Every finding on record at Aspen Ridge West Transitional Rehab

Based on observation, interview, and record review, the facility did not maintain an infection and prevention control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, for 3 out of 26 sampled residents, Enhanced Barrier Precautions (EBP) were not implemented for residents with wounds and indwelling medical devices. Additionally, clean linens were found to be on the floor in the laundry room. Resident identifiers:15, 17, and 55.Findings included: 1. On 1/12/26 at 8:12 AM, an initial tour of the facility was conducted. It should be noted that there was no EBP signage for residents 3, 15, 17.a. Resident 15 was admitted to the hospital on [DATE] with diagnoses which included sepsis and cutaneous abscess of buttock.Resident 15's medical record was reviewed 1/12/26 through 1/14/26. A review of resident 15's physician orders revealed on 12/30/25, an order for Enhanced Barrier Precautions d/t [due to] RUE [right upper extremity] PICC [peripherally inserted central catheter] was placed.On 1/12/26 at 10:01 AM, a concurrent interview and observation was conducted with resident 15. Resident 15 was observed to have a PICC line inserted in her right upper arm. Resident 15 stated that she had been receiving intravenous (IV) antibiotics since she arrived in the facility. Resident 15 stated that staff had only worn gloves when providing cares for her. There were no gowns observed in resident 15's room and no EBP sign on the door.On 1/13/26 at 12:05 PM, an observation was made of Certified Nursing Assistants (CNA) 2 and CNA 3 weighing resident 15 with the Hoyer lift. CNA 2 and CNA 3 were observed to be wearing gloves and no gowns. b. Resident 55 was admitted to the facility on [DATE] with diagnoses that included osteomyelitis and left third toe resection.Resident 55's medical record was reviewed 1/13/26 through 1/14/26.A review of resident 55's orders revealed on 1/12/26, an order for Enhanced Barrier Precautions due to PICC was placed.On 1/13/26 at 9:46 AM, an observation was made of resident 55 receiving IV antibiotics through the PICC line in her left upper arm. Registered Nurse (RN) 1 washed their hands and applied gloves. RN 1 did not apply a gown when handling the PICC line or attaching the Elastomeric Pump of vancomycin. RN 1 discarded gloves and exited the room without performing hand hygiene.c. Resident 17 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included left below knee amputation, and pressure ulcer of sacral stage 2.On 1/12/26 at 1:49 PM, an interview was conducted with resident 17. During the interview an observation was made that resident 17 was receiving a nasogastric (NG) tube feeding and also had an indwelling catheter with drainage bag attached to the bedside. Resident 17 stated that when staff were providing care, they would wear gloves, but they do not wear a gown.Review of resident 17's medical record was completed on 1/12/26 through 1/14/26.On 1/12/26 at 10:08 AM, a physician's order was created for EBP due to an NG tube and chronic wound to the left stump.On 1/13/26 at 11:56 AM, an observation was made of resident 17 being transported to his room by two staff members. Resident 17 stated to the staff that he wanted to lay down. Staff proceeded to close the door to resident 17's room. At 12:03 PM, the first staff member exited the room as they were doffing their gloves walking down the hallway. On the door to resident 17's room there was an EBP sign taped to the door and a three-drawer unit just inside of the room with personal protection equipment (PPE), which included gowns. As the second staff member exited, he was observed to be wearing a mask as he used the sanitizer and completed hand hygiene.On 1/13/26 at 12:08 PM, an observation of resident 17's trash can inside the room. The only item in the trash was a pair of gloves. It should be noted that no other disposed PPE was in resident 17's room.On 1/13/26 at 1:00 PM, an interview was conducted with CNA 3. CNA 3 stated that the EBP signs on residents' doors meant that precautions needed to be worn. CNA 3 stated that only residents with infections needed EBP. CNA 3 stated that gowns were only worn for residents in isolation. On 1/13/26 at 2:51 PM, an interview was conducted with CNA 4. CNA 4 stated that EBP was used for residents that had urinary catheters and PICC lines. CNA 4 stated that you had to wash your hands upon entering and exiting the room of a resident who required EBP. CNA 4 stated that she kept the doors closed for residents that required EBP. On 1/14/26 at 8:06 AM, an interview was conducted with RN 1. RN 1 stated that residents that had communicable diseases had EBP. RN 1 stated that he would only wear a gown if a resident had a respiratory infection because he could get droplets on his clothes. RN 1 stated that he only wore gloves for residents that had PICC lines and gowns were not needed. On 1/14/26 at 9:16 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that EBP was for a resident that had a chronic wound, IV, PICC line, foley catheter, or NG tube. The DON stated that staff should be wearing gowns and gloves when they were spending over 15 minutes in a room with a resident. The DON stated that every resident that required EBP should have a sign on their door. The DON stated that gowns could be found in a 3-drawer bin in the residents' rooms. The DON stated that she did not know why resident 15 did not have an EBP sign on her door. 2. On 1/14/26 at 8:18 AM, an observation was made of the facility laundry room. On the clean laundry side were multiple large piles of clean laundry on tables. There was a blanket that was hanging off a table and had one side of it on the floor. There was a pillowcase and a towel on the floor. An interview was conducted with the housekeeper. The housekeeper stated that all of the items in the laundry room were clean and just needed to be folded.

Based on observation, interview, and record review, the facility did not ensure the right to self-administer medications if the interdisciplinary team had determined that this practice was clinically appropriate. Specifically, for 1 out of 26 sampled residents, it was found that the resident did not have a nursing assessment or a physician's order in place to be able to self-administer medications. Resident identifier: 2Findings included: Resident 2 was admitted to the facility on [DATE] with diagnoses which included displaced transverse fracture of shaft of right fibula, displaced fracture of lateral malleolus of left fibula, age-related osteoarthritis, and diverticulitis of large intestine.On 1/12/26 at 10:18 AM, an interview was conducted with resident 2. During the interview an observation was made of an unlabeled prescription bottle filled with white colored tablets on resident 2's bedside table. Resident 2 stated that they were her digestive enzymes that she took throughout the day.On 1/14/26 at 10:01 AM, an observation was conducted of an unlabeled medication bottle on resident 2's bedside table filled halfway with white tablets.On 1/14/26 at 11:23 AM an interview with Certified Nursing Assistant (CNA) 1 was conducted. CNA 1 stated that if she saw any medications in a resident's room, she would notify the nurse. CNA 1 stated that she was not aware of any current residents that had medications in their rooms. CNA 1 stated that if a resident were able to have medications in their room, there would be a physician's order allowing self-administration, and the CNAs would be made aware.On 1/14/26 at 1:31 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated if a resident requested to self-administer their medication the admissions nurse would be notified. LPN 1 stated that the admissions nurse would assess the resident and get a full list of their medications. LPN 1 stated once the assessment was completed the admissions nurse would contact the physician to get an order for the resident to self-administer their medications. LPN 1 stated once there was an order the resident was allowed to store medications in their room. LPN 1 stated that she was aware that resident 2 kept medication in her room. LPN 1 stated that several of the staff had talked to resident 2 about the medication she kept in her room. LPN 1 stated that resident 2's family were very vocal regarding her care, and persistent that the medications were always available.It should be noted that a review of resident 2's physician's orders was made and an order to self-administer medications was not located.On 1/14/26 at 1:55 PM, an interview with the Nurse Manager (NM) was conducted. The NM stated that he was not aware that resident 2 had medication in her room. The NM stated prior to a resident having medication kept in their room, the resident would need a nursing assessment completed and a physician's order allowing the self- administration of medication. The NM stated that he did not see any orders or anything in resident 2's medical record about her self-administering medication.On 1/14/26 at 2:24 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that for a resident to have medication kept in their room, the resident would first need a nursing assessment conducted and a physician's order for self-administration of medication. The DON stated that most times the self-administering of medication was requested at the time of admission, which the admissions nurse would complete. The DON stated that if a resident made the request later, she expected the floor nurse would conduct the assessment and request an order from the physician. The DON stated that residents should not have medications kept in their room without a physician's order. The DON stated that she was unaware of the medication that resident 2 had in her room. The DON stated that she was unable to locate a nursing assessment or a physician's order in resident 2's medical record.

Based on interview and record review, the facility did not provide routine and emergency drugs and biologicals to its residents. Specifically, for 1 out of 26 sampled residents, the resident was not provided with multiple medications due to them being out of stock and unavailable from the pharmacy. Resident identifier: 3.Findings included: Resident 3 was admitted to the facility on [DATE] with diagnoses which included fracture of first lumbar vertebra, nondisplaced zone II fracture of sacrum, and chronic kidney disease.Review of resident 3's medical record was completed on 1/12/26 through 1/14/26.On 12/12/25, a physician's order was started for eszopiclone to be given at bedtime.Resident 3's December 2025 Medication Administration Record (MAR) revealed that the eszopiclone was not administered due to the drug being unavailable on 12/12/25, 12/13/25, 12/14/25, and 12/15/25.On 12/24/25, a physician's order was started for dronabinol to be given once a day.The MAR revealed that the dronabinol was not administered due to the drug being unavailable on 12/25/25, 12/26/25, 12/27/25, 12/28/25,12/29/25, and 12/30/25.On 1/14/26 at 1:31PM, an interview was conducted with Licensed Practice Nurse (LPN) 1. LPN 1 stated that if an ordered medication was unavailable, she would contact the pharmacy. LPN 1 stated that if the medication was critical there was an emergent pharmacy phone number to get the medication delivered as soon as possible. LPN 1 stated she would notify the Nurse Manager (NM) of the unavailable medication, since the NM was the one that puts in the physician's orders. LPN 1 also stated that she would leave a note for the physician regarding the unavailable medication. LPN 1 stated that the physician was usually here the next day and the NM would follow-up with the pharmacy.On 1/14/26 at 1:55 PM, an interview was conducted with the NM. The NM stated that if a medication was unavailable, he would call the pharmacy regarding the availability. The NM stated that if the medication was on backorder from the pharmacy, he would reach out to the resident's family to see if they have any of the medication on hand until they were able to receive it from the pharmacy. The NM stated that if that still did not fix the issue, he would contact the physician regarding the unavailable medication and get an updated order or possible substitution. The NM stated that he was not made aware that resident 3 had unavailable medications. The NM stated the floor nurses usually made him aware the next day when a medication was not in stock. The NM stated that possibly the pharmacy did not receive the signed physician's order due to the medications being controlled substances and could not be filled.On 1/14/26 at 2:24 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that when medication was unavailable, she expected the floor nurse to contact the pharmacy regarding the issue and to inform the physician. The DON stated that even if the medication was a controlled substance there were physicians on call that could submit a signed order. The DON stated that a resident's medication should not be unavailable for any period of time, especially more than a day or longer. The DON stated that she expected the nurses to contact the physician and inform them of the unavailable medication and get an updated order for a possible substitution.

