Every finding on record at Aviata at North Fort Myers

Based on observation and interview with the Dietary Manager, the facility failed to store food in an appropriate manner in accordance with guidelines of the FDA (Food and Drugs Administration) Food Code to ensure food was stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. The findings included:The facility policy and procedure titled, Food Storage: Cold Foods, revised 4/2018, policy #019's Policy Statement stated, All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA (Food and Drug Administration) Food Code. Procedures . All food will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination . References : https://www.fda.gov/downloads/food/guidanceregualtions/retailfoodprotection/foodcode/ucm374510.pdf. The undated dietary department policy titled, Labeling and Dating Inservice noted, . Importance of Labeling and Dating. Proper labeling and dating ensures that all foods are stored, rotated, and utilized in a First In First Out (FIFO) manner. This will minimize waste and ensure that items that are passed their due date are discarded. Guidelines for Labeling and Dating . Leftovers must be labeled and dated with the date they are prepared and the use by date.On 4/6/26 at approximately 9:34 a.m., observation of the kitchen with Dietary Manager (DM) during the initial tour of the kitchen revealed:In the beverage refrigerator, the following food items were not dated: 2 egg sandwiches in a clear plastic wrap; 2 facility made salads; and 12 fortified puddings in a bowl with a clear lid. In the walk-in refrigerator: 1 soup-based container-dated 2/26; a jar of grape jelly-dated 2/19, half of a block of margarine/butter which was not dated; a bottle of pancake syrup open and half empty-without a date; 2 bags of shredded cheese-open and undated; and a bag of hash browns-open and undated.In an interview, the Dietary Manager verified that all the food items observed during the initial tour of the kitchen in the beverage refrigerator and walk-in refrigerator were not dated and/or disposed of according to their policy. The Dietary Manager said that all food items prepared by dietary, opened and stored in the kitchen or pantries were required to have an appropriate label indicating what the food was, the date the food was made or opened to ensure they were rotated and used appropriately and/or disposed of as required per their policy and Food Storage and Retention Guide.

Based on record review, and staff interviews, the facility failed to ensure the clinical record of 1 (Resident #11) of 2 residents reviewed for accurate documentation was completely and accurately documented. The findings included: Review of the clinical record for Resident #11 revealed an admission date of 10/31/22.Diagnoses included: Acute gastric ulcer with hemorrhage; Traumatic subdural hemorrhage with loss of consciousness (head injury); Mild protein-calorie malnutrition; Dysphagia (difficulty swallowing); Epilepsy; Cerebrovascular disease (disease of the blood vessels in the brain).Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11scored 14 on the Brief Interview for Mental Status, indicating intact cognition. The MDS noted that Resident #11 required setup or clean-up assistance for eating.Review of the care plan completed on 2/19/26 revealed that Resident #11was at risk for malnutrition related to prior medical history of anxiety disorder, major depressive disorder, chronic obstructive pulmonary disease, gastroesophageal reflux disease, altered laboratory results, need for mechanically altered diet, body mass index of 23, mild protein calorie malnutrition, and Mini Nutritional Assessment score of 8. The goals included consumption of greater than 50-75% of meals/fluids.The approaches included to provide, serve diet as ordered; monitor intake and record every meal.Review of the Mini Nutritional assessment dated [DATE] revealed Resident #11was at risk for malnutrition. The meal intakes were noted to be 50 to 100%, mostly 75-100%. Resident #11's weight was noted at 157 pounds (lbs.) and his Body Mass Index was 21.3, which is considered low.Review of the Certified Nursing Assistants (CNAs) documentation for March 2026, and April 2026 revealed that the meal intake was not documented for 44 of 117 meals.For the breakfast meal, there was no meal intake documented on 3/1, 3/3, 3/4, 3/5, 3/8, 3/10, 3/11, 3/14, 3/16, 3/17, 3/21, 3/22, 3/24, 3/25, 3/28, 3/30, 4/4, 4/5, 4/6, 4/7, and 4/8.For the lunch meal no meal intake was documented on 3/1, 3/3, 3/4, 3/5, 3/7, 3/8, 3/10, 3/11, 3/14, 3/16, 3/17, 3/21, 3/22, 3/24, 3/25, 3/28, 3/30, 4/4, 4/5, 4/6, 4/7, and 4/8.No meal intake was documented for supper on 3/15. On 4/9/26 at 9:15 a.m., in an interview the Director of Nursing (DON) confirmed the CNAs did not document 44 meal percentages as required. The DON said that the CNAs should document meal intake and/or refusals for every meal.

Based on staff interviews and record review, the facility failed to ensure ongoing communication with the dialysis center related to the ongoing assessment of a dialysis resident before and after each dialysis treatment for 1 (Resident #128) of 1 resident receiving dialysis.The findings included:The facility's policy Coordination of Hemodialysis Services #N1359 with a revision date of 07/02/2019 stated residents which have required an outside ESRD (End Stage Renal Disease) facility will have services coordinated by the facility. There would be communication between the facility and the ESRD facility regarding the residents. A dialysis communication form would be initiated by the facility for any resident going to an ESRD center for hemodialysis. Nursing would collect and complete the information regarding the resident to send to the ESRD center . Upon the resident's return to the facility, nursing will review the dialysis communication form and information completed by the dialysis center or the information sent by the dialysis center. Nursing will complete the post dialysis information on the dialysis communication and file the completed form in the resident's clinical record.Review of Resident #128's medical record revealed an admission date of 3/26/26. Diagnoses included a medical history of ESRD and Chronic Kidney Disease, Stage 5. The admitting physician's orders included hemodialysis services every Tuesday, Thursday and Saturday at the dialysis center.Review of Resident #128's Dialysis Communication Record forms revealed:On 3/14/26, the form did not document if Resident #128 had received medication prior to going to the dialysis center as ordered by the physician, shunt site assessment while at the dialysis center and shunt site assessment upon return from the dialysis center to the facility.On 3/28/26, the form did not document if Resident #128 had received medication prior to going to the dialysis center as ordered by the physician; the assessment of Resident #128's shunt site upon return from the dialysis center was incomplete.On 4/2/26, the form lacked documentation that Resident #128's shunt site was assessed upon return to the facility.On 4/4/26, the dialysis communication information was written on a note pad and only documented pre-dialysis and post-dialysis vital signs and weight. The Dialysis Communication Record form was not completed by facility nursing staff or the Dialysis Center. There was no documentation of the shunt site before, during, or after dialysis.On 4/7/26, the dialysis communication form was missing documentation: if Resident #128 had received medication prior to going to the dialysis center as ordered by the physician, assessment of the shunt site at the Dialysis Center and shunt site assessment upon return from the dialysis center to the facility.An undated Dialysis Communication Record form was incomplete. It did not document if medications were administered prior to dialysis as ordered by the physician, a pre-dialysis or post-dialysis shunt site assessment.On 4/7/26 at 3:42 p.m., Registered Nurse (RN) Staff B reviewed Resident #128's Dialysis Communication Record forms dated 3/14/26, 3/28/26, 4/2/26, 4/4/26, 4/7/26, and the undated Dialysis Communication Record form. She confirmed the Dialysis Communication Record forms were incomplete and did not contain the required documentation. RN Staff B confirmed that Resident #128 received hemodialysis at the dialysis center every Tuesday, Thursday and Saturday. She said the facility nurse who sent Resident #128 to the dialysis center was required to complete the top portion of the Dialysis Communication Record form to include if the resident had received their physician ordered medication prior to leaving the facility, the name of the medication and if the medication was not given as ordered to document on the form why the medication was not administered as per physician orders. She said upon the resident's return from the dialysis center, the receiving nurse was required to review the documentation from the dialysis center and document their post-dialysis assessment of the resident's dialysis shunt site on the bottom portion of the communication form.On 4/7/26 at 4:04 p.m., in an interview Unit Manager Staff C confirmed that the nursing staff who sends the resident to the dialysis center was required to complete the top portion of the Dialysis Communication Record form. The nurse who receives the resident from the dialysis center was responsible to review the Dialysis Communication Record form for any new orders from the dialysis center, conduct and document a full assessment of the resident's dialysis shunt site on the bottom of the Dialysis Communication Record form. Unit Manager Staff C reviewed Resident #128's Dialysis Communication Record forms dated 3/14/26, 3/28/26, 4/2/26, 4/4/26, 4/7/26, and the undated Dialysis Communication Record form and stated they were missing the facility nurses' required documentation as required by the facility's policy.On 4/9/26 at 8:27 a.m., in an interview the Director of Nursing said Resident #128's Dialysis Communication Record forms were not completed as required by their Coordination of Hemodialysis Service Policy and Procedure.

