanned a copy into the EMR but had no part in entering orders into the EMR. During an interview on [DATE] at 11:39 AM, the Social Services Coordinator (SSC) stated that R16 and his wife stated that with his condition, they wanted his code status changed to DNR. The SSC verified that the new POLST for DNR was signed in [DATE]. During an interview on [DATE] at 11:46 AM, the MDS Coordinator (MDSC) stated she updated Care Plans quarterly or when there was a change. She reported she looked at orders with every care plan meeting, and orders were reviewed daily and discussed in huddle (the morning meeting). The MDSC was unaware of the POLST documenting the DNR request signed by the physician on [DATE]. During an interview on [DATE] at 12:10 PM, the Director of Nursing (DON) stated she expected that all areas matched: POLST, orders, and care plan. During an interview on [DATE] at 12:23 PM, the Medical Director stated he reviewed all POLSTs brought to him in his office or given to him while he was at the facility. Once signed, the Medical Director expected orders in the EMR reflected the resident/family wishes that were reflected on the POLST. During an interview on [DATE] at 3:45 PM, the Administrator stated she always went to the hard chart (POLST). She stated staff should go with the most current POLST. Review of the facility's undated Advanced Directives and Advanced Care Planning policy revealed a POLST served as a medical order. A DNR order informs medical staff that a CPR (cardiopulmonary resuscitation) is not wanted. Without a DNR order, medical staff will attempt every effort to restore your breathing and the normal rhythm of your heart. Review of the facility's undated Code Blue policy revealed BLS [Basic Cardiac Life Support] will be initiated on any resident who sustains a cardiac attest [sic] unless there is a physician's written order stating No CPR or No Code or DNR.

Based on interview, record review, and facility policy review, the facility failed to follow a care plan related to weight loss for one of six residents (Resident (R) 8) reviewed for nutrition out of 20 sampled residents. This had the potential for the resident to have a delayed response to weight loss. Findings include: Review of R8's Admitting and Discharge Record, located in the Facesheet tab of the electronic medical record (EMR) revealed the resident was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD) and dementia. Review of orders located under the Physician Orders Medispan of the EMR revealed an order for monthly weights, dated 10/17/22. Review of R8's Care Plan, located in the Care Plans tab of the EMR, revealed a problem of unintended weight loss dated 11/07/24. A goal was to maintain weight for three months. Interventions included for the aides to: weigh me every week. Review of R8's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/08/24 and located under the MDS tab of the EMR revealed she scored 13 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. R8 was on a mechanically altered diet and had no significant weight loss. R8 weighed 142 pounds (lbs). Review of the Reports section of the EMR under Weights as well as the Nursing tab of the EMR revealed R8 had the following monthly weights entered but no weekly weights: 07/03/24 153.4 lbs 08/06/24 157.4 lbs 09/05/24 150.0 lbs 10/03/24 148.6 lbs 11/06/24 141.2 lbs 11/07/24 142.6 lbs 12/04/24 140.1 lbs 01/01/25 134.2 lbs During an interview on 01/12/25 at 1:52 PM, R8 reported that staff weighed her the other day. R8 was unaware of any weight change. During an interview on 01/14/25 at 1:00 PM, Registered Dietician (RD) 2 stated she was unaware of any weight loss for R8 for the month. I tabulate the monthly weights, but I had not tabulated the monthly weights yet at this point. RD2 stated R8 was weighed monthly. During an interview on 01/14/25 at 3:34 PM, the MDS Coordinator (MDSC) reported Residents don't get a weekly weight unless they pop with weight loss or gain. The MDSC stated the care plan for weekly weights was probably from a while back because R8 used to be on weekly weights. During an interview on 01/15/25 at 10:53 AM, the Director of Nursing (DON) stated she expected the care plan to be followed. During an interview on 01/15/25 at 1:05 PM, the Administrator reported the facility did not have a policy regarding the following of care plans. The facility went by the RAI (Resident Assessment Instrument) Manual. Review of the RAI Manual, revised October 2023, revealed, The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care.