Based on interview and record review, the facility did not ensure that residents were offered the pneumococcal immunization and that the medical records included documentation that the resident either received the immunization or did not due to medical contraindications or refusal. Specifically, for 2 out of 5 sampled residents, there was no documentation of declination of the pneumococcal immunization. Resident identifiers: 15 and 55.Findings included:1. Resident 15's medical record was reviewed 1/12/26 through 1/14/26. A form labeled PNA [pneumonia], FLU [Influenza] COVID [Coronavirus Disease 2019], RSV [respiratory syncytial virus] Immunizations, Medication Consent was located in resident 15's medical record. The form was signed by resident 15 and dated 12/30/25. The form contained checkboxes to mark resident 15 as up-to-date on the recommended pneumococcal immunization. A Utah Statewide Immunization Information System (USIIS) immunization record was located in resident 15's medical record. The USIIS record documented that resident 15 had not received any pneumococcal immunizations. Resident 15's medical record did not indicate that she was offered or declined these immunizations.2. Resident 55's medical record was reviewed 1/13/26 through 1/14/26.A form labeled PNA, FLU COVID, RSV Immunizations, Medication Consent was located in resident 55's medical record. The form was signed by resident 55 and dated 1/12/26. The form contained checkboxes to mark resident 55 as up-to-date on the recommended pneumococcal immunization. A USIIS immunization record was located in resident 55's medical record. The USIIS record documented that resident 55 had received PCV-13 (Pneumococcal Conjugate Vaccine-Variant 13) on 8/7/17, and PPSV 23 (Pneumococcal Polysaccharide Vaccine 23) on 10/13/97 and 1/1/06. The USIIS record indicated that resident 55 was due to receive a pneumococcal immunization. It should be noted that according to the Centers for Disease Control (CDC) Pneumococcal Vaccine timing that resident 55 required an immunization of PCV 20 or PCV 21. Resident 55's medical record did not indicate that she was offered or declined these immunizations. On 1/14/26 at 8:55 AM, an interview was conducted with the Nurse Manager (NM). The NM stated that he had access to the USIIS system and would pull an immunization log on new admissions. The NM stated that if the USIIS log indicated that a resident was not current on an immunization then he would notify the Director of Nursing (DON) and have the immunization ordered. The NM stated that the admitting nurse went over all the immunizations upon admission with new residents. The NM stated that when a USIIS report indicated that a resident was not up-to-date on immunizations then he would go and talk with the resident and ask them if they wanted the immunization. The NM stated that if a resident declined to have an immunization then he would document this in a progress note. On 1/14/26 at 9:25 AM, an interview was conducted with the DON. The DON stated that the admission nurse was new in her position and was the one who discussed immunizations with new residents. The DON stated that if a resident stated they were current on their immunizations then the nurse would just check the box that they were up-to-date. The DON stated that the admission nurse did not have access to USIIS and did not have a way to verify if a resident was current on immunizations. The DON stated that the admission nurse should have verified if residents were current on immunizations and if they were not, then administer the vaccine or have the resident sign a declination form.

Based on interview and record review, the facility failed to report all allegations of abuse, neglect, exploitation, or mistreatment. Specifically, the facility failed to report an incident where a resident reported a Certified Nursing Assistant (CNA) made a resident feel threatened, and she was scared for her safety. Resident identifier: 1. On August 12, 2025, the surveyor reviewed the facility's grievance reports. A grievance report dated February 17, 2025 revealed the following:Documentation of the complaint, written by Resident 1: I called for help to use my commode and get ready for bed. [CNA 4] helped me to my commode but he seemed upset that he had to do so. I let it go, and when I called for help he got mad when I wanted to go to bed. He started to remove my sheets, and I informed him, I sleep on top of my covers. He was angry that I was correcting him. He started to grab my belongings and threw them on the chair, next to me. I was so scared and felt threatened and scared for my safety by how angry he was. I asked if i can have [CNA 5] come in and take care of the rest of my bedtime routine and he said no, she's busy with other patients and i have other people to take care of so hurry up He was so angry when I asked him to grab a pillow case for a pillow that was supposed to go under my leg. The Administrator documented that they spoke with Resident 1 on February 18, 2025, and that the employee was disciplined on February 17, 2025. The resolution section indicated, Yes, employee no longer working at the facility. Patient satisfied with investigation. On August 12, 2025, the surveyor interviewed the Administrator. The Administrator stated that he talked to Resident 1 the day after the incident. The Administrator stated that Resident 1 reported that CNA 4 presented as angry and rude, and she did not like how she was being treated. The Administrator asked Resident 1 if she felt like it was abuse, and Resident 1 stated that she did not feel like it was abuse. The Administrator stated that Resident 1 did not say that she felt unsafe. The Administrator stated that he felt like the situation was more poor customer service and not abuse. The Administrator decided to let CNA 4 go because there had been previous complaints from staff and residents regarding his customer service.

Based on interview and record review, the facility failed to thoroughly investigate an allegation of abuse. Specifically, the facility failed to thoroughly investigate an incident where a resident reported a CNA had made her feel threatened, and she feared for her safety. Resident identifier: 1. On August 12, 2025, the surveyor reviewed the facility's grievance reports. A grievance report dated February 17, 2025 revealed the following:Documentation of the complaint, written by Resident 1: I called for help to use my commode and get ready for bed. [CNA 4] helped me to my commode but he seemed upset that he had to do so. I let it go, and when I called for help he got mad when I wanted to go to bed. He started to remove my sheets, and I informed him, I sleep on top of my covers. He was angry that I was correcting him. He started to grab my belongings and threw them on the chair, next to me. I was so scared and felt threatened and scared for my safety by how angry he was. I asked if i can have [CNA 5] come in and take care of the rest of my bedtime routine and he said no, she's busy with other patients and i have other people to take care of so hurry up He was so angry when I asked him to grab a pillow case for a pillow that was supposed to go under my leg. The Administrator documented that they spoke with Resident 1 on February 18, 2025, and that the employee was disciplined on February 17, 2025. The resolution section indicated, Yes, employee no longer working at the facility. Patient satisfied with investigation. On August 12, 2025, the surveyor interviewed the Administrator. The Administrator stated that he talked to Resident 1 the day after the incident. The administrator stated that Resident 1 reported that CNA 4 presented as angry and rude, and she did not like how she was being treated. The administrator asked Resident 1 if she felt like it was abuse, and Resident 1 stated that she did not feel like it was abuse. The administrator stated that Resident 1 did not say that she felt unsafe. The administrator stated that he felt like the situation was more poor customer service and not abuse. The administrator decided to let CNA 4 go because there had been previous complaints from staff and residents regarding his customer service.The surveyor reviewed the facility's Abuse Policy and Procedure, and the following was revealed: The Administrator and/or Director of Nursing will complete an investigation of the incident including a written summary of the findings no later than five (5) working days of the reported occurrence.

Based on observation, interview, and record review it was determined, for 1 of 21 sampled residents, that the facility did not ensure that the resident right to self-administer medications was clinically appropriate and safe. Specifically, residents were observed to have medications on the bedside table and were not evaluated to determine if they were safe to self-administer medications. Resident identifiers: 20 and 27. Findings included: 1. Resident 20 was admitted to the facility on [DATE] with diagnoses which included wedge compression fracture of first, second, and third lumbar vertebra, fusion of spine, metabolic encephalopathy and cardiac arrhythmia. Resident 20's medical records were reviewed from 8/19/24 through 8/21/24. On 8/21/24 at 8:10 AM, an observation was made during morning medication pass for resident 20. Resident 20 stated, If I take any more pills, I will throw up. Registered Nurse (RN) 1 placed the medication cup with two large white pills and a medication cup with 10 milliliters (ml) of magic mouthwash on resident 20's bedside table. RN 1 stated to resident 20 to take them when she was able to, RN 1 then left resident 20's room. On 8/21/24 at 8:12 AM, an interview with RN 1 was conducted. RN 1 stated that she had left the medications at resident 20's bedside due to the resident stating, that if she took any more pills she would throw up. RN 1 identified the medications in the medication cup as omeprazole-sodium bicarbonate 20-1.1 (milligrams) mg and potassium chloride capsule 10 (milliequivalent) mEq. RN 1 stated she was not sure if resident 20 had any orders that allowed her to self-administer medications. RN 1 stated when a resident was not ready for their medications, she would leave them on the bedside table. RN 1 stated she would then follow up with the resident to make sure the medications were taken. 2. Resident 27 was admitted to the facility initially on 7/22/24, and readmitted on [DATE] with diagnoses that included presence of urogenital implants, long term use of anticoagulants, pretension of urine, pressure ulcer, acute respiratory failure with hypoxia, cardiac arrhythmia, Parkinson's disease, and pneumonia. On 8/19/24 at 9:30 AM, an interview was attempted with resident 27. Resident 27 appeared to be confused and was not answering questions appropriately. Resident 27 was observed to have a nasal cannula in place and was receiving oxygen and a significant tremor in both hands was observed. On 8/20/24 at 9:36 AM, an observation was made of resident 27, who was laying on her bed. It was observed that resident 27 had a small cup with several medications on the bedside table next to her bed. Resident 27 did not answer when asked if she administered her own medications or if she knew what medications were in the cup. Resident 27's medical records were reviewed between 8/19/24 and 8/21/24. An MDS (Minimum Data Set) admission assessment dated [DATE] revealed that resident 27 had a BIMS (Brief interview for Mental Status) assessment score of 6, suggesting significant cognitive impairment. On 8/17/24 at 10:13 AM, A nursing progress note revealed, .Mental Status: Alert & [and]cooperative; Oriented to: Person, Place, Time and Situation .Additional notes: Alert and oriented x [times] 3 .Takes medication whole with water. On 8/19/24 at 11:00 AM, a nursing progress note revealed, .Mental Status: Alert & cooperative; Oriented to: Person, place, time and situation .Additional notes: Alert and oriented x 3 .Takes medications whole with water. Needs help getting medications to mouth because of essential tremors in both hands. It should be noted that no Self Administration Assessment was located in resident 27's medical record. On 8/21/24 at 9:33 AM, an interview was conducted with RN 1 who stated resident 27 was alert and oriented x 4 today, but that resident 27 was confused at times. RN 1 stated that she had to feed resident 27 her pills because she was always shaking and had trouble taking the pills herself. RN 1 stated sometimes resident 27 would forget that she had medications remaining in her cup and would not take them. RN 1 stated that she provided resident 27's medications during meals and that resident 27 did not have difficulty swallowing. RN 1 stated the concerns with resident 27 taking medications on her own were forgetting to take the medicaitons, or spilling the medicaitons due to her tremors. On 8/21/24 at 7:58 AM, an observation was made of RN 1 walking into resident 27's room with a cup of medications. RN 1 stated to resident 27 upon entering the room, Here are your meds. RN 1 was then observed to walk out of resident 27's room prior to the resident taking the medications. On 8/21/24 at 8:12 AM, an observation was made as RN 1 walked into resident 27's room and stated, Did you take all of your pills? RN 1 was then observed to walk out of resident 27's room with an empty medication cup and threw it away in medication cart trash can. On 8/21/24 at 10:24 AM, an interview with RN 2 was conducted. RN 2 stated that he would not leave medication at the bedside and that nursing staff were not allowed to leave medications at the bedside. RN 2 stated that medication should not be left at the bedside because another resident could take the medications. On 8/21/24 at 10:48 AM, an interview with Director of Nursing (DON) was conducted. The DON stated if a resident refused medication, and if she could identify the medications, she would label the cup and lock the medications up. The DON stated if there were a lot of medications, she would waste them and repull them when the resident was ready to take them. The DON stated she would not leave any medications at the bedside for the resident to take when they were ready. The DON stated that a few residents could have eyedrops in their room which needed to be locked up. The DON stated prior to allowing a resident to have any medications left in their room the nursing staff would do a self-medication assessment. 47431