Based on record review and interviews, the facility failed to have documentation of a performance review and in-service education based on the outcome of the review for 1 (Staff E) of 4 Certified Nursing Assistants (CNAs) reviewed.The findings included:On 4/8/26, review of CNA Staff E's employee file revealed a date of hire of 9/11/24. The employee file lacked documentation of an annual performance evaluation for the year 2025.On 4/8/26 at 2:18 p.m., the Human Resources Director reviewed CNA Staff E's employee file and confirmed in an interview that no annual performance evaluation had been completed since CNA Staff E's original hire date.On 4/9/26 at 8:03 a.m., in an interview, the Nursing Home Administrator verified that CNA Staff E had been employed at the facility since 9/11/24. She said they were unable to find an annual performance evaluation for CNA Staff E.

Based on record review and staff interviews, the facility failed to have documentation of dementia management training for 2 (Staff E and Staff D) of 4 Certified Nursing Assistants (CNAs) reviewed.The findings included:Review of the CNA Staff E's employee file revealed the Dementia Care: Effective Communication training assigned to the CNA on 9/11/24 had a status of not started.No other annual dementia training was in the employee records.Review of CNA Staff D's employee file revealed the Dementia Care: Effective Communication training was assigned to the CNA on 9/1/23 and had a status of not started. No other annual dementia training was in the employee records.On 4/8/26 at 1:04 p.m., in an interview, the Human Resources Director said that the education transcripts of CNAs Staff D and Staff E did not include dementia training. She verified that CNAs Staff D and Staff E never completed the Dementia Care: Effective Communication training that were assigned to them respectively on 9/1/23 and 9/11/24.On 4/8/26 at 2:20 p.m., in an interview, the Nursing Home Administrator confirmed that CNA Staff D and CNA Staff E had not completed dementia training for 2025.

Based on observation, record review and staff interviews, the facility failed to ensure fall prevention interventions were implemented for 1 (Resident #53) of 3 residents reviewed who sustained multiple falls at the facility.The findings included:Review of the clinical record of Resident #53 revealed an admission date of 1/26/26. Diagnoses included Chronic Obstructive Pulmonary Disease, Systemic Lupus, unspecified displaced fracture of surgical neck of left humerus, syncope (fainting) and collapse.Review of the 5-Day Minimum Data Set (MDS) Assessment with an assessment reference date of 2/5/26 revealed that Resident #53's cognition was severely impaired. The resident required substantial/maximal assist with toileting, bathing and transfers; partial/moderate assistance with dressing, sit to stand, and bed mobility.A Change in Condition progress note dated 1/27/26 revealed Resident #53 resident had a fall. Nursing staff assisted the resident in getting back to bed. Education provided on fall prevention measures. Resident to call for assistance before getting out of bed/chair when needed.A care plan initiated on 1/27/26 documented that Resident #53 had an actual fall with no injury related to unsteady gait. The goal was for the resident to resume usual activities and minimize the risk of further incident. The intervention was a Physical Therapy consultation for strength and mobility.On 1/28/26, bilateral fall mats were added to the resident's care plan.A Change of Condition Progress Note dated 1/29/26 documented that Resident #53 had a fall. The Change in Condition did not include details of the fall.A physician progress note dated 1/29/26 documented that Resident #53 had another fall where he was found sitting on the side of his bed.On 1/29/26, a scoop mattress (specialized mattress with raised, bolstered sides for fall prevention) was added to the care plan interventions. A Change in Condition dated 1/30/26 documented Resident #53 had a fall. The Change in Condition did not include details of the fall.An Interdisciplinary Team (IDT) note dated 1/30/26 documented that Resident #53 gets anxious at night and attempts to climb out of bed. Resident does not have any trunk control and cannot stand up. Psychiatric evaluation and medication review to be completed.A nursing progress note dated 2/3/26 documented that Resident #53 was observed sitting on the floor by his bed. The resident was unable to report what he was doing at the time of the fall. The care plan was reviewed. Bilateral floor mats in place, scoop mattress to bed.The Certified Nursing Assistant (CNA) Kardex (contains instructions for daily care) did not include the bilateral fall mats interventions under safety for Resident #53.On 4/6/26 at 2:39 p.m., and on 4/7/26 at 8L45 a.m., Resident #53 was observed in bed. The floor mats were observed folded up against the wall.On 4/8/26 at 11:57 a.m., in an interview CNA Staff A said that when Resident #53 was admitted , he was very confused and would fall from bed. She said the resident should always have bilateral floor mats placed on the floor whenever the resident is in bed.On 4/9/26 at 12:41 p.m., Resident #53 was observed in bed. The bed was in high position. The floor mats were folded up against the wall.On 4/9/26 at 12:45 p.m., in an interview the Director of Nursing (DON) said the floor mats should be placed on the floor whenever Resident #53 is in bed. The DON verified that the floor mats were not listed on Resident #53's Kardex due to an error when the care plan was written.