Based on record reviews, interviews, and policy review, the facility failed to timely monitor the weights of two (Residents (R) 39 and R8) of seven residents reviewed for nutrition out of a total sample of 20 residents. Findings include: 1. R39 was originally admitted to the facility on [DATE] with diagnoses that included hemiplegia following intracerebral hemorrhage affecting her left non-dominant side and dysphagia. Review of R39's annual Minimum Data Set (MDS) and with Assessment Reference Date (ARD) of 10/17/24 located in the electronic medical record (EMR) revealed the resident had a Brief Interview for Mental Status (BIMS) of 13 out of 15, indicating R39 was cognitively intact. A review of R39's care plan revealed a focus indicating the resident had unintended weight loss due to a history of not eating or drinking enough as well as losing too much weight in the past. Interventions for this focus included weighing the resident and keeping an eye on how much I drink provide my nutrition and fluids as scheduled . The goal for this focus was to enjoy my meals, stay well hydrated, maintain my weight, be comfortable eating and drinking without choking or coughing, have my nutritional needs met. Another focus revealed a potential for alteration in nutrition related to tube feeding to supplement PO [by mouth] intake. The goal for this focus was to maintain current weight and have no significant weight loss using interventions that included monthly weights and monitoring intake and output. Review of the Reports section under the Weights section in the EMR revealed the residents' weights: 09/05/24 190.2lbs; 10/03/24 192.6lbs; 11/06/24 191.2lbs; 12/04/24 191.8lbs; 01/01/25 182lbs. This revealed a weight loss of 5.11% in approximately 30 days. During an interview with R39 on 01/13/25 at 10:00AM she stated that she eats three meals a day plus snacks and receives tube feedings overnight. An interview was conducted with Certified Nursing Assistant (CNA)1 on 01/13/25 at 1:21PM and she confirmed the resident's intake was typically less than 25% of the given meal. Adding that most times the resident received grilled cheese as a substitute for the provided meal and will only eat a few bites. Review of the CNA charting documentation revealed the resident had eaten 0-25% of the daily meals provided for the last 30 days. An interview was conducted with Registered Dietitian (RD) 1 on 01/13/25 at 1:43 PM, and she confirmed the resident was weighed every 30 days. The RD added that most residents are weighed monthly, unless a concern was identified, and that person would be on weekly weights. RD1 then explained that she pulls the weights weekly or monthly and puts them on a spreadsheet to discuss and share during the weekly staff meetings. RD1 was asked about R39 having significant weight loss and she stated that she was not aware as she and her team were just reviewing the 30-day weights taken on 01/01/25. In a subsequent interview with the RD1 on 1/13/25 at 2:03 PM, she confirmed that a re-weigh was done and confirmed a weight of 180.2 lbs, revealing a weight loss of 6.05% since 12/04/24. An interview was conducted with the Assistant Director of Nursing (ADON) on 01/14/25 at 11:19 AM, and she stated that the RD team provides the nursing team with a report weekly advising of any significant changes in resident weights. The ADON stated that R39 was not reported as her weight had been consistent before this month. 42440 2. Review of R8's Admitting and Discharge Record, located in the Facesheet tab of the EMR revealed the resident was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD) and dementia. Review of orders located under the Physician Orders Medispan of the EMR revealed a diet order for cardiac diet with chopped meats, gravy on the side, mechanical soft, and double portions all meals, dated 11/07/24. An order for monthly weights was dated 10/17/22. Review of R8's Care Plan, located in the Care Plans tab of the EMR, revealed a problem of unintended weight loss dated 11/07/24. A goal was to maintain weight for three months. Interventions included for the aides to: weigh me every week, setup my meal so I can eat, let me take as much time to eat as I need, let me eat uninterrupted, ask me if I like my meal offer me something else if I don't like the meal. Review of R8's Department Notes tab of the EMR revealed a Quarterly Dietary Note dated 11/07/24 which documented a less than one-percent weight loss over one month, three-percent weight loss over three months, and stable weight over six months. The nutritional approach stated, Will continue to follow for labs, intake, weight, skin integrity, GI [gastro-intestinal] status. Review of R8's quarterly MDS with an ARD of 11/08/24 and located under the MDS tab of the EMR revealed she scored 13 out of 15 on the BIMS, indicating intact cognition. R8 was on a mechanically altered diet and had no significant weight loss. R8 weighed 142 pounds (lbs). Review of the Reports section of the EMR under Weights as well as the Nursing tab of the EMR revealed R8 had the following weights entered since July 2024: 07/03/24 153.4 lbs 08/06/24 157.4 lbs 09/05/24 150.0 lbs 10/03/24 148.6 lbs 11/06/24 141.2 lbs 11/07/24 142.6 lbs 12/04/24 140.1 lbs 01/01/25 134.2 lbs The weight loss from 07/03/24 to 01/01/25 was a 12.52 percent loss in six months. During an interview on 01/12/25 at 1:52 PM, R8 reported that staff weighed her the other day. R8 was unaware of any weight change. R8 reported she ate in her room because she chose to, and if she liked something, she asked for more. During an interview on 01/14/25 at 1:00 PM, Registered Dietician (RD) 2 stated she was unaware of any weight loss for R8 for the month. I tabulate the monthly weights, but I had not tabulated the monthly weights yet at this point. RD2 stated R8 was weighed monthly. RD2 stated that R8 had some weight loss prior to January, but it had not reached a significant level, so she (R8) was just monitored. RD2 stated if a resident triggered for a five-percent weight loss in one month or 10 percent weight loss in six months, they were put on the weekly weight list. During an interview on 01/14/25 at 3:34 PM, the MDS Coordinator (MDSC) reported the facility ran a weight change roster when they did the MDS assessments. Residents don't get a weekly weight unless they pop with weight loss or gain. The MDSC reported that the Certified Nursing Assistants (CNAs) did the monthly weights the first part of the month and entered them into the EMR. We discovered either today or yesterday that CNAs couldn't see the previous weight when entering in weights [so were not aware if there had been a change]. Once weights are entered into the EMR, the RDs reviewed them by running a monthly report. During an interview on 01/15/25 at 10:53 AM, the Director of Nursing (DON) stated the restorative CNAs weighed residents. The RDs were to pull the monthly and weekly weight reports. The DON expected the dietician to pull the reports timely. Review of the facility's Weight Assessment and Intervention policy, revised September 2011, revealed Any weight change of 5% or more since the last weight assessment will be retaken for confirmation. If the weight is verified, nursing will immediately notify the Dietician.

Based on observation, interview, record review, and policy review, the facility failed to administer oxygen at the physician prescribed dose for one of two residents (Residents (R) 164) reviewed for respiratory care out of a total sample of 20. This had the potential to cause residents respiratory distress. Findings include: Review of R164's Admitting and Discharge Record, located in the Facesheet tab of the electronic medical record, (EMR) revealed the resident was admitted to the facility on [DATE] with diagnoses that included pneumonitis due to inhalation of food and vomit and autistic disorder. Review of R164's Care Plan, located in the Care Plans tab of the EMR, revealed a problem of potential for altered respiratory status dated 12/17/24. Interventions included, Administer oxygen as ordered. Review of R164's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/23/24 and located under the MDS tab of the EMR, revealed R164's Staff Assessment for Mental Status indicated short- and long-term memory problem. R164 utilized oxygen therapy. Review of R164's Medication Administration Record (MAR), located in the under EMR the MAR tab, revealed an order dated 01/02/25 for oxygen at two liters/minute per nasal cannula to keep oxygen saturations greater than or equal to 92% as needed. During an observation on 01/12/25 at 9:09 AM, R164 was observed lying in bed with his eyes closed. The resident had an oxygen cannula in place, running from a concentrator that was set at 3.5 liters per minute (LPM). During an observation on 01/13/25 at 9:30 AM, R164's oxygen concentrator was again set at 3.5 LPM. During an observation on 01/13/25 at 5:15 PM, R164's oxygen concentrator was again set at 3.5 LPM. During an interview on 01/13/25 at 5:20 PM, Certified Nursing Assistant (CNA) 1 stated R164 used oxygen routinely for many months. CNA1 was not aware of the specific oxygen settings for residents and made no adjustments to oxygen settings. During an interview on 01/13/25 at 5:23 PM, Registered Nurse (RN) 2 stated R164's nurse was on break. RN2 observed R164's oxygen concentrator setting and verified it was set at 3.5 LPM. During an interview on 01/14/25 at 04:25 PM, RN2 stated she was unaware on 01/13/25 of R164's oxygen setting when she verified it was set at 3.5 LPM. After the observation, RN2 reported that she spoke to R164's nurse, confirmed the order was 2 LPM, and R164's nurse corrected the concentrator setting to 2 LPM. During an interview on 01/15/25 at 10:46 AM, the Director of Nursing (DON) stated when an order was for oxygen at 2 LPM, the setting should not be changed without notification to the doctor and an order. The DON stated using oxygen at a non-prescribed setting could cause adverse effects. Review of the facility's Oxygen Administration policy, revised 11/24/14, revealed the purpose of providing oxygen administration per the physician's orders was to avoid the inappropriate administration of oxygen via incorrect devices or at incorrect liter flows, either of which could be detrimental to the patient. It stated, At no time shall anyone change the administration device or the prescribed liter flow without obtaining an order to do so from the physician.