Based on observation, interview, and record review it was determined the facility did not maintain an infection prevention and control program (IPCP) designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, when entering and exiting isolation rooms staff were observed not donning and doffing Personal Protective Equipment (PPE) per the IPCP, a resident's catheter bag was observed on several occasions to be left on the resident's floor without a barrier, a visitor was observed within an isolation room without wearing PPE, and cross contamination was observed during dining service. Resident identifiers: 83, 88, and 131. Findings include: 1. Observations were made of staff not doffing PPE per the IPCP when exiting isolation rooms. a. Resident 88 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/28/21 at approximately 10:00 AM, a Precautions: Quarantine sign was observed outside of resident 88's room. Registered Nurse (RN) 1 was interviewed. RN 1 stated resident 88 was on a new admission 14 day quarantine. RN 1 further stated resident 88 had not received the Coronavirus Disease 2019 (COVID-19) vaccine. On 6/28/21 at approximately 12:30 PM, Certified Nursing Assistant (CNA) 5 was observed to exit resident 88 rooms. Upon exiting resident 88's room CNA 5 was observed to doff a reusable cloth gown. CNA 5 put the reusable cloth gown on the cart that was used to distribute lunch trays to residents. CNA 5 was interviewed. CNA 5 stated she did not see a bin in resident 88's room to put the used gown in. CNA 5 was observed to walk half way down the hall with the used reusable cloth gown and put the gown in the laundry bin that was stationed in the hall. On 6/28/21 at 1:46 PM, an interview was conducted with resident 88. Resident 88 stated he was a new admission and was on quarantine because he had not yet received the COVID-19 vaccine. Upon exiting resident 88's room this surveyor doffed disposable PPE and placed the PPE in the garbage can in resident 88's bathroom. No PPE bins were located in resident 88's bathroom for staff to place used PPE. Resident 88's medical record was reviewed on 6/29/21. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] & inside of room . b. Resident 131 was admitted to the facility on [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/28/21 at 11:44 AM, an observation was made of resident 131's room. Resident 131 was on isolation precautions and there was no container observed within resident 131's room for staff to place used cloth gowns after doffing. On 6/30/21 at 11:48 AM, RN 2 was interviewed. RN 2 stated in quarantine rooms the PPE worn included gloves, a Negativity at Approximately 95 Milliseconds (N95) mask, eye protection, and a gown. RN 2 stated staff were to put used cloth gowns on the hooks within resident rooms during their shift and at the end of their shift, staff put their used cloth gown into the residents' laundry bin. RN 2 stated for isolation rooms, these laundry bins were supposed to be in the residents' bathroom. RN 2 stated when the staff member leaves the isolation room they take off their gloves and mask within the isolation room, and put the used gloves and mask in the resident's bathroom trash can. If the staff member does not plan to reuse the cloth gown, staff were to place the gown in a red biohazard bag, and then put the red biohazard bag into the laundry basket within the isolation room. On 6/30/21 at 11:53 AM, CNA 2 was interviewed. CNA 2 stated when staff enter a quarantine room they wore a cloth gown, changed their face mask to an N95 mask, and placed on eye protection, and gloves. CNA 2 stated the DON instructed staff they did not need to wear full PPE when entering an isolation room to deliver a meal tray. CNA 2 also stated, when staff leave the isolation room they were to hang up their cloth gown on a hook inside the isolation room. Then, the staff throw away their gloves and N95 mask in the isolation room's bathroom trash can. CNA 2 stated when a staff member was done with their shift, they take the cloth gown off of the hook and place the cloth gown in the isolation room's laundry basket. On 6/30/21 at 12:41 PM, CNA 5 was interviewed. CNA 5 stated, to enter isolation rooms, staff put on a face shield, gown, gloves, and an N95 mask. When staff leave the isolation room, cloth gowns were put into the laundry basket in the resident's bathroom. Staff then throw away other items, like their gloves and N95 mask, in the isolation room's bathroom. Per facility protocol and signage posted near isolation rooms, the steps for donning PPE included; 1. Sanitize hands. 2. Remove Universal source control mask. 3. Sanitize hands. 4. Put on washable or disposable gown. 5. Put on fit-tested N95 respirator. a. Use a face mask if a respirator is not available. 6. [Sanitize hands if reuse mask] 7. Put on eye protection. 8. Sanitize hands. 9. Put on gloves. 10. [Pick up equipment if applicable] 11. Knock, listen, and enter the room. 12. Ask patient to put on mask. Per facility protocol and signage posted near isolation rooms, the steps for doffing PPE included; 1. Remove gloves. 2. Remove gown. 3. Exit the room. 4. Sanitize hands. 5. Close the door. 6. [Disinfect surfaces, then equipment if applicable]. 7. Sanitize hands 8. Remove eye protection. a. [Disinfect, store safely if applicable]. 9. Remove face mask. 10. Sanitize hands. 11. Put on universal source control mask 12. Sanitize hands. Per facility protocol and signage posted near isolation rooms, Cloth gowns should be laundered after each use. 2. Observations were made of staff cross contamination during dining service and staff were not donning and doffing PPE per the IPCP while passing meal trays to resident rooms. On 6/28/21 at 12:12 PM, CNA 1 was observed to don PPE to enter an isolation room and deliver a resident's lunch tray. While wearing a face mask, CNA 1 was observed to put on gloves and a cloth gown. CNA 1 entered the isolation room, delivered the resident's meal tray and exited the room. After exiting the room, CNA 1 doffed her gown, and placed the used cloth gown into a housekeeping cart in the hallway. Without changing gloves, CNA 1 then delivered a meal tray to a resident across the hall from the isolation room. After delivery of the second tray, CNA 1 removed her gloves, did not sanitize her hands and continued to deliver trays to 8 other resident rooms. On 6/28/21 at 12:24 PM, CNA 6 was observed to don PPE to enter an isolation room and deliver a resident's lunch tray. While wearing a face mask, CNA 6 was observed to don gloves and a face shield. CNA 6 entered the isolation room without donning a gown or switching to an N95 face mask. On 6/28/21 at 12:28 PM, CNA 6 while wearing a face mask and gloves was observed to deliver a lunch meal tray to resident room [ROOM NUMBER]. CNA 6 moved items on the bedside table in room [ROOM NUMBER]. CNA 6 did not sanitize hands or change gloves prior to delivering a meal tray to resident room [ROOM NUMBER]. On 6/30/21 at 8:21 AM, CNA 3 was observed to deliver a breakfast meal tray to a resident on isolation. Prior to entering the isolation room CNA 3 sanitized their hands, placed on a gown and gloves and changed their mask to an N95 mask. CNA 3 did not place on eye protection. Prior to exiting the isolation room, CNA 3 removed the gloves, entered the bathroom and then left the isolation room. While in the hallway, CNA 3 removed the cloth gown and N95 mask, and then CNA 3 placed the used cloth gown within a red biohazard bag, which CNA 3 then left by the isolation room door. On 6/30/21 at 8:32 AM, CNA 4 was observed to enter an isolation room to deliver a breakfast tray. CNA 4 sanitized their hands, placed on gloves, gathered the resident tray and entered the isolation room without donning a gown, eye protection or switching to an N95 face mask. On 6/30/21 at 11:53 AM, CNA 2 was interviewed. CNA 2 stated the Director of Nursing (DON) instructed staff they did not need to wear full PPE when entering an isolation room to deliver a meal tray. On 6/30/21 at 12:41 PM, CNA 5 was interviewed. CNA 5 stated the hand hygiene routine with passing meal trays included either sanitizing hands between the passing of each meal tray or using and changing of gloves between the passing of each meal tray. CNA 5 also reported, PPE of an N95 mask, eye protection, a gown and gloves must be worn anytime a staff member entered an isolation room. 3. A resident, unvaccinated for COVID-19, and on isolation due to recent admission to the facility was observed to have a visitor within their room without wearing PPE. Resident 131 was admitted to the facility on [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/30/21 at 11:53 AM, resident 131 was observed to have a visitor within their room. The visitor was observed not wearing PPE (face mask, face shield, gown, gloves) and resident 131 was observed not wearing a face mask. On 6/30/21, resident 131's medical record was reviewed. An active order within resident 131's chart documented, Patient is on QUARANTINE x 14 days. Start date 06/19/2021. End date 07/02/2021. On 6/30/21 at 12:00 PM, RN 1 was interviewed. RN 1 stated a resident on quarantine should not have visitors in their room. RN 1 stated if the resident must have a visitor then the visitor should be wearing PPE like staff. RN 1 stated PPE like staff included a cloth gown, gloves, face mask, and face shield or eye protection. On 06/30/21 at 12:03 PM, CNA 2 was interviewed. CNA 2 stated being unaware a resident on quarantine had a visitor in their room. CNA 2 stated a resident on quarantine can have up to 2 visitors in their room. CNA 2 stated if the visit occurred in the resident room the visitor must wear a mask or they would have to meet outside the building. On 6/30/21 at 12:41 PM, CNA 5 was interviewed. CNA 5 stated a resident on quarantine can have 1 designated visitor, and if the visitor is in the isolation room they should be wearing PPE. On 6/30/21 at 12:41 PM, an interview was conducted with the DON. The DON stated new admission residents were on contact precautions. The DON stated staff could wear reusable cloth gowns. The DON stated staff were suppose to put the resuable cloth gown in the yellow bin that was located in the resident bathroom. The DON stated she was told that morning there were no bins in the resident bathrooms. The DON stated any staff that goes in a quarantine room should be in the full PPE that was posted. The DON stated staff were to sanitize hands between each resident when passing meal trays. The DON stated staff would request that visitors wear a mask. The DON stated if a resident was a new admission on quarantine the resident may have a compassionate care visit within the first 14 days and after the 14 days she would encouraged outdoor visit. 4. A resident's urinary catheter bag was not off the floor or protected from the floor surface at all times. Resident 83 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/28/21 at 10:21 AM, an observation was made of resident 83 in bed and his urinary catheter down drain bag was observed on the floor without a barrier. On 6/28/21 at 12:26 PM, an observation was made of resident 83 in bed and his urinary catheter down drain bag was observed on the floor without a barrier. Resident 83's medical record was reviewed on 6/30/21. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/30/21 at 9:27 AM, an interview was conducted with CNA 5. CNA 5 stated there were privacy bags for the urinary catheter down drain bags. CNA 5 stated if the resident was in bed the urinary catheter down drain bag was to be put in a privacy bag and hung on the side of the bed. CNA 5 stated if a resident got out of bed on their own the resident might throw the bag on the floor. CNA 5 stated resident 83 did not get out of bed on his own and required assistance to the bathroom for bowel movements. CNA 5 stated she was doing resident showers on Monday and was not aware that resident 83's urinary catheter down drain bag was on the floor. On 6/30/21 at 9:42 AM, an observation was made of resident 83 in bed and his urinary catheter down drain bag was observed on the floor without a barrier. On 6/30/21 at 10:53 AM, an observation was made of resident 83 walking in the hall towards his room with a walker and a therapy staff member assisting. The therapy staff member was observed exiting resident 83's room after assisting resident 83 to bed. Resident 83 was observed in bed and his urinary catheter down drain bag was observed on the floor without a barrier. On 6/30/21 at 12:36 PM, an interview was conducted with the DON. The DON state the urinary catheter down drain bag had a hook on the back that allowed the bag to be hook to an item. The DON stated the urinary catheter down drain bag had the ability to be secured. The DON stated the urinary catheter down drain bag should not be on the floor.