Based on observation, record review, residents, staff and contractor's interview, the facility failed to have an effective pest control program to ensure a pest free environment in residents' rooms and in the kitchen of the food serving establishment.The findings included:On 10/20/25 at 9:05 a.m., during a tour of the [NAME] Unit, a live brown insect was observed crawling on the bathroom floor of room [ROOM NUMBER].On 10/20/25 at 9:49 a.m., in an interview Resident #6 said she's had ants crawling in her bed.On 10/21/25 at 3:50 a.m., in an interview Registered Nurse (RN) Staff BB said ants were an issue at the facility. During the interview, multiple ants were observed crawling on the wall at the nurse's station next to the [NAME] Unit.On 10/21/25 at 4:00 a.m., during a tour of the [NAME] Unit the following observations were made:Live crawling insects in the hallway and in room [ROOM NUMBER].Numerous ants were crawling on the clean linen in the linen cart.During confidential interviews, direct care staff who routinely work during the night shift said roaches and ants have been a constant issue at the facility.During a confidential interview during the night shift on 10/21/25 a direct care staff said recently 13 roaches were killed on their assigned unit.Review of the facility's pest control log for June 2025, July 2025, 8/2025, 9/2025, and 10/2025 revealed recurrent entries of roaches and ants sightings as follows:6/17/25: Roaches in the bathroom of room [ROOM NUMBER].6/27/25: Roaches and ants in the activities department.8/19/25: Ants in room [ROOM NUMBER] W.8/21/25: Ants in room [ROOM NUMBER] A.8/21/25: Ants in the pantry of the [NAME] Unit.9/21/25: Roach in the entry hall of [NAME] Lane.9/30/25: Roches on/in the dresser in room [ROOM NUMBER] W.10/17/25: Kitchen-Dishpit Roaches 100 S.Review of the pest control company inspection reports revealed:On 10/14/25 dead roaches and American cockroaches were found in the kitchen storage area.10/21/25, Issues with roaches in the kitchen and with ants in rooms.On 10/21/25 at 10:10 a.m., in an interview the pest control technician said there was an ongoing problem with ants in residents' rooms due to food in the rooms. He said he started his inspection in the kitchen and found an area with cracks on the floor. He said, I squirted some material in there and forced a roach out. He said the floor of the hallway where the dishwasher is needed to be replaced as it was a hiding place for roaches. On 10/22/25 at 10:30 a.m., a tour of the kitchen was conducted with the Kitchen Manager. The flooring tiles next to the sink and dishwasher were lifting, creating an open space between the tiles and the floor underneath. The Kitchen Manager verified the pest control technician found the roach underneath the flooring.Review of the facility's survey history revealed noncompliance identified during the last recertification survey completed on 3/13/24 included the facility failure to maintain an effective pest control program. On 10/22/25 at 1:00 p.m., in an interview the Administrator verified pest control remained a concern. The program in place has not been effective to contain common household pests. On 10/22/25 at 2:00 p.m., a brown insect was observed crawling on the bathroom floor in room [ROOM NUMBER].

Based on observation, record review, residents and staff interviews, the facility failed to provide housekeeping, and maintenance services to maintain a clean, comfortable and pest free environment in all 3 ([NAME], [NAME] and [NAME]) of 4 units observed. The facility failed to maintain the walk-in refrigerator and freezer in a clean and sanitary mannerThe findings included:1. On 10/20/25 at 9:05 a.m., a tour of the [NAME] unit revealed the following: room [ROOM NUMBER]: Unlabeled, uncovered wash basins were stacked and stored on the toilet tank of the shared bathroom. Photographic evidence obtained. A live brown insect was observed crawling on the bathroom floor. Photographic evidence obtained. The raised toilet seat was rusty. Photographic evidence obtained. The bed remote of room [ROOM NUMBER] B was coated with a sticky brown substance. The bed control was not functioning properly. The head of the bed could not be raised. room [ROOM NUMBER]: An extension cord was observed plugged to the wall next to the bed by the window. Two chargers were plugged to the extension cord. A large hole was observed in the wall behind the bed by the door. On 10/20/25 at 11:45 a.m., the Maintenance Director said the extension cord was not approved and should not be used. He observed the hole on the wall behind the bed by the window. He said he was not aware that the wall needed to be repaired. The shared bathroom had an unlabeled, uncovered urinal stored on the toilet, next to an unlabeled, uncovered emesis basin. Photographic evidence obtained. A used washcloth was observed on the floor under the sink. room [ROOM NUMBER]: The wall behind the beds had large areas patched, not painted. The shared bathroom had 4 unlabeled, uncovered wash basins stacked up and stored on the bathroom floor. room [ROOM NUMBER]: The wall behind the bed by the window had multiple large gouges. An unlabeled wash basin and an unlabeled emesis basin were stored uncovered on the toilet tank. room [ROOM NUMBER]: Unlabeled, uncovered wash basins were stored on the shared bathroom floor. room [ROOM NUMBER]: An unlabeled wash basin and unlabeled emesis basin were observed stored uncovered on the toilet tank of the shared bathroom. The grout around the toilet was dirty with a large accumulation of black and brown substance. room [ROOM NUMBER]: The grout around the toilet of the shared bathroom was dirty with a large accumulation of black and brown substance. room [ROOM NUMBER]: The top drawer of the nightstand was broken. The shared bathroom had multiple uncovered, unlabeled bed pans and wash basins stacked up on the toilet tank. room [ROOM NUMBER]: The dresser was noted to be in a state of disrepair. The legs appeared gnawed, exposing the underlying material. room [ROOM NUMBER]: The wheelchair armrests in room [ROOM NUMBER] A were torn, exposing the underlying padding material. Two used urinary catheter drainage bags were observed stored in the shared bathroom handrail with the tubing wrapped around the handrail. Photographic evidence obtained. room [ROOM NUMBER]: The wall across 233 A was damaged with indentation in the drywall above the baseboard. On 10/20/25 at 9:49 a.m., in an interview Resident #6 said she's had ants crawling in her bed. On 10/20/25 at 11:00 a.m., a tour of the [NAME] Unit was conducted with the Infection Preventionist. The Infection Preventionist verified the wash basins, urinals and/or emesis basins were not stored in a sanitary manner in rooms 218, 219, 220, 221, 222, 224, and 226. She said the urinary catheter drainage bag in room [ROOM NUMBER] was not stored in a sanitary manner. The Infection Preventionist said resident's personal care items and the foley catheter drainage bag should be labeled and stored in plastic bags and were an infection control concern. The Infection Preventionist said she has been employed at the facility for three weeks and had not identified these concerns and had not in-serviced the staff on the proper storage of residents' care items. On 10/20/25 at 11:40 a.m., a tour of the [NAME] Unit was conducted with the Maintenance Director. He verified the bed control in room [ROOM NUMBER] B was not working properly and needed to be replaced. He verified the extension cord in room [ROOM NUMBER] B was not hospital graded and should not be used in a resident's room. The Maintenance Director verified the observations made in the residents' rooms on the [NAME] Unit. He said he made daily rounds in the residents' rooms but did not keep a list of repairs to be made. 2. On 10/21/25 at 4:00 a.m., during a tour of the [NAME] Unit the following observations were made: Live crawling insects in the hallway and in room [ROOM NUMBER]. Numerous ants were crawling on the clean linen in the linen cart. During confidential interviews, direct care staff said roaches and ants have been a constant issue at the facility. Review of the facility's pest control log for June 2025, July 2025, 8/2025, 9/2025, and 10/2025 revealed recurrent entries of roaches and ants sightings as follows: 6/17/25: Roaches in the bathroom of room [ROOM NUMBER]. 6/27/25: Roaches and ants in the activities department. 8/19/25: Ants in room [ROOM NUMBER] W. 8/21/25: Ants in room [ROOM NUMBER] A. 8/21/25: Ants in the pantry of the [NAME] Unit. 9/21/25: Roach in the entry hall of [NAME] Lane. 9/30/25: Roches on/in the dresser in room [ROOM NUMBER] W. 10/17/25: Kitchen-Dishpit Roaches 100 S. Review of the pest control company inspection reports revealed: On 10/14/25 dead roaches and American cockroaches were found in the kitchen storage area. 10/21/25, Issues with roaches in the kitchen and with ants in rooms. On 10/21/25 at 10:10 a.m., in an interview the pest control technician said there was an ongoing problem with ants in residents' rooms due to food in the rooms. He said he started his inspection in the kitchen and found an area with cracks on the floor. He said, I squirted some material in there and forced a roach out. He said the floor of the hallway where the dishwasher is needed to be replaced as it was a hiding place for roaches. On 10/21/25 at 3:53 p.m., in an interview the housekeeping supervisor said she has been employed at the facility since 10/6/25 but has been helping at another facility. She said 2 days ago, she came back to this facility. When she went in the residents' rooms, she noted the rooms, including the windowsills were dusty. She said the grout around the toilets needed to be cleaned. The housekeeping supervisor said she did not make a list of all the rooms that needed to be cleaned. She said she found a check off list for the daily cleaning, but they have not started using them. 3. On 10/21/25 at 4:35 a.m., observation of the kitchen with Dietary Staff U revealed: The floor of the walk-in refrigerator was heavily soiled with large amount of built-up black substance. Photographic evidence obtained A large hole was observed in the wall of the walk-in refrigerator. Photographic evidence obtained The pipes in the walk-in refrigerator had large amount of frost build up. Photographic evidence obtained The seal of the walk-in refrigerator was heavily soiled with a large accumulation of black substance. Photographic evidence obtained. The side wall of the walk-in refrigerator was covered in condensation. Photographic evidence obtained. A large pool of water was observed on the kitchen floor behind the walk-in refrigerator's door. The walk-in freezer had ice built up and melting ice on the floor behind the door. Photographic evidence obtained On 10/21/25 at 4:05 p.m., in an interview the Dietary Manager was asked about processes in place to clean and make necessary repairs to kitchen equipment. The Dietary Manager replied that he was working on repairing the areas observed. He said the kitchen staff was responsible for the cleaning listed on the daily cleaning list posted. The floor and the door of the walk-in refrigerator should be cleaned weekly. He said the daily cleaning list was posted but there was no log for staff to sign that the cleaning was completed. Review of the cleaning schedule provided by the Dietary Manager revealed on Thursdays the evening cook was responsible to clean the walk-in refrigerator and freezer. On Thursdays, the morning aide 1 was responsible to clean the refrigerator and freezer doors and walls thoroughly. When asked about training and competency of staff for safe food handling during tray line, the Dietary Manager said he started working at the facility in July 2025 and Dietary Aide Staff W was already employed. The Dietary Manager provided a list of in-services for Dietary Aide Staff W which showed a date of hire of 5/4/24. On 2/25/25, 4/10/25, Staff W scored 100 on a Glove usage inservice Quiz. On 3/5/35 and 8/12/25, Staff W scored 100 on a Time and Temperature inservice Quiz. 4. On 10/20/25 at 9:10 a.m., during a tour on [NAME] and [NAME] Halls the following was observed: room [ROOM NUMBER]: A wash basin was stored on the floor of the shared bathroom. room [ROOM NUMBER]: The bed sheets had multiple black stains and food crumbs. An open urinal was wedged in the handrail of the bathroom. room [ROOM NUMBER]: An unlabeled and uncovered wash basin was stored on top of the toilet tank of the shared bathroom. Photographic evidence obtained. room [ROOM NUMBER]: An unlabeled, uncovered wash basin was stored on top of the toilet tank of the shared bathroom. room [ROOM NUMBER]: An unsecured tube of Arthritis Relief Cream and unlabeled, uncovered wash basins were stored on top of the toilet tank of the shared bathroom. room [ROOM NUMBER]: An unlabeled, unbagged wash basin was stored on the toilet of the shared bathroom. Photographic evidence obtained. room [ROOM NUMBER]: Flying insects were observed in the room. An unlabeled oxygen tubing was on the floor at the foot of the bed. Photographic evidence obtained. room [ROOM NUMBER]: Three unlabeled wash basins were stacked on the toilet tank of the shared bathroom. Photographic evidence obtained. room [ROOM NUMBER] A: The left arm rest of the wheelchair was missing. The four alcohol-based hand sanitizer dispensers mounted on the walls of the [NAME] and [NAME] units were empty and not functioning. Photographic evidence obtained. On 10/21/25 at 3:00 p.m., observation of the [NAME] Hall communal shower room with Licensed Practical Nurse (LPN) Staff E revealed two shower stalls. The shower head was missing from one of the stalls. An opened bottle of body wash and shampoo was stored in a rusted metal holder in the shower room. Photographic evidence obtained. LPN Staff E said, Well, this one works when asked about the missing shower head. She did not reply when asked about the opened bottle of body wash and shampoo stored in the rusted metal holder. On 10/21/25 at 3:12 p.m., observation of the communal shower room of the [NAME] Hall with LPN Staff E revealed two shower stalls. One of the showers was not functioning. The pipe was protruding from the wall and was missing the shower head. In an interview during the observation, LPN Staff E said, Obviously the staff are not using that shower. Photographic evidence obtained.