Based on record review, staff interviews, and review of facility policy titled, 'Resident Assessments', the facility failed to complete a Quarterly Minimum Data Set (MDS) Assessment not less than every three months for one resident (R) (#16) of 21 sampled residents. Findings include: Review of facility policy titled 'Resident Assessments' effective 11/2018 revealed 1. The Resident Assessment Coordinator is responsible for ensuring that the Interdisciplinary Team conducts timely and appropriate resident assessments and reviews according to the following requirements: a. 2. Quarterly Assessment-Conducted not less frequently than three (3) months following the most recent OBRA assessment of any type. Review of R#16's MDS Assessments revealed that a Quarterly MDS Assessment was completed 3/10/2023 with a target date of 12/24/2022. An interview on 4/30/2023 at 9:47 a.m. with Administrator revealed the current MDS Coordinator started 4/17/2023. Stated prior to the new MDS Coordinator starting, the facility was without an MDS Coordinator for approximately 5 months. Stated she attempted to keep up with the assessments herself because she was previously an MDS Coordinator and has experience. Further interview revealed she became aware the assessments were behind in March and has been working to catch them up. Confirmed R#16's assessment should have been submitted in December 2022 and another Quarterly MDS assessment should have been submitted in March 2023.

Based on record review, staff interviews and review of facility policy titled, 'Electronic Submission of MDS', the facility failed to ensure that Minimum Data Set (MDS) assessments were transmitted within 14 days of completion to CMS's (Centers for Medicare and Medicaid Services) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system for two residents (R) (R#27 and R#33) of five residents reviewed. The sample size was 21. Findings include: Review of facility policy titled, 'Electronic Submission of MDS' dated 7/2020 revealed All MDS assessments (e.g. admission, annual, significant change, quarterly review, etc.) and discharge reentry records are completed and electronically encoded into our facility's MDS information system and transmitted to CMS's QIES Assessment and Submission Processing (ASAP) system in accordance to with current OBRA regulations governing the transmission of MDS data. 1. Review of R#27's completed MDS revealed an Entry Assessment with target date of 11/8/2022 and completed date 11/8/2022, an Admission Assessment with target date 11/20/2022 and completed 11/21/2022, and a Discharge Return Not Anticipated Assessment with target date 12/15/2022 and completed 12/21/2022. The facility did not provide evidence these assessments were submitted to the QIES System. 2. Review of R#33's completed MDS revealed a Quarterly Assessment with a target date of 8/19/2022 and completed on 9/2/2022, a Quarterly Assessment with target date 11/19/2022 and completed on 11/23/2022, and a Discharge Return Not Anticipated Assessment with a target date 12/1/2022 and completed 12/13/2022. The facility did not provide evidence these assessments were submitted to the QIES System. An interview on 4/30/2023 at 9:47 a.m. with the Administrator revealed the current MDS Coordinator started 4/17/2023. Stated prior to the new MDS Coordinator starting, the facility was without an MDS Coordinator for approximately 5 months. Stated she attempted to keep up with the assessments herself because she was previously an MDS Coordinator and has experience. Confirmed the R#27 and R#33's MDS assessments were not submitted within 14 days of completion.

Based on observation, record review, resident and staff interviews, and review of the facility policy titled Using the Care Plan, the facility failed to provide catheter care as care planned for one resident (R) (A) of 35 sampled residents. Findings include: Review of the facility policy titled Using the Care Plan revised 3/2019 revealed a policy statement: the care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident. The Admission Minimum Data Set ((MDS) dated [DATE] for R A documented that the resident had a Brief Interview of Mental Status (BIMS) score of 14, indicating cognition was intact. [DIAGNOSES REDACTED]. Review of Section H - Bowel and Bladder revealed resident has an indwelling catheter. The care plan which was last updated on 11/15/19 revealed the following: Problem: [MEDICAL CONDITION] related to obstruction, neuromuscular impairment manifested by bladder distention and no urine output. Interventions included: catheter care qd (daily) and catheter care with care and PRN (as needed). During an interview on 12/2/19 at 1:44 p.m., RA stated that she has had a Foley catheter since before she got to the facility from the hospital. She stated that staff change it every month but do not clean the tubing near the insertion site. She stated she washes down there when taking a shower. Observation at this time revealed the catheter stabilization device was dated for 11/26/19. Observation of catheter care on 12/04/19 at 3:30 p.m. revealed CNA BB provided peri care and Licensed Practical Nurse (LPN) DD entered the room and provided instruction to the CNA on cleaning the catheter. The catheter stabilization device was still dated 11/26/19 and was not changed during catheter care. CNA BB stated that she is supposed to do catheter care every shift. During a follow up interview on 12/04/19 at 4:10 p.m., RA asked if staff were supposed to be cleaning the catheter like that every day. The resident confirmed that the care just provided is not something that is done daily. RA stated she would remind them from now on. In-services were conducted on 10/1/19, 8/6/19, and 5/20/19 related to peri care. CNA BB's signature was not included on the in-service sign in sheets. Cross Refer to F690.