Based on observation, interview and record review it was determined, for 6 of 18 sample residents, that the facility did not provide a safe, clean, comfortable and homelike environment. Specifically, resident wheelchairs had torn arm rests, coban wrapped around arm rests and tape on wheelchairs. Resident identifiers: 9, 92, 96, 97, 136, and 286. Findings include: On 7/29/19 at 8:00 AM, an observation was made of resident 92 in the main dining room. Resident 92's wheelchair was observed to have blue coban wrapped around his right arm rest. Resident 92's wheelchair was observed to have the left arm rest cracked. On 7/29/19 at 10:57 AM, an interview was conducted with resident 92. Resident 92 stated that his wheelchair was from the facility and he received it upon admission. Resident 92 stated that he had the blue coban on the wheelchair since he received it. Resident 92 stated that he did not know why there was coban on his wheelchair. On 7/31/19 at 7:54 AM, observations were made of resident wheelchairs. Resident 92 had blue coban on his right arm rest and the left arm rest was cracked. Resident 136's wheelchair was observed to have black tape below the left arm rest and both arm rests were cracked. Resident 286's wheelchair was observed to have bright green coban on the right arm rest and on the left leg rest. Resident 286 had coban on the right arm rest. Resident 286 also had pink coban on handles of her walker. Resident 96's wheelchair had black tape on right arm rest. Resident 97's wheelchair arm rests were both cracked. Resident 9's wheelchair right arm rest was cracked. On 7/31/19 at 8:00 AM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated that if a wheelchair had torn arm rests she wrote the resident's name on the maintenance log for the Maintenance Director to repair. CNA 2 stated that she would also put the wheelchair in the electrical room for the Maintenance Director or the Administrator to repair. On 7/31/19 at 8:13 AM, an interview was conducted with CNA 3. CNA 3 stated that the Maintenance Director fixed wheelchairs. CNA 3 stated that if a wheelchair needed repair she would report that to the nurse. CNA 3 stated there was a maintenance log that she wrote the residents name and the part that needed to be fixed. CNA 3 stated that wheelchairs needed to be perfect for residents so they did not get hurt. A clipboard with forms titled Maintenance Log was reviewed and there were no items regarding resident's wheelchair arm rests needing to be repaired since (MONTH) 2019. On 7/31/19 at 8:18 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that she had not noticed cracked arm rests or coban on residents wheelchairs. RN 2 stated that when a resident's wheelchair needed repaired she told the Administrator or the Maintenance Director. RN 2 was observed to ask the Director of Nursing (DON) the facility process for replacing arm rests on wheelchairs. RN 2 then stated that the facility had replacement arm rests for wheelchairs and therapy staff or the Maintenance Director replaced them. On 7/31/19 at 8:30 AM, an interview was conducted with Physician Therapist (PT) 1. PT 1 stated that the facility had extra wheelchair so if a wheelchair needed to be repaired the resident's had other wheelchairs to use. PT 1 stated that Maintenance Director replaced arm rests on wheelchair. PT 1 stated that coban was used for a short time if an arm rest needed to be repaired but there was not time before an appointment or something like that. PT 1 stated that coban was usually not used for more than a day. PT 1 stated that coban had been used on foot rests in the past to keep the residents leg from slipping off the wheelchair. On 7/31/19 at 9:37 AM, an interview was conducted with the Maintenance Director. The Maintenance Director stated that he replaced cracked or torn arm rests on wheelchairs. The Maintenance Director stated that staff left wheelchairs in the electrical room that needed to be repaired. The Maintenance Director stated that facility staff also wrote any repairs needed on the maintenance log. The Maintenance Director stated he was not aware there were cracked arm rests. The Maintenance Director stated that some of the staff used coban over cracked arm rests and he did not know why. The Maintenance Director stated that he had arm rests in stock at the facility. On 7/31/19 at 9:45 AM, an interview was conducted with the DON. The DON stated that she was not aware there were cracked arm rest or that wheelchairs had coban on them. The DON stated that the Maintenance Director or Administrator replaced arm rests.

Based on observation, interview and record review it was determined, for 1 of 18 sample residents, that the facility did not promote and facilitate resident self-determination through support of resident choice for healthcare and plan of care. Specifically, facility staff did not assess a resident for a self releasing seat-belt for his wheelchair. Resident identifier: 92. Findings include: Resident 92 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/29/19 at approximately 7:45 AM, an observation was made of resident 92. Resident 92 was observed to ask facility staff if he could have a self-releasing seat-belt for his wheelchair. Facility staff were observed to tell resident 92 they were unable to allow him to have a self-releasing seat-belt because it was considered a restraint. On 7/29/19 at 10:57 AM, an interview was conducted with resident 92. Resident 92 stated that he would like a self-releasing seat-belt for his wheelchair because he had unexpected [MEDICAL CONDITION] in his wheelchair in the past. Resident 92 stated that staff told him he was unable to have his wheelchair with a self-releasing seat-belt because it was considered a restraint. Resident 92's medical record was reviewed on 7/30/19. An admission Minimum Data Set ((MDS) dated [DATE] revealed that resident 92 had a Brief Interview for Mental Status score of a 14. A score of 15 revealed that a resident was cognitively intact. The MDS further revealed that resident 92 did not have limited range of motion to his upper extremities. There was no information regarding resident 92 requesting his wheelchair with a seat-belt. On 7/30/19 at 2:34 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that if a resident asked for a seat-belt the nurse and therapy talked with the resident. CNA 1 stated that the facility was free from restraints. CNA 1 stated that she was not aware of resident 92 asking to bring his wheelchair with a seat-belt from home. On 7/31/19 at 8:22 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that seat-belts were not allowed in the facility because they were considered a restraint. RN 1 stated that resident 92 had not asked about a seat-belt. On 7/31/19 at 9:43 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that if a resident asked for a seat-belt nursing staff evaluated the resident, documented the failed conservative measures taken and obtained a physicians order. The DON stated that a restraint evaluation was to be completed. The DON stated that resident 92's family member asked her if resident 92 could have his wheelchair with a seat-belt at the facility. The DON stated that she told resident 92's family member seat-belts were considered a restraint and she could not bring in his wheelchair. The DON stated she did not think that resident 92 would be able to release a self-releasing seatbelt all the time. The DON stated that resident 92 had not been evaluated if he was able to release a seat-belt. The DON stated that she did not ask resident 92's family member why she wanted the seat-belt. The DON stated that staff had not tell her that resident 92 had been asking for his self-releasing seat-belt.

Based on interview and record review it was determined, for 1 of 18 sampled residents, that the facility did not ensure that the resident's drug regimen was free from unnecessary drugs. Specifically, the facility did not administer [MEDICATION NAME] according to physician's orders [REDACTED]. Findings include: Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 2's medical record was reviewed on 7/31/19. A Physician order [REDACTED].<100 or DBP <65. Systolic Blood Pressure (SBP) less than 100 or Diastolic Blood Pressure (DBP) less than 65. A review of the Medication Administration Record [REDACTED]. The (MONTH) 2019 MAR indicated [REDACTED]. On 7/31/19 at approximately 8:00 AM, an interview was conducted with the Director of Nursing (DON. The DON stated, I do not know why they gave it outside of parameters.