Based on observations, record review, review of facility's policies and procedures, resident and staff interviews, the facility failed to ensure 1 (Resident #2) of 1 resident reviewed for dialysis received care and services to meet her needs. The findings included: The facility's policy and procedure Coordination of Hemodialysis Services with a revision date of 07/02/2019 noted, Residents requiring an outside ESRD (End Stage Renal Disease) facility will have services coordinated by the facility. There will be communication between the facility and the ESRD facility regarding the resident . Procedure: The Dialysis Communication form will be initiated by the facility for any resident going to an ESRD center for hemodialysis. Nursing will collect and complete the information regarding the resident to send to the ESRD Center. The ESRD facility is to review the Dialysis Communication form and either : a. Complete the communication form and return with the resident or b. Provide treatment information to the facility. Upon the resident's return to the facility, nursing will review the Dialysis Communication form and information completed by the dialysis center OR the information sent by the dialysis center; communicate with the resident's physician and other ancillary departments as needed, implement interventions as appropriate. Nursing will complete the post dialysis information on the Dialysis communication form and file the completed form in the Resident's Clinical record. 1. Review of the clinical record for Resident #2 revealed a re-admitted [DATE]. Diagnoses included chronic kidney disease stage 4 (severe) and dependence on renal hemodialysis (procedure that filters blood to remove waste and excess fluid when the kidneys are no longer functioning properly). The physician's orders included: Hemodialysis to a dialysis center on Mondays, Wednesdays and Fridays. The order specified to be sure to send the dialysis binder with the completed hemodialysis communication record. Collect binder on return, complete hemodialysis sheet and send to medical records. Review of the Medication Administration Record (MAR) for October and November 2024 revealed Resident #3 went to the dialysis center hemodialysis on 10/2/24 (Wednesday), 10/4/24 (Friday), 10/11/24 (Friday), 10/14/24 (Monday), 10/16/24 (Wednesday), 10/18/24 (Friday), 11/1/24 (Friday), 11/8/24 (Friday), and 11/11/24 (Monday). No communication forms were found in the clinical record for those dialysis days. On 11/13/24 at 1:38 p.m., a joint interview was conducted with the Director of Nursing (DON) and the Regional Nurse Consultant. The Director of Nursing (DON) verified the lack of documentation the facility coordinated with the dialysis center on 10/2/24,10/4/24, 10/11/24, 10/14/24, 10/16/24, 10/18/24, 11/1/24, 11/8/24 and 11/11/24. She said she's had multiple communications with the dialysis center but did not document her conversations. On 11/13/24 at 2:20 p.m., in a telephone interview a representant of the dialysis center said the facility does not follow up on their concerns. She said the dialysis center has even tried to call the facility multiple times. They finally spoke with the DON but the dialysis center was still having concerns with fluid overload and the facility not following the renal diet for resident #2. 2. Review of Resident #2's physician's orders revealed a prescribed controlled carbohydrate renal diet. On 11/13/24 at 8:45 a.m., in an interview Resident #2 said she went to the dialysis center on Mondays, Wednesdays, Fridays and sometimes Thursdays and Saturdays. She said the facility gives her a lunch meal on dialysis days that usually consists of a peanut butter sandwich and graham crackers. On 11/13/24 at 10:45 a.m., with the resident's permission the lunch meal provided by the facility was observed. It consisted of a sliced dark pink lunch meat and cheese sandwich, graham crackers, a cup of apple sauce, a cup of pudding and a bottle of water. On 11/13/24 at 1:38 p.m., a joint interview was conducted with the Director of Nursing (DON) and the Regional Nurse Consultant. The DON said Resident #2 was her own person and was not compliant with the controlled carbohydrate and renal diet. She said the resident frequently consumes food that is not within the prescribed diet. She showed a grocery bag containing a bag of popcorn, two candy bars and a can of soda which she said belonged to Resident #2. She said she did not know where the resident obtained the food. On 11/13/24 at 2:20 p.m., in a telephone interview a representant of the dialysis center said today (11/13/24) the facility gave Resident #2 a sandwich with a thick slice of ham and cheese. She said there was too much sodium in the food provided, and Resident #2 had excess fluid. Review of the hemodialysis communication form dated 11/4/24 showed documentation from the dialysis center stating, Pt (patient) needs to comply with strict fluid/sodium restrictions. On 11/13/24 at 2:36 p.m., in a telephone interview the facility's Registered Dietitian (RD) said she consulted with the dialysis center for foods Resident #2 could not have and printed the renal diet for the kitchen. She said regular ham would be high in salt and would not be recommended. She said cheese can be high in phosphorus. She said as far as what they send with Resident #2, they are renal diet compliant. She said she spoke with the dialysis Renal Dietitian monthly or more if there are concerns. She said she has tried to educate Resident #2 but she is not receptive to education at all. Review of the Diet and Nutrition Care Manual used by the facility showed for renal dialysis sodium should be restricted if needed to avoid excess fluid retention and weight gain between dialysis treatments. Phosphorus should be adjusted to maintain serum phosphate levels in the normal range. The bioavailability of phosphorus food sources should be taken into consideration. Normally, phosphate binders are prescribed with meals. The list of high phosphorus foods to limit if indicated included Swiss cheese. On 11/13/24 at 2:45 p.m., in an interview the Dietary Director said Resident #2 was provided with a turkey sandwich and Swiss cheese. She said she did not have the packaging for the turkey used in the sandwich, it was left over turkey. On 11/13/24 at 5:15 p.m., in an interview Resident #2 said she gets her snacks from the activity department. The resident verified she got the package of popcorn, doughnuts, candy bars and sodas from the activity department. On 11/13/24 at 5:20 p.m., in an interview the Activity Director verified Resident #2 purchases snacks from the activity department. She said the Registered Dietitian gave them a list of each resident's diet so they'll know what snacks they can have. She said her assistant provided the resident with the snacks. Review of the diet list showed Resident #2's diet was listed as CCD (carbohydrate controlled) Renal diet. The Activity Staff said she did not know what a CCD Renal Diet was. On 11/14/24 at 10:30 a.m., the Dietary Director provided a list of Dialysis Lunch Bag Menu Selections. She said the dietary department selects food items from the list to provide a lunch to Resident #2 on dialysis days. The list included turkey sandwich and specified No cheese or Tomato and Peanut Butter sandwich with the Registered Dietitian's approval. The Dietary Director verified Resident #2 gets a peanut butter at times to go to dialysis. She said she did not have the Registered Dietitian's approval for the peanut butter sandwich but she could get it. 3. Review of the Physician's ordered medications revealed an order for Renvela oral tablet 800 milligrams (binds phosphorus from the food to control phosphorus level), one tablet three times daily with meals. Review of the facility's mealtime schedule showed breakfast is from 7:15 a.m., to 8:00 a.m., lunch is from 12:15 p.m., to 1:15 p.m., and dinner is at 5:15 p.m., to 6:00 p.m. The Medication Administration Records (MARs) for October and November 2024 showed the Renvela was administered every day in the morning, in the evening and at HS (bedtime). The MARs lacked documentation the Renvela was administered with the dinner meals. On 11/13/24 at 1:38 p.m., a joint interview was conducted with the Director of Nursing (DON) and the Regional Nurse Consultant. When asked about the administration time of the Renvela with meals, The DON said the Renvela was, liberalized. She (Resident #2) gets it in the morning, in the evening when she comes back from dialysis and at bedtime. The Regional Nurse Consultant said the liberalized medication administration time for HS was between 7:00 p.m., to 10:45 p.m. She reviewed the administration time for the Renvela for October and November 2024 and verified the Renvela was not administered with the dinner meals as ordered. She also verified Resident #2 was provided a lunch meal on dialysis days but the Renvela was not administered with the lunch meal on dialysis days.