Based on record review and staff interview, the facility failed to ensure that [MEDICAL CONDITION] medications including an antianxiety medication was not ordered as needed (PRN) for more than 14 days unless clinically indicated for one resident (R) (R#45) of five residents (R#24, R#40, R#34, R#47) reviewed for unnecessary medications. Findings include: Review the Minimum Data Set (MDS) Annual assessment for R #45 dated 10/25/19 indicated the resident's Section C-Cognition: Brief Interview of Mental Status (BIMS) score of three (3) indicating a severe cognitive deficit, and Section I-Diagnoses: [REDACTED]. Review of R#45 [DIAGNOSES REDACTED]. Review of R#45 care plans revealed: A potential of adverse medication side effects related to [MEDICAL CONDITION] medications, manifested by lethargic, loss of appetite, tardive dyskinesia. The goals include no visible side effects and no changes in her Abnormal Involuntary Movement Scale (AIMS) score, observe for change in function and report to the Physician, and Pharmacist Consultant evaluations. Potential for Violence directed at others; administer prescribed medications, observe for side effects, assess for effectiveness. Potential for anxiety; administer antianxiety medications as ordered by the Physician. Review of R#45 Physician orders [REDACTED]. Review of R#45 AIMS score dated 6/19/19 revealed a score of 0 indicating no side effects from the use of an antipsychotic. Review of the Medication Administration Record [REDACTED]. Review of the document titled Archbold High Tech Pharmacy Consultant Pharmacist's Medication Regimen Review Summary Prepared for Glenn-Mor Nursing Home, not dated, indicated: Current Review/Recommendations for Action for [MEDICATION NAME]: Please remind the staff to request a 14 day stop order for PRN psychoactive medications. Review of the document titled Pharmacist's Consult to Physician dated 11/1/19 revealed: The resident receives the psychoactive medication, [MEDICATION NAME] 0.5 MG by mouth (PO) TID PRN. New guidelines seek to decrease the use of these medications on an as needed basis and require re-evaluation of these orders after 14 days. The Physicians response was: This medication improves the quality of the resident's life. The resident is responding to therapy and is experiencing no adverse effects from this therapy. An interview held on 12/05/19 at 8:30 a.m. with LPN AA stated R#45 hardly ever gets the [MEDICATION NAME] PRN, she indicated the residents daughter requested to keep the [MEDICATION NAME] PRN. The nurse verified the [MEDICATION NAME] order did not have a stop date. She indicated the residents original order for the [MEDICATION NAME] was discontinued (not sure of the date) and then a new order was written on 10/11/19. Last dose the resident received was on 11/27/19. An interview held on 12/05/19 at 8:35 a.m. with the Director of Nursing (DON) revealed the Pharmacy Consultant comes in monthly and evaluates all the residents medications including the PRN antipsychotic's. She looked at the Consultant Pharmacist recommendation completed in (MONTH) in her Consultant Pharmacist book and in R#45 medical record, the DON indicated the order for the [MEDICATION NAME] should not be a PRN or it should have an end date or stop date. She indicated the resident had a Pharmacy Recommendation completed on 11/1/19 to reevaluate the use of the [MEDICATION NAME] on a PRN basis after 14 days. Her process included when she receives the recommendations from Consultant Pharmacist she gives them to the Physician, when medical records get them back from the Physician, she will then review the recommendations and write any orders that are on the recommendations. She verified the [MEDICATION NAME] order for [REDACTED]. An interview held on 12/05/19 at 10:00 a.m. with the Administrator revealed they do not have a policy dedicated to the use of PRN antipsychotic's. She indicated the residents daughter, who is a nurse, insists the resident have the PRN [MEDICATION NAME] available if her mother needed it. She also indicated the DON informed her that the resident doesn't take it very often. Her expectations are for all the PRN antipsychotic's to have a stop date or be stopped and re-ordered when needed.

Based on observation, record review, resident and staff interviews, and review of the facility policy titled, Insertion, Removal, and Care of Indwelling Catheter, the facility failed to provide catheter care as ordered for one resident (R) (A) of four residents reviewed with catheters. Findings include: Review of the facility policy titled, Insertion, Removal, and Care of Indwelling Catheter revised 2/2017 revealed the purpose is to provide guidelines for catheter care and specimen collection from the catheter. XI. Infection Control Considerations: B. Clean the perineal area and catheter tubing proximal to distal, with body cleanser/perineal cleanser or sage wipes daily and after every bowel movement. The Admission Minimum Data Set ((MDS) dated [DATE] documented resident with a Brief Interview of Mental Status (BIMS) score of 14, indicating cognition intact. [DIAGNOSES REDACTED]. Review of Section H - Bowel and Bladder revealed resident has an indwelling catheter. The (MONTH) 2019 Physician Orders included orders dated 10/21/19 for the following: Catheter Care: Ensure that CNA (certified nursing assistant) has completed catheter care daily. Change catheter stabilization device one time per week on Tuesday. During an interview on 12/2/19 at 1:44 p.m., RA stated that she has had a Foley catheter since before she got to the facility from the hospital. R A stated that staff change it every month but do not clean the tubing near the insertion site. She stated she washes down there when taking a shower. Observation at this time revealed the catheter stabilization device was dated for 11/26/19. Observation of catheter care on 12/04/19 at 3:30 p.m. revealed CNA BB provided peri care and Licensed Practical Nurse DD entered the room and provided instruction to the CNA on cleaning the catheter. The catheter stabilization device was still dated 11/26/19 and was not changed during catheter care. CNA BB stated that she is supposed to do catheter care every shift. During a follow up interview on 12/04/19 at 4:10 p.m., RA asked if staff were supposed to be cleaning the catheter like that every day. The resident confirmed that the care just provided is not something that is done daily. RA stated she would remind them from now on. During an interview on 12/05/19 at 12:00 p.m., CNA CC was asked about receiving in-services related to catheter care. CNA CC stated that she has only been working on this unit for three days. CNA CC stated that she does not normally work on this unit and is PRN (as needed). During an interview on 12/5/19 at 12:30 p.m., the Infection Control Nurse stated that the CNA's are provided in-services with return demonstration for peri care which includes catheter care. Review of the in-service sign in sheets dated 10/1/19, 8/6/19, and 5/20/19 revealed education provided to staff on peri care. CNA BB and CNA CC were not included in the signatures. In-service sign in sheets were provided by the facility for Foley catheter dated 6/12/19 and external catheter dated 9/17/19 which did not include the signatures of CNA BB or CNA CC. Interview of the Director of Nursing (DON) on 12/05/19 at 12:39 p.m. revealed that the CNA's are responsible for catheter care and they should know how to provide catheter care and that it should be done daily.

Based on observation, interview and record review, the facility failed to complete Quarterly Minimum Data Sets (MDS) as required by the guidelines in the Resident Assessment Instrument (RAI) for two residents (R) (2, #8) out of 35 sampled residents. Findings Include: 1. R#2 admitted to the facility with [DIAGNOSES REDACTED]. Record review of an un-named report dated 7/25/18 submitted by the MDS Consultant for R#2 revealed an Entry Tracking Assessment with a target date of 2/21/18 was not completed until 6/28/18. Further review revealed the (MONTH) (YEAR) Quarterly Assessment scheduled to follow the Annual MDS dated [DATE] was not completed. 2. R#8 admitted to the facility with [DIAGNOSES REDACTED]. Record review of an un-named report dated 7/25/18 submitted by the MDS Consultant for R#8 revealed a Quarterly MDS assessment dated [DATE] without any further assessments documented as being completed. Interview on 7/25/18 at 8:32 a.m. with the MDS Consultant regarding R#8's last MDS assessment she confirmed that 3/1/18 was the last assessment for R#8. She further revealed that the system they use is not providing the correct information when they run the report for Assessment Reference Date (ARD). Further interview with the MDS Consultant revealed that the facility relies solely on the electronic system to provide information for ARD's. She further revealed the MDS staff use the Resident Assessment Instrument (RAI) manual as the policy. Interview with the Director of Nursing (DON) on 7/25/18 at 2:04 p.m. revealed the (MONTH) (YEAR) quarterly assessment is missing for R#2. Interview on 7/25/18 at 9:28 a.m. with the Administrator revealed she confirmed it is a system failure they were unaware of. Review of the Center for Medicare/Medicaid Services (CMS) RAI Version 3.0 Manual, page 5-4 dated (MONTH) (YEAR) revealed: Assessment schedule - An Omnibus Budget Reconciliation Act (OBRA) a quarterly assessment is due every quarter unless the resident is no longer in the facility. There must be no more than 92 days between OBRA assessments.