Based on interview and record review, it was determined for 3 of 24 sample residents, that the facility did not ensure that each resident was free of significant medication errors. Specifically, insulin was not administered as ordered by the physician. Resident identifiers: 10, 19 and 86. Findings include: 1. Resident 86 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 86's medical record reviewed on 7/16/18. On 7/14/18 at 3:00 PM, a PHYSICIAN(s) ORDER was received to administer Humalog insulin subcutaneously per the following sliding scale: .if BG (blood glucose) (less than) 140 do nothing, if 141-170 give 1 unit, if 171-200 give 2 units, if 201-230 give 3 units, if 231-260 give 4 units, if 261-290 give 5 units, if 291-320 give 6 units, if 321-350 give 7 units, if (greater than) 350 call MD (Medical Doctor); . The Humalog sliding scale was to be followed before meals and at bedtime. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. The Registered Nurse (RN) caring for resident 86 documented that Humalog 1 unit was not administered due to Nurse discression (sic) not to give 1 unit insulin at this time. On 7/16/18 at 4:57 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated, I felt like in my mind, 1 unit would not make enough difference to give it. RN 1 further stated, I probably was not concerned about following the doctor's order. RN 1 stated that it was, Nursing discretion. On 7/16/18 at 5:10 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that insulin was to be administered as ordered by the physician and that, Nurses don't have discretion to hold insulin. They need to call the physician. 2. Resident 19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 19's medical record was reviewed on 7/16/18. Upon admission to the facility, resident 19's primary care physician wrote an order to administer Humalog insulin as follows: If Blood Sugar is 140 to 170, give 1 unit. If Blood Sugar is 171 to 200, give 2 units. If Blood Sugar is 201 to 230, give 3 units. If Blood Sugar is 231 to 260, give 4 units. If Blood Sugar is 261 to 290, give 5 Units. If Blood Sugar is 291 to 320, give 6 units. If Blood Sugar is 321 to 350, give 7 Units. If blood Sugar is greater than 350, call MD. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. The RN documented that 8 units of insulin was administered. On 7/16/18 at 4:57 PM, an interview was conducted with RN 1. RN 1 stated that sent the doctor a text but was unable to provide documented evidence that resident 19's physician gave an order to administer 8 units of insulin. RN 1 further stated that she did not write a Telephone Order to administer 8 units of insulin as it was a one time order. RN 1 stated that she did not document the order in a progress note. On 7/16/18 at 5:10 PM, an interview was conducted with the DON. The DON stated that nurse's were expected to contact the primary care physician for blood sugars that greater than the given range by the physician. The DON stated that one-time orders were to be documented on a telephone order and put into the computer system. 3. Resident 10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/16/18 resident 10's medical record was reviewed. A review of resident 10's medical orders revealed the following: Humalog I-100 Insulin . solution; 100 unit/mL (milliliters); Amount to Administer: Per Sliding Scale; If Blood Sugar is 140 to 180, give 1 Unit. If Blood Sugar is 181 to 220, give 2 Units. If Blood Sugar is 221 to 260, give 3 Units. If Blood Sugar is 261-300, give 4 Units. If Blood sugar is 301 to 340, give 5 Units. If Blood Sugar is 341- 380, give 6 Units. If Blood Sugar is 381 to 420, give 7 Units. If Blood Sugar is greater than 420, call MD. A review of resident 10's (MONTH) and (MONTH) (YEAR) MARs revealed the following: a. On 6/7/18 at 5:19 PM, resident 10's blood sugar (BS) was 160, notes revealed, Not Administered . nurse discression (sic) not to give 1 unti (sic) at this time. b. On 6/9/18 at 4:57 PM, resident 10's BS was 192, notes revealed, Not Administered . nurse discression (sic) not to give 2 units at this time. c. On 6/12/18 at 4:51 PM, resident 10's BS was 206, notes revealed, Not Administered . nurse discression (sic) not to give insulin at this time. d. On 6/14/18 at 4:51 PM, resident 10's BS was 171, notes revealed, Not Administered . nurse discression (sic) not to give 1 unit at this time . e. On 6/16/18 at 4:51 PM, resident 10's BS was 148, notes revealed, Not Administered . nurse discression (sic) to not administer 1 unit insuloin (sic) at this time. f. On 6/18/18 at 4:40 PM, resident 10's BS was 152, notes revealed, Not Administered . nurse dicression (sic) not to give 1 unit at this time. g. On 6/26/18 at 5:22 PM, resident 10's BS was 171, notes revealed, Not Administered . nurse discression (sic) not to give 1 unit at this time. h. On 7/3/18 at 4:32 PM, resident 10's BS was 159, notes revealed, Not Administered . nurse discression (sic) not to give 1 unit at this time. i. On 7/4/18 at 4:39 PM, resident 10's BS was 164, notes revealed, Not Administered . nurse discression (sic) not to give 1 unit at this time. j. On 7/5/18 at 4:36 PM, resident 10's BS was 180, notes revealed, Not Administered . nurse discression (sic) not to give 1 unit at this time. k. On 7/7/18 at 5:04 PM, resident 10's BS was 173, notes revealed, Not Administered . nurse discression (sic) not to give 1 unit at this time. l. On 7/9/18 at 4:47 PM, resident 10's BS was 143, notes revealed, Not Administered . nurse discression (sic) not to give 1 unit at this time. m. On 7/10/18 at 4:33 PM, resident 10's BS was 198, notes revealed, Not Administered . nurse discression (sic) not to give 2 units at this time. n. On 7/13/18 at 7:32 AM, resident 10's BS was 456, notes revealed, 8 units given. o. On 7/13/18 at 8:32 PM, resident 10's BS was 561, notes revealed, 11 units given. p. On 7/15/18 at 9:21 PM, resident 10's BS was 496, notes revealed, 9 units given. On 7/16/18 at 2:30 PM, an interview was conducted with RN 1. RN 1 stated she was unaware if the facility had a policy allowing a nurse to hold medications from residents upon her discretion. RN 1 stated, I don't think that they (have a policy allowing a nurse to hold resident medications), but I don't know that. I was thinking in my mind as long as I was noting why I was not giving (a resident their medication) it would be sufficient. No one has ever told me that I could not do that. On 7/17/18 at 12:30 PM, an interview was conducted with RN 2. RN 2 stated he was told in the morning report resident 10 was on medication that would increase her blood sugar and, the practitioner was aware of that. RN 2 stated the insulin order indicated 'continue' on his computer screen and he calculated how much insulin to give by following the, trend in the order. RN 2 stated that he did not call the physician when resident 10's blood sugar was out of physician ordered ranges because, they already knew (resident 10's) blood sugar would be high. On 7/16/18 at 5:10 PM, an interview was conducted with the DON. The DON stated the physician should be called and a telephone order should be written and put into the computer every time a medical order is changed. The DON stated, nurses should be putting orders in so I can track them. The DON confirmed RN 2 did not call physician when resident 10's blood sugar was over 420 as per the medical order. The DON confirmed RN 2 calculated the amount of insulin to give resident 10 when her blood sugar was greater than 420. The DON stated, The nurses do not have discretion to hold insulin or calculate the amount of insulin to give residents with out consulting the physician. The DON stated, They need to call the doctor.