Based on record review, review of facility's policies and procedures, and staff interviews, the facility failed to report a resident's injury of unknown origin to the Agency for Health Care Administration within the required time for 1 (Resident #3) of 3 residents' incidents reviewed. The findings included: The facility's Abuse, Neglect, Exploitation & Misappropriation with a revision date of 11/16/2022 noted under reporting/response, Any employee or contracted service provider who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect . including injuries of unknown source . to a resident, is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . to the Administrator and to other officials in accordance with State law . Once the allegation of abuse is reported, the Executive Director, as the abuse coordinator, is responsible for ensuring that reporting is completed timely and appropriately to appropriate officials in accordance with Federal and State regulations. Review of the clinical record for Resident #3 revealed an Annual Minimum Data Set Assessment with a target date of 8/7/24 which noted the resident's cognition was moderately impaired with a Brief Interview for Mental Status score of 11. Resident #3 range of motion was impaired on one side of the upper extremity and lower extremity. Resident #3 required substantial/maximal assistance to transfer from chair to bed and bed to chair. The resident's care plan initiated on 8/10/21 noted the resident had impaired cognitive function/dementia or impaired thought processes. A nursing progress dated 8/12/24 at 3:55 p.m., noted the resident was lying in bed with moan of pain. When staff asked where it hurt the resident initially touched her abdomen. As they attempted to get her dressed for the day a blue discoloration of approximately 3.0 centimeters (cm) was noted to the right foot, a blue discoloration to the front of the right lower leg approximately 5.0 cm and swelling to the leg and foot. When asked how she sustained the discoloration and pain to the right foot the resident said, the other one. When asked if she fell , she initially said no. When asked again if she fell , she said yes. The nurse noted she notified the Director of Nursing and the Advanced Practice Registered Nurse. On 8/12/24 at 11:50 p.m., a nursing progress note documented an X-ray result of the right lower extremity showed a proximal tibia/fibula (the two long bones in the lower leg) fracture. Resident #3 was sent to the hospital for evaluation and treatment. Review of the facility's investigation showed documentation the Director of Nursing and the Administrator were notified of the discoloration and pain to the resident's right lower extremity on 8/12/24 at 3:59 p.m. The preliminary report was not submitted to the Agency for Health Care Administration until 8/13/24 at 11:06 a.m. On 11/13/24 at 8:40 a.m., Resident #3 was observed in bed. Resident #3 said yes when asked if she recalled breaking her leg. When asked if she remember how she sustained the injury, she said no. On 11/14/24 at 12:00 p.m., in an interview the Director of Nursing said the resident was not able to say how she sustained the fracture to her right lower extremity. The Administrator and the Regional Nurse Consultant who were present during in the interview verified the initial reporting of the injury of unknown source should have been made to the Agency for Health Care Administration within two hours of being aware of the incident.