Based on observation, interview and record review, the facility failed to successfully submit Minimum Data Sets (MDS) to the state agency as required by the guidelines in the Resident Assessment Instrument (RAI) for two resident's (R) (#3, #49) out of 35 sampled residents. Findings include: 1. R#3 admitted to the facility with [DIAGNOSES REDACTED]. Record review of an un-named report dated 7/25/18 submitted by the MDS Consultant for R#3 revealed an Annual MDS assessment dated [DATE] with one unsuccessful attempt to submit the report to the state agency. No further attempts were made. 2. R#49 admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review of an un-named report dated 7/25/18 submitted by the MDS Consultant for R#49 revealed an Admission MDS dated [DATE] with one unsuccessful attempt to submit the report to the state agency. No further attempts were made. Further review revealed a five-day Admission assessment dated [DATE] and a 30-day MDS assessment dated [DATE] with one unsuccessful attempt to submit the report to the state agency. No further attempts were made. Interview with the Director of Nursing (DON) on 7/25/18 at 2:04 p.m. revealed we print what we have submitted then we check the next day or week to make sure it was accepted. If it wasn't accepted, we look to see why. Interview on 7/25/18 at 9:28 a.m. with the Administrator revealed she confirmed that this is a system failure that they had not previously been aware of. Review of the Center for Medicare/Medicaid Services (CMS) RAI Version 3.0 Manual, page 5-3 dated (MONTH) (YEAR) revealed: Within seven days after completing a resident's MDS assessment or tracking record, the provider must encode the MDS data for comprehensive assessment (Admission, Annual, Significant Change in Status and Significant Correction to Prior Comprehensive), encoding must occur within seven days after the Care Plan Completion Date (V0200C2 + 7 days).

Based on observation, staff interview and review of facility policy, the facility failed to store canned and dry goods in such a way as to prevent food-borne illness. Census in facility was fifty-three (53), with fifty-two (52) residents on oral alimentation and one (1) resident with a PEG tube who receives oral pleasure feedings. Findings include: Observation on 04/15/15 at 11:00 a.m. revealed that four (4) jars of grape jelly, one (1) jar of Ham Base, two (2) jars of Bacon Base, six (6) jars of Chicken Base and six (6) bags of corn bread mix had no received date and no best by date. This observation was confirmed at the time by the Dietary Manager. Interview with the Dietary Manager at the time revealed that the facility uses a first- in, first-out storage system. The Dietary Manager confirmed in interview that without a consistent system where received dates are written on cans and boxes or best by date is visible on cans or boxes that it is not possible to confirm that the facility is using a first-in, first-out storage system. Observation on 04/16/15 at 1:56 p.m. revealed seven (7) cans of chili with received dates of 2011 and also revealed one (1)-can of ketchup, one(1) can of tuna, five (5)-cans of tropical fruit salad, and four (4) cans of fruit cocktail with no received date or best by date. Review of Facility Policy states that Dry Storage Life of canned goods is one (1) year or follow expiration date and that food should be disposed of if beyond the one (1) year timeframe. An interview with the Registered Dietitian (RD) "AA", on 04/16/15 at 2:00 p.m. revealed that he/she understood and confirmed the importance of rotating stock to prevent food-borne illness. RD "AA" went on to reveal that he/she understands the importance of having a system in place so that rotation of stored foods could be verified.

Based on observation, staff interview, and record review, the facility failed to ensure that the correct form of aspirin was administered for one (1) resident (#22) and the correct dosage of cough syrup was administered for one (1) resident (#21) by two (2) of two (2) nurses on two (2) of two (2) medication carts for a medication error rate of 6.89%. Findings include: During an observation of medication administration on 4/15/15 at 8:13 a.m., Licensed Practical Nurse "BB" administered Aspirin 81 milligram (mg) chewable to resident #22. Review of resident # 22's physician's orders [REDACTED]. On 4/15/15 at 9:25 a.m. Licensed Practical Nurse "BB" confirmed he/she administered Aspirin 81 milligram( mg) chewable to resident #22. Licensed Practical Nurse "BB" confirmed at this time that he/she should have given [MEDICATION NAME] coated delayed response Aspirin not chewable and did not administer the Aspirin as ordered. During an observation of medication administration on 4/15/15 at 8:42 a.m. Licensed Practical Nurse "CC" administered five (5) milliliters (ml) of [MEDICATION NAME] (DM) 100 mg/10 mg per 5 ml to resident #21. Review of resident #21's physician's orders [REDACTED]. An interview on 4/15/15 at 9:30 a.m. with Licensed Practical Nurse "CC" confirmed that he/she administered five (5) ml of [MEDICATION NAME] to resident #21and should have administered ten (10) ml as ordered. During an interview with the Director of Nursing (DON) on 4/15/15 at 11:00 a.m. revealed that he/she expects the nurses to administer medications as ordered by the physician and they failed to do so.