Based on interview and medical record review, it was determined the facility did not immediately consult with the resident's physician when resident's treatments were altered for 6 of 24 sample residents. Specifically, the facility nursing staff did not notify the Medical Doctor (MD) when blood pressure and diabetic medications were not administered as per MD orders. Resident identifiers: 10, 19, 21, 23, 86, 136. Findings include: 1. Resident 10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/16/18 resident 10's medical record was reviewed. A. A review of resident 10's medical orders revealed the following for diabetic medication: Humalog I-100 Insulin . solution; 100 unit/mL (milliliters); Amount to Administer: Per Sliding Scale; If Blood Sugar is 140 to 180, give 1 Unit. If Blood Sugar is 181 to 220, give 2 Units. If Blood Sugar is 221 to 260, give 3 Units. If Blood Sugar is 261-300, give 4 Units. If Blood sugar is 301 to 340, give 5 Units. If Blood Sugar is 341- 380, give 6 Units. If Blood Sugar is 381 to 420, give 7 Units. If Blood Sugar is greater than 420, call MD. A review of resident 10's (MONTH) and (MONTH) (YEAR) MARs revealed the following: 1. On 6/7/18 at 5:19 PM, resident 10's blood sugar (BS) was 160, notes revealed, Not Administered . nurse discression (sic) not to give 1 unti (sic) at this time. 2. On 6/9/18 at 4:57 PM, resident 10's BS was 192, notes revealed, Not Administered . nurse discression (sic) not to give 2 units at this time. 3. On 6/12/18 at 4:51 PM, resident 10's BS was 206, notes revealed, Not Administered . nurse discression (sic) not to give insulin at this time. 4. On 6/14/18 at 4:51 PM, resident 10's BS was 171, notes revealed, Not Administered . nurse discression (sic) not to give 1 unit at this time . 5. On 6/16/18 at 4:51 PM, resident 10's BS was 148, notes revealed, Not Administered . nurse discression (sic) to not administer 1 unit insuloin (sic) at this time. 6. On 6/18/18 at 4:40 PM, resident 10's BS was 152, notes revealed, Not Administered . nurse dicression (sic) not to give 1 unit at this time. 7. On 6/26/18 at 5:22 PM, resident 10's BS was 171, notes revealed, Not Administered . nurse discression (sic) not to give 1 unit at this time. 8. On 7/3/18 at 4:32 PM, resident 10's BS was 159, notes revealed, Not Administered . nurse discression (sic) not to give 1 unit at this time. 9. On 7/4/18 at 4:39 PM, resident 10's BS was 164, notes revealed, Not Administered . nurse discression (sic) not to give 1 unit at this time. 10. On 7/5/18 at 4:36 PM, resident 10's BS was 180, notes revealed, Not Administered . nurse discression (sic) not to give 1 unit at this time. 11. On 7/7/18 at 5:04 PM, resident 10's BS was 173, notes revealed, Not Administered . nurse discression (sic) not to give 1 unit at this time. 12. On 7/9/18 at 4:47 PM, resident 10's BS was 143, notes revealed, Not Administered . nurse discression (sic) not to give 1 unit at this time. 13. On 7/10/18 at 4:33 PM, resident 10's BS was 198, notes revealed, Not Administered . nurse discression (sic) not to give 2 units at this time. 14. On 7/13/18 at 7:32 AM, resident 10's BS was 456, notes revealed, 8 units given. 15. On 7/13/18 at 8:32 PM, resident 10's BS was 561, notes revealed, 11 units given. 16. On 7/15/18 at 9:21 PM, resident 10's BS was 496, notes revealed, 9 units given. There was no documentation available for review which indicated that resident 10's primary care physician was notified that the Humalog insulin was held. B. A review of resident 10's Medication Administration Record [REDACTED] 1. Carvedilol tablet; 25 mg (milligrams) . twice a day . dx (diagnosis)[MEDICAL CONDITION](hypertension). a. On 6/11/18 at 6:56 PM, resident 10's BP was 104/58. Carvedilol was, Not Administered: Due to condition . Comment: low BP . b. On 6/17/18 at 9:11 PM, resident 10's BP was 103/56. Carvedilol was, Not Administered: Due to condition. There was no documentation available for review which indicated that resident 10's primary care physician was notified that the carvedilol was held. 2. Losartan tablet; 100 mg . once a day . dx HTN. On 7/3/18 at 8:29 AM, resident 10's BP was 104/57. Losartan was, Not Administered: Due to condition. There was no documentation available for review which indicated that resident 10's primary care physician was notified that the Losartan was held. 3. [MEDICATION NAME] . tablet; 10 mg . once a day . dx HTN. On 7/3/18 at 8:29 AM, resident 10's BP was 104/57. [MEDICATION NAME] was, Not Administered: Due to condition. There was no documentation available for review which indicated that resident 10's primary care physician was notified that the [MEDICATION NAME] was held. 2. Resident 23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/16/18 resident 23's medical record was reviewed. A review of resident 23's (MONTH) and (MONTH) (YEAR) MAR indicated [REDACTED] Entresto . tablet; 24-26 mg . twice a day . special instructions . heart failure. a. On 6/11/18 at 6:56 PM, resident 23's BP was 107/68. Entresto was, Not Administered: Due to condition. b. On 7/1/18 at 8:36 AM, resident 23's BP was 91/54. Entresto was, Not Administered: Due to condition. c. On 7/1/18 at 7:10 PM, resident 23's BP was 105/60. Entresto was, Not Administered: Due to condition. d. On 7/6/18 at 7:50 AM, resident 23's BP was 102/55. Entresto was, Not Administered: Due to condition. e. On 7/6/18 at 7:33 PM, resident 23's BP was 107/57. Entresto was, Not Administered: Due to condition. f. On 7/8/18 at 7:41 PM, resident 23's BP was 106/58. Entresto was, Not Administered: Due to condition. g. On 7/10/18 at 8:29 AM, resident 23's BP was 98/58. Entresto was, Not Administered: Due to condition. h. On 7/12/18 at 5:00 PM, resident 23's BP was 94/61. Entresto was, not Administered: On Hold . low bp. i. On 7/13/18 at 9:15 AM, resident 23's BP was 105/67. Entresto was, Not Administered: Due to condition. j. On 7/15/18 at 8:34 PM, resident 23's BP was 101/58. Entresto was, Not Administered: Due to condition. There was no documentation available for review which indicated that resident 23's primary care physician was notified that the Entresto was held. 3. Resident 136 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/16/18 resident 136's medical record was reviewed. A review of resident 136's (MONTH) and (MONTH) (YEAR) MAR indicated [REDACTED] [MEDICATION NAME] tablet; 25 mg . twice a day . Dx: A-fib ([MEDICAL CONDITION]) . a. On 7/11/18 at 8:20 PM, resident 136's BP was 101/62, [MEDICATION NAME] was, Not Administered: Due to condition. b. On 7/12/18 at 4:58 PM, resident 136's BP was 96/60, [MEDICATION NAME] was, Not Administered: On Hold Comment: pt b/p low. c. On 7/13/18 at 8:08 PM, resident 136's BP was 95/59, [MEDICATION NAME] was, Not Administered: Due to condition. d. On 7/14/18 at 8:40 PM, resident 136's BP was 97/66, [MEDICATION NAME] was, Not Administered: Due to condition. e. On 7/15/18 at 8:29 AM, resident 136's BP was 91/63, [MEDICATION NAME] was, Not Administered: Due to condition. There was no documentation available for review which indicated that resident 136's primary care physician was notified that the [MEDICATION NAME] was held. On 7/16/18 at 2:30 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated she was unaware if the facility had a policy allowing a nurse to hold medications from residents upon her discretion. RN 1 stated, I don't think that they (have a policy allowing a nurse to hold resident medications), but I don't know that. I was thinking in my mind as long as I was noting why I was not giving (a resident their medication) it would be sufficient. No one has ever told me that I could not do that. RN 1 confirmed that she did not notify the MD when resident 10 was in her care and insulin administrations were held or altered contrary to MD orders. RN 1 confirmed she had held resident 23's blood pressure medications without notifying the MD. RN 1 confirmed she did not notify the MD when she held resident 136's blood pressure medications. On 7/17/18 at 12:30 PM, an interview was conducted with RN 2. RN 2 stated he was told in the morning report resident 10 was on medication that would increase her blood sugar and, the practitioner was aware of that. RN 2 stated the insulin order indicated 'continue' on his computer screen and he calculated how much insulin to give by following the, trend in the order. RN 2 stated that he did not call the MD when resident 10's blood sugar was out of MD ordered ranges because, they already knew (resident 10's) blood sugar would be high. RN 2 confirmed he did not notify the MD when he held resident 23's heart failure medication. RN 2 confirmed he did not notify the MD when he held resident 136's blood pressure medication. On 7/17/18 at 10:28 AM, an interview was conducted with RN 3. RN 3 stated the policy to hold medications were sometimes part of the medical order. RN 3 stated she, typically held blood pressure medications if the systolic is less than 110, the diastolic less than 60, and the pulse is less than 60 or 65. I look at trends in the resident's vital signs before I hold medications. I don't notify the doctor if I hold a medication Mondays through Fridays; I give that information to the nurse manager. If it's a weekend or before or after normal hours I call the MD if I hold a medication. RN 3 stated, I believe the facility policy is to hold blood pressure medications is if the systolic blood pressure is lower than 110 or the diastolic blood pressure is lower than 60; that was what I was trained on when I got here. RN 3 confirmed she did not notify the MD when resident 136's blood pressure medications were held. On 7/16/18 at 5:10 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the MD was to be called and a telephone order was to be written and put into the computer every time a medical order was changed. The DON stated, nurses should be putting orders in so I can track them. The DON confirmed RN 2 did not call the MD when resident 10's blood sugar was over 420 as per the medical order. The DON confirmed RN 2 calculated the amount of insulin to give resident 10 when her blood sugar was greater than 420. The DON stated the nurses did not have discretion to hold insulin or calculate the amount of insulin to give residents with out consulting the physician. The DON confirmed RN 1 and RN 3 had held resident medications without notifying the MD. The DON stated, they need to call the doctor. 4. Resident 86 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 86's medical record reviewed on 7/16/18. a. On 7/14/18 at 3:00 PM, a PHYSICIAN(s) ORDER was received to administer Humulog (sic) insulin subcutaneously per the following sliding scale: .if BG (blood glucose) (less than) 140 do nothing, if 141-170 give 1 unit, if 171-200 give 2 units, if 201-230 give 3 units, if 231-260 give 4 units, if 261-290 give 5 units, if 291-320 give 6 units, if 321-350 give 7 units, if (greater than) 350 call MD (Medical Doctor); . The Humalog sliding scale was to be followed before meals and at bedtime. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. The Registered Nurse (RN) caring for resident 86 documented that Humalog 1 units was not administered due to Nurse discression (sic) not to give 1 unit insulin at this time. There was no documentation available for review which indicated that resident 86's primary care physician was notified that the Humalog insulin was held. On 7/16/18 at 4:57 PM, an interview was conducted with RN 1. RN 1 stated, I felt like in my mind, 1 unit would not make enough difference to give it. RN 1 further stated, I probably was not concerned about following the doctor's order. RN 1 stated that it was, Nursing discretion. On 7/16/18 at 5:10 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that insulin was to be administered as ordered by the physician and that, Nurses don't have discretion to hold insulin. They need to call the physician. b. Review of the admission orders [REDACTED] i. [MEDICATION NAME] 0.1 mg by mouth twice a day; and ii. [MEDICATION NAME] 20 mg by mouth twice a day. It should be noted that resident 86's primary care physician did not develop parameters with which to hold the [MEDICATION NAME] or [MEDICATION NAME]. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. The [MEDICATION NAME] was not administered due to low diastolic. There was no documentation available for review which indicated that resident 86's primary care physician was notified of the blood pressure or that the [MEDICATION NAME] and [MEDICATION NAME] were not administered. 5. Resident 19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 19's medical record was reviewed on 7/16/18. Upon admission to the facility, resident 19's primary care physician wrote an order to administer Humalog insulin as follows: If Blood Sugar is 140 to 170, give 1 unit. If Blood Sugar is 171 to 200, give 2 units. If Blood Sugar is 201 to 230, give 3 units. If Blood Sugar is 231 to 260, give 4 units. If Blood Sugar is 261 to 290, give 5 Units. If Blood Sugar is 291 to 320, give 6 units. If Blood Sugar is 321 to 350, give 7 Units. If blood Sugar is greater than 350, call MD. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. The RN documented that 8 units of insulin was administered. On 7/16/18 at 4:57 PM, an interview was conducted with RN 1. RN 1 stated that she, sent the doctor a text but was unable to provide documented evidence that resident 19's physician gave an order to administer 8 units of insulin. RN 1 further stated that she did not write a Telephone Order to administer 8 units of insulin as it was a one time order. RN 1 stated that she did not document the order in a progress note. On 7/16/18 at 5:10 PM, an interview was conducted with the DON. The DON stated that nurse's were expected to contact the primary care physician for blood sugars that were greater than the range given by the physician. The DON stated that one-time orders were to be documented on a telephone order and put into the computer system. 6. Resident 21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 21's medical record was reviewed on 7/17/18. Review of the admission orders [REDACTED]. It should be noted that resident 21's primary care physician did not develop parameters with which to hold the [MEDICATION NAME]. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. The licensed nurses documented, Due to condition but did not document what the condition was. There was no documentation available for review to indicate resident 21's physician was notified that the [MEDICATION NAME] was not administered.