Based on record review, resident and staff interviews, the facility failed to obtain necessary medical follow-up appointment for 1 (Resident #2) of 3 residents reviewed. The findings included: Review of the facility policy and procedure titled, Medical Consultations with a revision date of 8/24/2017 showed, The medical staff requesting a consultation will order the consultation and a Request for Consultation will be initiated by nursing to the consulting physician . The consultation will include the examination of the resident and the medical record . The attending will need to note in his re-certification notes that consultation occurred and the outcome of this. On 7/1/24 at 10:55 a.m., in an interview Resident #2 said she had a mammogram done on 5/1/24. She said she already had a biopsy before coming to the facility but needed another one. Resident #2 stated, I'm scared and started crying. She said, I don't know why they are not making an appointment for me. Resident #2 said she has told staff that her breast hurts and needed the biopsy done. Clinical record review revealed Resident #2 was admitted on [DATE]. Diagnoses included localized enlarged lymph nodes, and muscle weakness. The Admission Minimum Data Set (MDS) assessment with a target date of 3/27/24 showed Resident #2's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 15. Review of Resident #2's Care Plan initiated on 4/23/2024, showed the resident had cellulitis (skin infection) of the left breast. Interventions included administer antibiotic as per physician's orders dated 4/23/24. Review of Advanced Practice Registered Nurse (APRN) Staff A progress note with an effective date of 5/2/2024 at 11:36 a.m., showed, Orders placed to arrange outpatient mammogram due to suspected malignant process. Continue to monitor WBC[white blood cell ]/temperature curve. On 5/3/24 at 1:47 p.m., APRN Staff A documented in a progress note, Completed outpatient mammogram inconclusive. Requires biopsy. Unit secretary will make arrangements. May need outpatient follow up with surgical oncologist. On 5/13/24, APRN Staff A documented recommending repeat mammogram in 6 months. Referral provided to two different breast surgeons. On 5/14/24 the Director of Nursing (DON) documented APRN Staff A dropped off the report from a mammogram study done on 5/1/24. She provided the report to Licensed Practical Nurse (LPN) Staff H to secure an appointment for Resident #2 for continuum of care. On 5/21/24 LPN Staff H documented calling, (name) Health Cancer and was awaiting a call back. No other progress note was found in the electronic and physical clinical record related to the follow up appointments with the breast surgeon for Resident #2 as requested by APRN Staff A. Further review of the clinical record showed APRN Staff B visited Resident #2 on 4/5/24, 4/16/24, 4/23/24, 5/10/24 and 7/1/24. The practitioner's progress notes did not address the abnormal findings to the resident's left breast and follow up appointment with the breast surgeon. On 7/2/24 at 9:15 a.m., in an interview APRN Staff B said Resident #2 needed the follow up for her left breast. APRN Staff B said LPN Staff H told her the cancer center will not see the resident while she was at a nursing facility and had a conversation in passing about it with Resident #2. APRN Staff B verified she did not document the conversation with Resident #2 or LPN Staff H and said, I trust my staff. On 7/2/24 at 9:25 a.m., in an interview LPN Staff H said the Cancer center told her they would not see or treat Resident #2 if she had cancer while she resided at the facility but she did not document her conversation. LPN Staff H verified the lack of documentation the facility followed through and obtained a follow up appointment with the breast surgeon for Resident #2. On 7/2/24 at 9:40 a.m., in an interview the Director of Nursing (DON) verified the lack of documentation that the facility obtained the follow-up appointment with the breast surgeon for Resident #2. She said her expectation was for the scheduler to document all attempts to schedule appointments with outside providers in the resident's clinical record, including who she spoke with. The DON said she reviews the progress notes every morning and discusses them with the Interdisciplinary Team. On 7/2/2024 at 9:50 a.m., in an interview the Administrator said he expects staff to document in the electronic health record when trying to make appointments.

Based on resident and staff interviews and record reviews the facility failed to follow Physician orders to ensure the health and safety of one resident, Resident #1, of 4 residents reviewed for significant medication errors. The findings included: Administering Medications Policy dated 2001 and Revised April 2019 states, Medications are administered in a safe and timely manner, and as prescribed. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the Medication Administration record space provided for that drug and dose. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: The date and time the medications was administered; the dosage; the route of administration; the injection site; Any complaints or symptoms for which the drug was administered; Any results achieved and when those results were observed; and the signature and title of the person administering the drug. Medical record review for Resident #1 show he was admitted to the facility on [DATE] for post Cerebrovascular Accident (CVA) causing left upper and lower paralysis. He also had a history of diabetes. His cognition was evaluated using the BIMS (Brief Interview for Mental Status) and had a score of 15 out of 15 which indicates intact cognition. The care plan initiated 4/10/24 identified resident #1 had Diabetes Mellitus and implemented goals and interventions that included medications as ordered by doctor and fasting serum blood sugar as ordered by doctor. The original physician order/start date written on 3/28/24 by the Physician Assistant with an end date of 4/22/24 read Insulin Lispro Injection Solution Lispro Insulin inject subcutaneously before meals & at bedtime per sliding scale PRN (as needed), inject as per sliding scale; if 151-299 = 2 units into skin as per sliding scale; less than 151 = 0 units; 201-250 = 4 units; 251-300 = 6 units; 30-350 = 9 units; 351-400 = 11 units; greater than 400 give 12 units and call MD, subcutaneously as needed for DM (Diabetes Mellitus) AC/HS (before meals and Hour of sleep). Review of the MAR/TAR (Medication Administration Record/Treatment Administration Record) for the month of April 2024 had the order listed but there were no documented blood sugar results recorded or insulin administered recorded. The DON (Director of Nursing) provided a list of completed blood sugars documented elsewhere in the chart as follows: 4/1/24 Blood sugar recorded as 299 4/3/24 Blood sugar recorded as 301 4/5/24 Blood sugar recorded as 206 4/17/24 Blood sugar recorded as 289 4/18/24 Blood sugar recorded as 158 4/20/24 Blood sugar recorded as 226 4/21/24 Blood sugar recorded as 266 4/23/24 Blood sugar recorded as 144 Per the physician order for April 2024 there should have been blood sugars completed four times daily starting on 3/28. Only 8 blood sugar checks were documented and of the 8 documented, 7 should have received coverage with insulin and did not. On 4/23/24 at 2:30 p.m., in an interview with Staff A, LPN (Licensed Practical Nurse), said she had been at employed at the facility for about 6 months now. She said she does not remember ever checking Resident #1 blood sugar before. She looked it up on the computer and said it was only scheduled for morning and evening. She pulled up all the completed blood sugars for April 2024 and there were only 8. She said there should be more blood sugars documented but he refuses treatment a lot so that may be why. She was unable to find documentation of his refusal of blood sugar checks. The last blood sugar documented for Resident #1 was this morning and it was 144. On 4/23/2024 at 3:05 p.m., the DON and the ADON (Assistant Director of Nursing) were asked about the physician order for insulin and the blood sugars not being documented. The DON said she was unsure what the issue was but would investigate and let me know. On 4/23/2024 at 4:30 p.m., the DON said the order for sliding scale insulin must have been entered into the system incorrectly because it was not showing up for the nurses to perform the blood sugar test and administer if needed the ordered dose for insulin. She said the order was written PRN (as needed) from the hospital and that is how it was written and resumed at the facility. There were several PRN blood sugars obtained but that has now been discontinued by the Physician. On 4/24/2024 at 12:20 p.m., in an interview with the Regional Nurse, she said Resident #1 medical record had been reviewed and they could not find any documentation that the blood sugar tests performed were covered with any insulin as ordered. On 4/24/2024 at 4:05 p.m., in an interview with the Primary Care Physician Assistant, she verified that she wrote an order for sliding scale insulin coverage for Resident #1. She verified that his blood sugar was supposed to be monitored daily and medicated with insulin if out of normal ranges. She was unaware that the resident had not been monitored using accucheck (blood sugar check) and that when his blood sugar was checked and found to be elevated that he was not administered insulin. She cannot explain how it happened. She said, maybe it got entered into the computer incorrectly. On 4/25/24 at 9:30 a.m., in an interview with the Administrator and Regional Nurse, they said they had identified the issue on 4/23/24 (after the surveyor brought it to their attention) and started a PIP (Performance Improvement Project) for inputting sliding scale and adding supplementary documentation. They have had Ad Hoc meeting to address issues, audited all residents requiring sliding scale Insulin, and educated staff.