Based on observation and staff interviews, the facility failed to ensure expired medications were properly disposed of in a timely manner in one (1) of one (1) medication room and on one (1) of two (2) medication carts. Findings Include: Observation of the medication room on 4/16/15 at 3:05 p.m. with Licensed Practical Nurse (LPN) "EE"revealed the following expired medications: [REDACTED] Ferrous Sulfate oral solution 300 milligrams (mg)/5 milliliter (ml) five (5) ml containers ten (10) per box with following expiration dates: Two (2) unopened boxes with an expiration date of 4/14. Four (4) unopened boxes with an expiration date of 7/14. Two (2) unopened boxes with an expiration date of 3/14. During an interview on 4/16/15 at 3:05 p.m. Registered Nurse (RN) "DD" confirmed the medications were beyond their expiration dates and should not be in the medication room. Observation of the medication cart referred to as the short hall cart on 4/16/15 at 3:20 p.m. revealed the following expired medications: [REDACTED] Ferrous Sulfate oral solution 300 mg / 5 ml one(1) open box of ten (10) with eight (8) containers present with an expiration date of 7/14 with open date written on the box of 4/15/15. During an interview on 4/16/15 at 3:20 p.m. with Registered Nurse (RN) "DD" confirmed the presence of Ferrous Sulfate oral solution with an expiration date of 7/14. During further interview on 4/16/15 at 3:30 p.m. "DD" revealed the medications should not be given after the expiration date. On 4/16/15 at 4:17 p.m. the Director of Nurses (DON) revealed one (1 ) resident (#23) had received the expired Ferrous Sulfate with an open date of 4/15/15 on the container.