Based on interview and record review, it was determined that for 4 of 24 sample residents, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, blood pressure medications were not administered as ordered by physician for 3 residents. Additionally, heart failure medications were not administered as ordered for a resident. Resident identifiers: 10, 21, 23 and 136. Findings include: 1. Resident 10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/16/18 resident 10's medical record was reviewed. A review of resident 10's (MONTH) and (MONTH) (YEAR) Medication Administration Records (MARs) revealed the following prescribed blood pressure (BP) medications and dates and times when they were not administered: a. Carvedilol tablet; 25 mg (milligrams) . twice a day . dx (diagnosis)[MEDICAL CONDITION](hypertension). i. On 6/11/18 at 6:56 PM, resident 10's BP was 104/58. Carvedilol was, Not Administered: Due to condition . Comment: low BP . ii. On 6/17/18 at 9:11 PM, resident 10's BP was 103/56. Carvedilol was, Not Administered: Due to condition. b. Losartan tablet; 100 mg . once a day . dx HTN. On 7/3/18 at 8:29 AM, resident 10's BP was 104/57. Losartan was, Not Administered: Due to condition. c. [MEDICATION NAME] . tablet; 10 mg . once a day . dx HTN. On 7/3/18 at 8:29 AM, resident 10's BP was 104/57. [MEDICATION NAME] was, Not Administered: Due to condition. 2. Resident 23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/16/18 resident 23's medical record was reviewed. A review of resident 23's (MONTH) and (MONTH) (YEAR) MARs revealed the following prescribed heart failure medication and dates and times when it was not administered: Entresto . tablet; 24-26 mg . twice a day . special instructions . heart failure. a. On 6/11/18 at 6:56 PM, resident 23's BP was 107/68. Entresto was, Not Administered: Due to condition. b. On 7/1/18 at 8:36 AM, resident 23's BP was 91/54. Entresto was, Not Administered: Due to condition. c. On 7/1/18 at 7:10 PM, resident 23's BP was 105/60. Entresto was, Not Administered: Due to condition. d. On 7/6/18 at 7:50 AM, resident 23's BP was 102/55. Entresto was, Not Administered: Due to condition. e. On 7/6/18 at 7:33 PM, resident 23's BP was 107/57. Entresto was, Not Administered: Due to condition. f. On 7/8/18 at 7:41 PM, resident 23's BP was 106/58. Entresto was, Not Administered: Due to condition. g. On 7/10/18 at 8:29 AM, resident 23's BP was 98/58. Entresto was, Not Administered: Due to condition. h. On 7/12/18 at 5:00 PM, resident 23's BP was 94/61. Entresto was, not Administered: On Hold . low bp. i. On 7/13/18 at 9:15 AM, resident 23's BP was 105/67. Entresto was, Not Administered: Due to condition. j. On 7/15/18 at 8:34 PM, resident 23's BP was 101/58. Entresto was, Not Administered: Due to condition. 3. Resident 136 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/16/18 resident 136's medical record was reviewed. A review of resident 136's (MONTH) and (MONTH) (YEAR) MARs revealed the following prescribed blood pressure medication and dates and times when it was not administered: [MEDICATION NAME] tablet; 25 mg . twice a day . Dx: A-fib ([MEDICAL CONDITION]) . a. On 7/11/18 at 8:20 PM, resident 136's BP was 101/62, [MEDICATION NAME] was, Not Administered: Due to condition. b. On 7/12/18 at 4:58 PM, resident 136's BP was 96/60, [MEDICATION NAME] was, Not Administered: On Hold Comment: pt b/p low. c. On 7/13/18 at 8:08 PM, resident 136's BP was 95/59, [MEDICATION NAME] was, Not Administered: Due to condition. d. On 7/14/18 at 8:40 PM, resident 136's BP was 97/66, [MEDICATION NAME] was, Not Administered: Due to condition. e. On 7/15/18 at 8:29 AM, resident 136's BP was 91/63, [MEDICATION NAME] was, Not Administered: Due to condition. 4. Resident 21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 21's medical record was reviewed on 7/17/18. Review of the admission orders [REDACTED]. It should be noted that resident 21's primary care physician did not develop parameters with which to hold the [MEDICATION NAME]. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. The licensed nurses documented, Due to condition but did not document what the condition was. There was no documentation available for review to indicate resident 21's physician was notified that the [MEDICATION NAME] was not administered. On 7/16/18 at 4:57 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated, In my thought process if the blood pressure was too low like 100, I used my nurses discretion not to administer the medication. RN 1 confirmed she did not contact the physician when she held medications. RN 1 stated she had no knowledge of a facility policy regarding holding medications and notifying physicians to hold medications. On 7/17/18 at 10:28 AM, an interview was conducted with RN 3. RN 3 stated the policy to hold medications were sometimes part of the medical order. RN 3 stated she, typically held blood pressure medications if the systolic is less than 110, the diastolic less than 60, and the pulse is less than 60 or 65. I look at trends in the resident's vital signs before I hold medications. I don't notify the doctor if I hold a medication Mondays through Fridays; I give that information to the nurse manager. If its a weekend or before or after normal hours I call the physician if I hold a medication. RN 3 stated, I believe the facility policy is to hold blood pressure medications is if the systolic blood pressure is lower than 110 or the diastolic blood pressure is lower than 60; that was what I was trained on when I got here. On 7/17/18 at 12:30 PM, an interview was conducted with RN 2. RN 2 stated the doctor will usually instruct to hold BP medications in the order. RN 2 stated the facility had a standing order to hold blood pressure medications and they did not need to notify the physician every time a medication was held. On 7/16/18 at 5:21 PM, an interview was conducted with the Director of Nursing (DON). The DON stated, if there is a concern to hold a medication the nurse should call the physician and get an order to do so. On 7/17/18 at 7:09 AM, an additional interview was conducted with the DON. The DON stated the facility did not have a standing order policy to hold blood pressure medications and she had created a policy after identifying this issue.

Based on interview and record review, it was determined for 1 of 24 sample residents, that the facility did not ensure that each resident's drug regimen was free from unnecessary medications including duplicate therapy. Duplicate therapy refers to multiple medications of the same pharmacological class/category or any medication therapy that substantially duplicates a particular effect of another medication that the individual was taking. A [MEDICAL CONDITION] drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, anti-psychotics, anti-depressants, anti-anxieties, and hypnotics. Specifically, a resident received [MEDICATION NAME] sleep aids. Resident identifier: 21. Findings include: Resident 21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 21's medical record was reviewed on 7/17/18. The admission orders [REDACTED]. On 6/30/18, a telephone order was written to administer [MEDICATION NAME] (an anti-depressant also prescribed for [MEDICAL CONDITION]) 200 mg by mouth at bedtime for [MEDICAL CONDITION]. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. On 7/17/18 at 1:06 PM, an interview was conducted with the Director of Nursing (DON). The DON was unable to provide additional information as to why resident 21 received duplicate medication therapy for [MEDICAL CONDITION].

Based on interview and record review, it was determined for 1 of 24 sample residents that the facility did not develop a discharge summary that included, but was not limited to, the following: (i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. (ii) A final summary of the resident's status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative. (iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter). (iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any post-discharge medical and non-medical services. Specifically, a recapitulation of resident's stay was not developed. Resident identifier: 14. Findings include: Resident 14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 14's medical record was reviewed on 7/16/18. On 7/10/18, resident 14 was discharged to home. Review of the DISCHARGE INSTRUCTIONS & (and) SUMMARY form revealed that resident 14 was discharged to home with a home health agency to provide physical therapy, occupational therapy, and nursing services. Resident 14 was on a regular fortified diet with no milk products. A list of medications that resident 14 was taking at the time of discharge were listed. The DISCHARGE INSTRUCTIONS & SUMMARY form did not include a recapitulation of resident 14's stay while at the facility. On 7/16/18 at 11:31 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that a recapitulation of resident 14's stay was not completed and that the facility staff were only completing the DISCHARGE INSTRUCTIONS & SUMMARY form which did not include a recapitulation of resident 14's stay at the facility.

Based on observation, interview and record review it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, sanitizer solution was stronger than the manufacture instructions, there was out dated food in the refrigerator, there was food not dated in the refrigerator, and a dietary staff member was touching the silverware by the part that residents ate from. Findings include: 1. On 4/17/17 at 7:15 AM, an initial tour was conducted of the facility kitchen. The following observations were made in the kitchen refrigerators: a. There were 2 plates with fruit and cottage cheese that did not have a date. b. There was a container of mandarin oranges dated 4/9/17. c. There were hard boiled eggs dated 4/11/17 with a use by date 4/14/17. d. There was a small bowl of french cut green beans with no date. e. There was a container of roast beef sandwich meat dated opened 3/31/17. f. There was a carton of nectar thickened orange juice with no open date. g. There was a carton of nectar thickened cranberry juice with an open date of 4/3/17. The label on the thickened liquids revealed, .refrigerate for up to 7 days. 3. During the initial tour Cook 1 was observed to check the sanitizer solution. The solution was 500 parts per million of quarts sanitizer solution. There was a sign hanging next to the sanitizer solution that revealed, Compare to chart on test paper dispenser immediately. Solution should be 200 PPM concentration. 4. On 4/18/17 at 12:50 PM, an observation was made of dietary staff placing silverware on the tables. The staff member was holding the silverware by the part that residents ate from. An interview was conducted with the staff member. The staff member stated that the silverware was to be held by the handle. On 4/19/17 at approximately 3:00 PM, an interview was conducted with the Dietary Manager (DM). The DM stated that the out dated and undated food should have been discarded. The DM stated that Cook 1 told her the sanitizer solution was stronger than the manufacture instructions on 4/17/17 but did not know why the sanitizer was not at 200 PPM.

Based on observation and interview, it was determined the facility did not implement an infection control program designed to prevent the spread of infections. Specifically, a metal laundry cart was used to take garbage to the dumpster outside and used to transport linen. Findings include: On 4/18/17 at 12:38 PM, Laundry Aide (LA) 1 was observed while pushing a metal laundry cart full of garbage bags to the outside garbage dumpster. LA 1 emptied the garbage into the dumpster with gloved hands then pushed the laundry cart back into the facility and placed the laundry cart on the Clean Linen side of the laundry room. LA 1 then removed the gloves off of her hands. On 4/18/17 at approximately 12:45 PM, LA 1 was interviewed. LA 1 stated that the laundry bins were used a lot of things which included gathering and emptying trash and transporting laundry. On 4/19/17 at 7:20 AM, LA 1 was observed while gathering trash out of the administrative office and placing the trash bags into the laundry bin. On 4/19/17 at 7:25 AM, the Administrator was interviewed. The Administrator stated that the laundry bins had been labeled in the past and that there was a laundry bin that was previously designated for garbage only.