Based on record review, facility policy review, and staff interview the facility failed to provide the advance beneficiary notice to 2 (Residents #24, and #27) of 3 sampled residents reviewed. The findings included: Review of facility policy titled Advanced Beneficiary Notice (ABN), revised 11/10/2015, which states, Policy: An ABN will be utilized to notify resident of the possibility that Medicare will not pay for the item(s) or service(s) that are described in the form .The form will be reviewed with the resident or authorized representative . Procedure: 1. The facility will give a completed copy of the ABN far enough in advance that the beneficiary or representative has time to consider the options and make an informed choice . 2. The resident must comprehend the contents. If the resident is unable to comprehend the contents of the notice, it must be delivered to and signed by an authorized representative . If the resident refuses to sign the notice, the notice is still valid as long as the facility documents that the notice was given but the resident refused to sign. 3. In the event that the resident is not competent, an authorized representative acting on behalf of the resident shall be notified. On 3/11/24 at 1:55 p.m., Residents, #24, and #27, clinical records were reviewed for ABN. Resident #24 last covered day for Medicare Part A was 10/20/23. Resident #24 remained at the facility. Resident #27 last covered day for Medicare Part A was 1/21/24. Resident #27 remained at the facility. On 3/11/24 3:15 p.m., during an interview with the Business Office Manager (BOM) she said she had been with the facility since January 2024. The BOM said the Minimum Data Set (MDS) nurse, Staff H, was completing the Notice of Medicare Non-Coverage (NOMNC) and then giving them to her to scan into the clinical records. BOM said, I have not received any ABN forms from the MDS Nurse Staff H. On 3/11/24 at 3:30 p.m., interviewed MDS Nurse, Staff H, who confirmed she was completing the beneficiary notices. I was covering for the times we did not have a social worker. I completed the NOMNC but did not know I needed to complete the ABN. Confirmed she was covering the responsibility for several months and no residents discharged from Medicare services had received an ABN form while she was covering the responsibility. On 3/11/24 at 3:40 p.m., during an interview the Social Services Director (SSD) was asked about process for ABN and replied, We need to do an ABN for anyone who stays in the facility after services end. The SSD did not know why Residents #24 and #27 did not receive the required ABN notice. On 3/11/24 at 3:52 p.m., interviewed the Facility Administrator who said he was unaware that the staff was not providing ABN forms as required.