Based on observations, staff interviews and review of computerized and paper records, it was determined that the facility had failed to provide a two person assist with transfer and to do an investigation of an incident which resulted in a serious injury on 3/19/12 for one (#37) of two residents, who had sustained a fracture in the facility, from a total sample of 33 residents. Therefore it was determined that the likelihood of a serious injury or harm had existed for resident #37 since 3/23/12 and continues. Findings include: According to the "Resident Census and Conditions of Residents" form (CMS 672) it has 63 residents. Forty (40) of its 63 residents require the assistance of one or two staff. Another thirteen (13) of the 63 residents are totally dependent on staff for transfers. Resident #37 had [DIAGNOSES REDACTED]. Resident #37 was out of bed and at medical appointment on 5/31/12 at 8:30 a.m. She had been transferred back to bed was asleep during a subsequent observation at 11 a.m. There was 5/31/12 physician's orders [REDACTED]. The 1/7/12 nurses note said that the resident fell out of the wheelchair in the facility hallway and had sustained a hip fracture on 1/7/12. The Plan of treatment for [REDACTED]. After the left hip at fracture, the facility staff completed a significant change comprehensive assessment on 1/14/12. Facility staff assessed and coded the resident on the 1/14/12 Minimum Data Set (MDS) as declining from a one person transfer to a two person person transfer. The facility had developed a care plan dated 12/13/11 for the resident's potential for falls related to devices used by staff for resident #37's transfers. However, the staff did not develop any care plan to specifically address how to transfer resident #37. There was documentation in the 1/25/12 electronic physical therapy daily progress notes that instructions had been given (to nursing staff) on how to use the lift to transfer the resident from the bed to the geri-chair. Those daily progress notes did not include instructions on whether the resident required a one or two person assist to transfer. During an interview on 6/01/12 at 10:00 a.m., the Physical Therapist stated that prior to 3/19/12, the resident was safe to transfer with a mechanical lift with a one person assist. A licensed nurse on the 3-to-11 shift documented in the 3/19/12 nurses notes that CNA "CC" had reported that the resident's left lower leg was swollen. The nurse wrote that CNA "CC" reported that the resident's leg had gotten caught in the Geri-chair while he/she was transferring the resident from the Geri-chair into bed. The resident was sent to the emergency room for an x-ray. The 3/19/12 hospital radiology report noted that the resident had sustained non-comminuted, minimally displaced fractures of the left tibia and fibula. The 3/19/12 nurses note does not mention the number of CNAs who were involved in the transfer or if a mechanical lift was used and if so, the type of lift. According to the 1/7/12 nurses note, CNA "CC" said that the resident's leg had gotten caught in the geri-chair during the transfer from the chair to the bed. However during the 6/1/12 interview at 10:00 a.m., the physical therapist said that CNA "CC" told her that the resident's leg had gotten pinned in the side rail. There was no documentation that an investigation had been done to determine how the resident sustained [REDACTED]. In an interview on 5/31/12 at 2:30 p.m., licensed nurse "BB" stated on 3/19/12 he/she had gone into resident #37's room after "CC" reported that the resident's left leg was swollen. He/She said that since the incident that no one had asked her for a statement about what she had seen. During an interview on 5/31/12 at 1:40 p.m. licensed nurse "OO", who had been on duty and at the nurses station on 3/19/12, said that he/she thought that CNA "CC" had used a mechanical lift to transfer the resident but, no one had interviewed her/him about the incident. There was no evidence in the resident's medical record or provided by the facility that the facility had investigated the specific circumstances of the avoidable accident that resulted in the resident sustaining fractures of her left tibia and fibula to try to prevent further injury and to reduce his/her risk of harm from the the use of the Hoyer lift, inadequate number of staff assisting with transfer, inappropriate technique during transfer and to reduce the potential risk of entrapment of body parts. Administrative nurse "AA" was unable to provide any documentation that the facility had investigated the incident the 3/19/12 accident when it was requested on 5/31/12 at 10:30 a.m.,1:45 p.m. and 2:30 p.m. During the interview about the 3/19/2012 incident on 5/31/12 at 10:30 a.m., Administrative nurse "AA" said that she did not know if a mechanical lift was used during transfer of the resident or how many staff were present during the transfer. During an interview on 5/31/12 at 6:35 p.m., CNA "CC" said that no one had ever asked her specifically what had happened during the transfer of the resident on 3/19/12. In separate interviews, the Administrator (on 5/31/12 at 4:40 p.m.) and the Director of Nursing (on 5/31/12 at 5:40 p.m.) were asked for any evidence that the facility had identified and developed interventions to ensure the safety of resident #37 during transfer with the Hoyer lift However, as of the interviews, they had not done an investigation or have any evidence to identify or develop interventions to ensure the resident's safety since the 3/19/12 accident when the resident sustained [REDACTED].'s leg fractures. There was no evidence that the facility conducted an investigation in order how to reduce the likelihood of serious harm or injury to resident #37 from the the use of the Hoyer lift, the level of staff assistance required during transfer with the lift or the potential risk of entrapment of body parts. After the resident fell out of her chair in the hallway and sustained a fractured left hip, he/she was referred for skilled physical therapy services on 1/10/12. In a review of the electronic medical record, there was a 1/25/12 "Daily Physical Therapy Progress Note" that resident required total staff assistance assist for transfer with a mechanical lift and nursing staff had been trained on the transfer technique. On 6/1/12 at 10:00 a.m., the physical therapist said that until the accident on 3/19/12 the resident was safe to transfer with a one person assist and a mechanical lift. The physical therapist said that she had trained the nursing staff on how to transfer the resident with a one person assist and a Hoyer lift in January. According to the 1/24/12 to 1/25/12 daily progress notes, nursing staff had been trained and demonstrated the transfer technique. The resident had a care plan since 12/13/11 which did not specify a one or two person assist with transfers. The CNA flow sheet entry for his/her transfer were for the assist of one person to transfer with a Hoyer lift. When the resident returned from the hospital after the 3/19/12 with a [DIAGNOSES REDACTED]. The 3/23/12 Physical Therapy screen noted that an (physical therapy) evaluation was not indicated. The physical therapist, who had also done the 1/25/12 note, also did the 3/23/12 screening. The physical therapist wrote in the electronic medical record by the heading "Evaluation" that the resident did not have new positioning needs or training required. However, the physical therapist wrote a recommendation that nursing staff provide the assistance of two people with the lift transfer for the resident's safety. During the interview on 6/1/2012 at 10 a.m., the physical therapist said after her 3/23/12 screening of the resident, that she had recommended to the Director of Nursing (DON) that because of the resident's two fractures, that the resident be provided a two person transfer with the mechanical lift. She said that she had also discussed with the Director of Nursing the specific training that nursing staff needed to have with CNA "CC". She said that her expectation was that the nursing staff would train that CNA. In an interview with the DON on 5/31/12, she said that the resident had been transferred with a two person assist since the 3/23/12. However, the care plan and CNA flow sheet since 3/23/12 does not include the use of a two person assist to transfer the resident with a lift. In an interview on 5/31/12 at 6:25 p.m., CNA "CC" said that after the 3/19/12 accident, the physical therapist told her that the nurses would provide training to her. However, CNA "CC" stated that no one had ever provided any training for her on how to transfer the resident after the accident. CNA "CC" stated that the only training that she had received had been instructions on how to transfer to do a one person transfer of the resident with a lift but, that training had been before the 3/19/12 accident. CNA "CC"'s name was not on the list of four CNAs who were trained by the physical therapist on 1/24-25/12 on how to transfer resident #37. CNA CC said that after the accident she had demonstrated how to do a one person assist transfer with the Hoyer lift to the DON for two residents. CNA "CC" said that she had continued to transfer resident #37 by herself using the mechanical lift as recently as 5/26/12. She said that she had not been told to use a two person assist with the Hoyer lift to transfer resident #37. The use of a two person assist to transfer resident #37 with a lift was not included as an entry on the CNA flow sheet for May 2012 (as of the time of the interview). She stated that no one had ever asked her specifically what had happened during the transfer of the resident on 3/19/12. During an interview on 5/31/12 at 5:40 p.m., the Director of Nursing stated that the resident was supposed to have a two person assist transfer with the mechanical lift after the 3/19/12 accident. She said that she had provided in-service and training of the correct transfer method with CNA "CC" three times after the 3/19/12 accident but, she did not document it. There was no evidence that training on the use of a two person assist with the lift for transfer for resident #37 had been done. In an interview on 6/1/12 at 10 a.m., the physical therapist said that she had provided the DON with specific information on the training CNA "CC" after the accident. The DON stated that (physical) therapy and the Minimum Data Set (MDS) Coordinator would have been responsible for assessing the resident's transfer needs before and after the resident's 3/19/12 accident that had resulted in a fracture. In an interview on 6/1/12 at 9:45 p.m., the licensed nurse "PP" said that the normal process is that if the resident has had a fall or change in condition then a referral is made to skilled therapy for the safest and correct way to transfer. She said that if the skilled therapist made a recommendation to nursing then, then the nurse should tell her about the recommendation so the resident's care plan can be revised. Licensed nurse "PP" said that nursing staff had not notified her about the physical therapist's 3/23/12 recommendation for the resident #37 to have a two person assist to transfer with the mechanical lift. During the discussion about care plan entries on how to transfer a resident, at 11:35 p.m. on 6/1/12, licensed nurse "PP" said that there did not need to be a physician's orders [REDACTED]. Although, in an interview on 6/1/12 at 10 a.m., the physical therapist said that it would be up to the CNA to decide if one or more people should be present for a transfer using a Hoyer lift, licensed nurse "PP" said that was not within the CNA's scope to assess a resident to determine that resident's transfer needs. There was a note written on the 3/31/12 care plan by an unidentified writer that CNA "CC" whose transfer of resident #37 on 3/19/12 transfer had resulted in the resident sustaining left leg fractures was trained by DON on safe transfer technique for resident. The unidentified writer also noted that the staff had demonstrated a safe transfer technique but the writer did not identify who those staff were. Unidentified staff had also written on the care plan that several staff were previously trained by PT on safe transfer technique for the resident. The 3/31/12 care plan did not include an intervention for the use of a one or two person assist to transfer resident #37 with a mechanical lift, The was no evidence that training had been provided to CNA "CC" on the use of a two person assist with the mechanical lift for transfer of resident #37. The physical therapist said in the 6/1/12 interview at 10 a.m. that the transfer education she had provided for nursing staff on 1/25/12 was to demonstrate the one person transfer with a mechanical lift for resident #37. After the resident sustained [REDACTED]. Although the facility had completed significant change assessments on 12/13/12 and 3/23/12, the resident was assessed as requiring two people for transfers There was a 3/23/12 physical therapist's recommendation for nursing staff to use two people to transfer the resident with the mechanical lift for his/her safety. When the electronic CNA flow sheets and the care plans were reviewed and the MDS licensed nurse was interviewed on 6/1/12 at 11:30 about the facility's normal process, there was no documentation of any evidence that those assessments of the resident's safety needs had been communicated to the direct care nursing staff. The Director of Nursing did not have any documentation on 5/31/12 at 5:40 p.m. that interventions to promote the resident's safety during transfers had been communicated to the nursing staff. The interdisciplinary care plan team did not include that change in resident #37's assessed transfer needs in his/her care plan. There was no evidence that supervisory nursing staff had communicated to CNAs, who were providing direct care to the resident, that two people should assist the resident to transfer with the Hoyer lift for resident 37 's safety. There was no documentation that nursing staff had been trained on the use of a two person assist with the mechanical lift to transfer resident # 37. The resident #37's care plan and the CNA flow sheet did not reflect the resident's 3/23/12 assessed needs for transfers and to promote his/her safety with the provision of a two people assist during transfer with the mechanical lift. CNA "CC", who had been involved in the 3/19/12 accident, said he/she was using a one person assist with the mechanical lift to transfer the resident #37 and had done one on 5/26/12. After resident #37 had sustained fractured tibia and fibula during a one person assist transfer with the Hoyer lift, the facility failed to develop a care plan to ensure that a two person assist was being used to transfer resident #37. The facility's failure to ensure that a two person assist was provided to resident #37 during transfer with a Hoyer lift increased likelihood of serious injury or harm while being be transferred with Hoyer lift.