Based on interview and record review it was determined, for 5 of 28 sample residents, that the facility did not provide routine and emergency drugs and biological's to its residents. Specifically, medications were not available for administration and medications were administered late. Resident identifiers: 3, 50, 143, 216, and 225. Findings include: 1. Resident 143 was admitted on [DATE] with a [DIAGNOSES REDACTED]. On 4/19/17 resident 143's medical record was reviewed. Review of the Medication Administration Record [REDACTED] a. Glimepiride 2 mg (milligrams) was administered late on day shift on 2/24/17, 2/26/17, 3/11/17, 3/16/17, 3/19/17, 3/21/17, 3/22/17, 3/25/17, 3/28/17, 4/7/17, 4/9/17, 4/11/17, and 4/12/17. b. Coreg 12.5 mg was administered late on evening shift on 3/1/17. c. Coreg 12.5mg was not administered on evening shift on 3/10/17 and day shift on 3/12/17 because the drug/item unavailable. d. Coumadin 3 mg was administered late on evening shift on 3/1/17. e. Culturelle 10 billion cells was not administered on day shift on 3/6/17 because the drug/item unavailable. f. Krill oil 500 mg was not administered on day shift 3/6/17, 4/13/17, 4/14/17, and 4/17/17 because the drug/item unavailable. g. Lipitor 20 mg was administered late on evening shift on 3/1/17. h. Lyrica 50 mg was administered late on evening shift on 3/1/17. 2. Resident 216 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 4/19/17 the resident 216's medical record was reviewed. Review of the MARs from 3/31/17 to 4/19/17 revealed the following: a. Avapro 300 mg was administered late, just received from pharmacy on evening shift on 3/31/17. b. Cleocin 300 mg was administered late on day shift on 4/2/17. c. Flecainide 50 mg was administered late, just received from pharmacy on evening shift on 3/31/17. d. Flecainide 50 mg was administered late on day shift on 4/2/17. e. Levothyroxine 125 mcg (micrograms) was administered late on day shift on 4/8/17 and 4/9/17. f. Lipitor 20 mg was administered late, just received from pharmacy on evening shift on 3/31/17. g. Oxycodone 15 mg was administered late, just received from pharmacy on evening shift on 3/31/17. h. Trazodone 100 mg was administered late, just received from pharmacy on evening shift on 3/31/17. i. Xarelto 20 mg was administered late, just received from pharmacy on evening shift on 3/31/17. 3. Resident 225 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 4/19/17 resident 225's medical record was reviewed. Review of the April 2017 MAR indicated [REDACTED] a. Alprazolam 0.5 mg was administered late on day shift and evening shift on 4/16/17 b. Symbicort HFA aerosol inhaler 80-4.5 mcg was not administered on day shift on 4/14/17 and 4/16/17 and also on evening shift on 4/13/17, 4/14/17, and 4/16/17 because drug/item unavailable 4. Resident 50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 50's medical record was reviewed on 4/19/17. A physicians order dated 4/2/17 revealed, Horizant 600 mg. Another physicians order dated 4/18/17, Megace 400 mg/10 mL (milliliters). Resident 50's April 2017 MAR indicated [REDACTED]Drug/Item unavailable. The drug Megace was not administered on 4/18/17 with the documented reason of, Drug/Item unavailable. On 4/19/17 at 1:00 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that she did not know why the items were marked as unavailable. On 4/19/17 at 1:17 PM, a follow up interview was conducted with the DON. The DON stated that the Horizant was not delivered until 10:30 PM and that the Megace order was obtained at 6:15 PM and then to start at 7:00 PM which would have not given the pharmacy enough time to deliver the medications. 5. Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 3's medical record was reviewed on 4/19/17. admission orders [REDACTED] a. Cymbalta 60 mg twice a day for depression; b. Eliquis 2.5 mg twice a day for atrial fibrillation; c. Flecainide 50 mg twice a day for atrial fibrillation; d. Hydrochlorathiazide 25 mg daily for hypertension; e. Lipitor 40 mg at bedtime for high cholesterol; f. Minocycline 100 mg twice a day for an abdominal wound; g. Miralax 17 grams twice a day for constipation; h. Qvar 80 mcg 1 inhalation twice a day for asthma; and i. Senna S 8.6-50 mg twice a day for constipation. Review of the MARs from 3/30/17 to 4/19/17 revealed the following: a. Cymbalta 60 mg was not administered the evening of 3/30/17 due to (d/t) Drug/Item unavailable. (Note: The medical record documented that resident 3 was admitted to the facility at approximately 1:00 PM.) b. Eliquis 2.5 mg was not administered the evening of 3/30/17 d/t Drug/Item unavailable. c. Flecainide 50 mg was not administered the evening of 3/30/17 and the morning of 4/10/17 d/t Drug/Item unavailable. d. Hydrochlorathiazide 25 mg was not administered on 4/10/17 d/t Drug/Item unavailable. e. Lipitor 40 mg was not administered on 3/30/17 d/t Drug/Item unavailable. f. Minocycline 100 mg was not administered the evening of 3/30/17, the evening of 4/8/17 and the morning of 4/9/17 d/t Drug/Item unavailable. g. Miralax 17 grams was not administered the evening of 3/30/17 and the morning on 4/17/17 d/t Drug/Item unavailable. h. Qvar 80 mcg was not administered the evening of 3/30/17 d/t Drug/Item unavailable. i. Senna 2 8.6-50 mg was not administered the evening of 3/30/17 d/t Drug/Item unavailable. On 4/19/17 at 8:57 AM, the facility DON was interviewed. The DON stated that the above medications should have been available for administration as ordered by the physician.

Based on interview and record review it was determined that the facility did not treat and care for, 1 of 28 sample residents in a manner and in an environment that promoted maintenance or enhancement of his quality of life recognizing his individuality. Specifically, a safety alarm was placed on a resident who was assessed as being alert and oriented. Additionally, the safety alarm continued to be used despite the resident signing a risk versus benefits form. Resident identifier: 50. Findings include: Resident 50 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 4/18/17 at 2:00 PM, an interview was conducted with resident 50. Resident 50 stated that he did not want alarms placed on or under him. Resident 50 stated that he had signed a form that he refused to have an alarm and was aware of the risks. Resident 50's medical record was reviewed on 4/19/17. A form titled Fall Risk Assessment dated 4/2/17 revealed that resident 50 was at moderate risk for falls. The interventions documented were fall mats and a therapy consult. A physicians order dated 4/2/17 revealed that resident 50 had an order for [REDACTED].) A physicians order dated 3/14/17 with a discontinued date of 3/31/17 revealed that resident had a motion alarm in bed and in the wheelchair. Another physicians order dated 3/14/17 with a discontinued date of 3/31/17 revealed to place a tab alarm on resident while in bed and the wheelchair. A form titled, Refusal of Treatments was signed by resident 50 on 4/13/17. The form revealed that resident 50 refused all alarms. Resident 50's nurses notes revealed the following entries: a. 4/4/17 at 2:41 PM, Pt (patient) is alert and oriented x (times ) 2-3 (person, place and time) with some noted memory deficits. b. 4/11/17 at 1:31 PM, Pt is alert and oriented x 2 (person and place) with noted confusion. Pt found in room, in w/c (wheelchair) leaving bathroom. Nurse asked pt what he was doing, pt stated that he just used the restroom. The call light was not activated, pt pressure alarm was intact on bed and not alarming. Nurse asked pt how come the alarm wasn't going off, the pt stated: 'I turned it off, that sound is a nuisance'. Nurse educated pt on the importance of the fall alarm, as a precaution to alarm staff in case of a fall. Pt stated that he doesn't need the alarm and that he is able to do toilet himself. Staff assisted pt back to bed, alarm activated, monitoring pt frequently, as pt is noncompliant with fall precautions. Pt currently sleeping with call light in reach. Will continue with plan of care. c. 4/13/17 at 2:47 PM, .Pt has fall mats and bed alarms in place for fall risk, pt has been educated to use call light for needs prior to trying to do it on his own. d. 4/17/17 7:28 AM, .Pt is alert and oriented x 3. Pt has bed alarm, bed is kept at lowest level. On 4/18/17 at 2:35 PM, a follow up interview was conducted with resident 50. Resident 50 stated that staff told him the alarms were for safety. Resident 50 stated that he was unable to move without an alarm sounding. Resident 50 stated he felt like the alarm was tattling on him. Resident 50 stated that he turned off the alarms and used his call light when he needed assistance. Resident 50 stated he did not feel like he was treated with dignity with the alarm. An observation was made of resident 50's bathroom and there was a tab alarm on the grab bar by the toilet. On 4/18/17 at 2:20 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that resident 50 was not at risk for falls. CNA 1 stated that resident 50 had a tab alarm. CNA 1 stated that resident 50 was very alert and able to use his call light for assistance. On 4/18/17 at 2:20 PM, an interview was conducted with CNA 2. CNA 2 stated that resident 50 was at risk for falls and had a bed alarm and fall mats since his initial admission. CNA 2 stated that resident 50 was alert and oriented and able to use his call light. CNA 2 stated that resident 50 always has the alarm on. On 4/18/17 at 2:25 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 50 was at risk for falling. RN 1 stated that resident 50 had a bed alarm and fall mats since his initial admission. RN 1 stated that resident 50 used his call light to ask for assistance. RN 1 stated that nurses obtained a physician order [REDACTED].>On 4/18/17 at 3:50 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that when a resident was admitted a fall assessment was completed and an alarm was placed if the resident was a high fall risk. The DON stated that orders were obtained from the physician for alarms. The DON stated that resident 50 hates the alarm. The DON stated that he was able to use a call light. The DON stated that she did not know why the alarm was implemented when resident 50 was assessed as a moderate fall risk. The DON stated that she did not know why nurses were continuing to document that resident 50 had an alarm on after the resident signed a risks vs (versus) benefits. The DON further stated that she did not know why there was an alarm in resident 50's bathroom. The DON stated that she contacted the facility admissions nurse and the admissions nurse did not know why an alarm was placed on resident 50 after readmission.