Based on staff interview and record review, it was determined that the facility failed to develop a care plan based on the assessed number of people required for transferring for one (#37) of two residents, who had sustained a fracture in the facility, from a total sample of 33 residents. While one CNA assisted resident #37 to transfer with a Hoyer lift on 3/19/12, the resident's leg became entrapped and the resident's left tibia and fibula were fractured. On 3/23/12 the facility completed a significant change comprehensive assessment and assessed the resident as requiring a two (2) person assist with transfers. However, the facility did not include that assessment in the care plan which was reviewed on 3/31/12. The interdisciplinary care plan team's failure to develop a care care plan for the resident which addressed the number of staff required to assist him/her to transfer had the likelihood of resulting in serious harm or injury for resident #37. It was determined that an immediate jeopardy had existed for resident #37 since 3/23/12 and continues. Findings include: According to the "Resident Census and Conditions of Residents" form (CMS 672) completed by the facility on 5/29/12, its census was 63 residents. Forty (40) of its 63 residents required the assistance of one or two staff to transfer. Another thirteen (13) of the 63 residents were totally dependent on staff for transfers. Resident #37's [DIAGNOSES REDACTED]. The resident's [DIAGNOSES REDACTED]. an accident. The facility developed a care plan dated 12/13/11 that the resident had the potential for falls related to the devices used for transfers. However the facility had developed care plan approaches which addressed the resident's specific transfer needs including the number of people required to assist the resident. According to the 1/7/12 nurses notes, the resident fell out of his/her wheelchair in the hallway of the facility on 1/7/12 and sustained a left [MEDICAL CONDITION]. After the resident sustained [REDACTED]. Facility staff coded the resident on the Minimum Data Set (MDS) as having declined from needing the assistance of one (1) person to transfer to needing two (2) people to assist with his/her transfer. However, the facility did not include the number of people required to safely transfer the resident in his/her 1/14/12 care plan. There was an 1/12/12 electronic "Daily Progress Note" by the physical therapist that the staff was supposed to provide total assistance and the use of a (mechanical) lift to transfer the resident. In an interview on 6/1/12 at 10 a.m., the physical therapist said that one person assist with transfer with the lift was safe at that time for resident #37 and had trained nursing staff to transfer the resident with a one person assist with a Hoyer lift. However, the facility did not address the physical therapist training for nursing staff or number of people required to safely transfer the resident with a mechanical lift in his/her care plan. The resident left leg was entrapped on 3/19/12 while certified nursing assistant (CNA) "CC" was transferring him/her with a Hoyer lift which resulted in the resident sustaining a fractured tibia and fibula . The facility completed a significant change comprehensive assessment including the Minimum Data Set (MDS) on 3/23/12. The staff coded the resident as needing a two person assist to transfer, but they did not include that in the resident's plan of care. During an interview on 6/1/12 at 9:45 p.m. licensed nurse "PP" stated that her responsibilities included doing the Minimum Data Set (MDS) assessment. "PP" said if the physical therapist made recommendation to nursing staff then the nurse should tell her about that recommendation so the resident's care plan could be revised. She denied having been notified about the physical therapist 3/23/12 recommendation for a two (2) person assist with a Hoyer lift to transfer resident #34. The resident #37's care plan dated 3/31/12 did not include the 3/23/12 physical therapist recommendation for the use of a two person assist with a Hoyer lift to transfer or the 3/23/12 significant change assessment done by facility staff that the resident required the assistance of two people with a mechanical lift to transfer. Those care plan did not address the number of people needed to promote a safe transfer of the resident. Additionally the CNA flow sheets from 3/23/12 until 5/31/12 and the corresponding CNA documentation did not include the use of two people to safely transfer the resident with a Hoyer lift. The staff continued to transfer the resident with a one person assist from 3/23/12 until the physician ordered the staff not to get the resident out of bed on 5/31/12. The facility developed a 12/31/11 care plan which the facility's care plan team documented as having reviewed on 3/31/12. It included the problem of the resident's risk for falls related to devices that the staff used to transfer the resident. However, the care plan team did not develop any approaches which addressed the resident's individualized transfer needs or risk factors. Although, the resident sustained [REDACTED]. The facility's failure to include residents' assessed transfer needs in his/her care plan had the likelihood of resulting in serious harm or injury to resident #37 and to other residents who required staff assistance to transfer.

Based on observations of four resident transfers, record review, and staff interview, it was determined that the facility failed to ensure that its Quality Assessment and Assurance (QA&A) committee identified care concerns, developed and implemented interventions to address identified care problems, and evaluated the effectiveness to resolve the care issue related to the transfer of one resident (#37), who was injured while being transferred with the a Hoyer lift and the assistance of one person. Findings include: According to the "Resident Census and Conditions of Residents" form (CMS 672) completed by the facility on 5/29/12, its census was 63 residents. Forty (40) of the facility's 63 residents required the assistance of one or two staff to transfer. Another thirteen (13) of the 63 residents were totally dependent on staff for transfers. During an interview on 6/01/12 at 7:10 p.m., the Quality Assurance (QA) nurse stated that the facility's QA&A committee reviewed past surveys, trending reports, and occurrence reporting at a monthly meeting in order to determine action plans. However, although, resident #37 had an accident while being transferred by CNA "CC" with a mechanical lift on 3/19/12 which resulted in a [MEDICAL CONDITION]'s tibia and fibula, the QA&A committee had been informed of the avoidable accident. In an interview on 6/01/12 at 7:10 p.m., the QA nurse confirmed that the facility's QA&A committee had not identified that resident #37 had sustained a fractured left leg during an accident while being transferred by CNA "CC". The facility had a system for ensuring that quality deficiencies got to the committee, but the system failed to ensure that the QAA committee was informed about this accident which resulted in resident #37 sustaining a fracture left leg. The QAA committee did not investigate the accident to determine if it had been avoidable and to develop an action plan to promote resident #37's safety and that of other residents, who required staff assistance and a mechanical lift, in order to prevent a re-occurrence during transfers with a mechanical lift. The QAA committee did not ensure that the resident's 3/31/12 care plan was based on his/her 3/23/12 assessments and that care was being appropriately provided based on the facility's and physical therapist 3/23/12 assessments of his/her transfer needs. Refer to F323 for additional information about resident #37.