Based on observation, resident and staff interviews and record review the facility failed to provide a safe, sanitary, and homelike environment in 3 (Canterbury, Buckinham and [NAME]) of 4 halls, as evidenced by dry wall damage in resident's rooms, damaged resident furnishings and rusted resident equipment. Failure to identify and complete needed repairs could cause safety and sanitary hazards to vulnerable residents. The findings included: On 3/10/24 during the initial tour of the rooms on the 100 hallway; observation revealed there was damage to the dry walls next to the bathroom and behind the resident's beds in rooms [ROOM NUMBER]; a large hole was noted in the dry wall next to the air conditioner unit in room [ROOM NUMBER]; and also noted were the over the bed tables in room [ROOM NUMBER] and 115 and the over the toilet commode chair in room [ROOM NUMBER] had multiple rusted areas. Review of the Maintenance Plan policy and procedure #ALF-1015, dated 11/30/14, stated the facility would ensure the continued maintenance of the building and grounds in a clean, orderly condition and in good repair. All equipment and furnishings would be maintained in good condition. When a staff member noticed an item needing repair, he/she would complete a work order request defining the area or item needing repair. The maintenance staff would review the log and make the appropriate repairs. Review of the Maintenance Log policy and procedures #M-210, dated 11/30/2014, stated all maintenance performed on the buildings and grounds should be documented clearly and succinctly and in an organized manner so that it may be monitored by the Executive Director at any time. On 3/13/24 at 11:53 a.m., a tour of the 100 hallway was conducted with the Director of Maintenance (DOM) and he confirmed the damage to the dry walls in rooms 106, 109, 112, 113 and the rusted resident equipment in rooms [ROOM NUMBERS] which had been observed during the initial room tour on 3/10/24. The DOM said all facility staff were required to document in the maintenance logbook, located at each nursing station, any facility damage, all areas needing repair and damaged residents' equipment and furnishings. He said the maintenance assistant, during his morning rounds, would collect the maintenance logbook from each nursing station and bring them back to the maintenance office where he reviewed and prioritized each items listed to ensure the appropriate repairs and/or replacements were completed in a timely manner. The DOM reviewed the maintenance log for the 100 hallway and said the facility staff did not document in the maintenance logbook as required and he was unaware of the room damage and the rusted resident equipment in rooms 106, 109, 112, 113 and 115 which caused the needed repairs and/or replacements not to be completed in a timely manner. 41155 On 3/10/24 during initial tour of [NAME] Hall, the following was observed: room [ROOM NUMBER] in the shared bathroom an unlabeled urinal was hanging from the towel rack. A bed pan with a mirror inside was on the toilet tank and a wash basin was on the floor. room [ROOM NUMBER] in the bedroom dirty linen was on the floor and 2 urinals without a name to identify who they belonged to were on the dresser in the shared room. Photographic evidence obtained. room [ROOM NUMBER] in the shared bathroom there were unlabeled personal items on the toilet top. There was black grime around the toilet base and cracked wall tiles under the sink. Photographic evidence obtained. room [ROOM NUMBER]-B the wall had been patched in area near the nightstand. There was a urinal with urine approximately 3/4 full sitting on the nightstand with person effects. Photographic evidence Obtained. room [ROOM NUMBER] in the shared bathroom the toilet tank top was off. There was black grime around the base of the toilet. Personal items were stored on the sink. On 3/10/24 at 9:51 a.m., Licensed Practical Nurse (LPN) Staff W confirmed the findings in the bathroom of room [ROOM NUMBER] and placed the toilet tank top back on the toilet. She said she did not know why it had been removed but would notify maintenance. Photographic evidence obtained. Resident #71 residing in the 200 hall said he was a smoker and he had cigarettes on his nightstand. Resident #71 said he was able to light his own cigarettes and opened his nightstand drawer to reveal a cigarette lighter. Photographic evidence obtained. The Director of Nursing, the Regional Nurse Consultant and the Unit Manager Staff B were immediately notified of the lighter and removed it. room [ROOM NUMBER] there were patched marks on the wall around the window. The air conditioning unit had black grime and missing grout where it met the wall. Photographic evidence obtained. room [ROOM NUMBER]. On 3/10/24 at 9:28 a.m., observation of a live small brown insect in the bathroom sink. A wash basin was on the floor under the sink with two large brown insects on their back with legs in the air, not moving. There was a live brown crawling insect making a web from the sink to the wash basin. Several small insects were in the wash basin, not moving. On 3/10/24 at 9:29 a.m., Central Supply Staff D was in the hallway, and came into the room and verified the observation of the live and dead insects in the bathroom. Photographic evidence obtained. On 3/10/24 at 10:12 a.m., LPN Staff W verified the observation made in the bathrooms of rooms 225, 223, 213, 232, 229, and 204. On 3/10/24 at 12:00 p.m., a second observation of room [ROOM NUMBER]'s bathroom revealed five live medium brown pests crawling from the sink. On 3/10/24 at 12:21 p.m., observation of room [ROOM NUMBER]'s bathroom with the Administrator revealed a large brown crawling insect on the bathroom sink. On 3/10/24 at 3:28 p.m., observation of room [ROOM NUMBER] revealed the wall behind the bed had areas of patched holes, it was dirty and in need of repair. The wall had peeling paint and the wooden section of the wall was unattached in sections where the wood and the wall meet. On 3/12/24 at 9:47 a.m., in an interview the Maintenance Director verified the dirty wall and patched holes in room [ROOM NUMBER]. He said I have only been here a few weeks and there is such a turnover. All the rooms are like that behind the beds, all of them. I am working on cleaning and repairing them, but I can only do so much. The problem is the resident needs to be out of the room or discharged because the chemicals used, the smells they need to be out of the room. I have completed two rooms so far. Every day the maintenance logs are checked, and we remove the slips. If it something we can repair right away, we do it and I keep all the slips in a binder in my office. If it is something that will take several days, then we place the slip here in this continuing maintenance log. This log stays on the Maintenance cart until it is resolved. I am working on repairing the resident rooms. I am aware of the patched walls in the rooms, they were like that when I started here, I can only fix so much in a day. There is myself and an assistant maintenance person. 44307 On 3/10/24 at 10:43 a.m., observed in room [ROOM NUMBER] A wall damage and missing baseboard, over bed bedside table with missing trim and exposed particle material, and dresser missing drawer pulls. On 3/10/24 at 11:26 a.m., observed Resident #99's room air conditioning unit set for 70 degrees, actively blowing air but air does not feel cool to the touch. Resident #99, in an interview said the air conditioner was not working and only blows air but not cool air. I worry as the weather gets warmer. Resident #99 said the facility was aware the air conditioner has not worked for a couple of months. On 3/10/24 at 12:44 p.m., observed in room Resident #101's bedroom dresser with missing drawer. On 3/10/24 at 1:09 p.m., observed Resident #6's room bedside nightstand with missing drawer pull. Resident #6 was aware the drawer was broken saying, It still works. Resident did not know when the facility was going to fix the drawer. On 3/13/24 at 10:23 a.m., interviewed Registered Nurse Staff K about furniture and room disrepair. RN Staff K said, We have a maintenance book where we put any work orders needed. On 3/13/24 at 10:30 a.m., reviewed facility maintenance binder and did not see any work orders for room [ROOM NUMBER], or Residents #6, #101, and #99's rooms. On 3/13/24 at 11:35 a.m., toured identified rooms with the facility Administrator. Previous observations unchanged. The Facility administrator said, I have ordered more furniture but understand it's not acceptable. I did not know about the air conditioner but I can see that it is not blowing cold. I will get the maintenance director to check. 49527 On 3/13/24 at 12:33 p.m., during a tour of the Canterbury and [NAME] hallways with the Maintenance Director, the following observations were made: A large hole in Resident #46's bathroom wall. A hole in the wall in Resident #62's room. Two small holes in the wall of the room and plaster of the ceiling in the bathroom of Resident #53's room. On 3/13/24 at 12:35 p.m., in an interview Resident #53 said the plaster fell off the ceiling when she was in the bathroom but did not fall on her. The Maintenance Director confirmed an area on the ceiling in the bathroom is missing plaster. A large area of plaster off the corner wall of Resident #84's room. Holes in the wall of Resident #83 room. The Maintenance Director said each nurse's station has a binder where staff documents the areas in need of repair. He said staff are not reporting issues with walls, ceiling or furniture. He said housekeeping also go in the rooms every day and should report the issues.

Based on observation, review of facility policies and procedures, clinical record review and staff and resident interviews, the facility failed to follow procedures to thoroughly evaluate and analyze the fall incidents, for 1(Resident #19) of 2 residents. The facility also failed to ensure smoking material including lighters were securely stored for 1 (Resident #71) of 25 residents identified by the facility as currently smoking. The findings included: 1. The facility policy N-1259 Fall Management effective 11/30/14 (Revised 7/29/19) documented Residents are evaluated for fell risk. Patient centered interventions are initiated based on resident risk. Purpose: Is to identify residents at risk for falls and establish/modify interventions to decrease the risk of future falls and minimize the potential for a resulting injury. Fall Mitigation: Fall risk is based off results of the Fall Risk Evaluation. Fall Mitigation Strategies: Develop resident centered interventions based on resident risk factors. Update the residents care plan and Nurse Aide Kardex with interventions. On 3/10/24 at 12:37 p.m., in an interview Resident #19 said she has had several falls recently and was grateful she was not injured. She said she had three falls this year, that she can remember. Review of the clinical record revealed Resident #19 had an admitted [DATE] with diagnoses including schizoaffective disorder bipolar type, anxiety, diabetes mellitus, morbid obesity, diabetic polyneuropathy and overactive bladder. The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 2/9/24 documented Resident #71 was independent with ambulation and toileting transfers. The MDS noted Resident #71's cognitive skills for daily decision making were intact. Review of the care plan initiated 4/1/22 (revised 10/19/23) documented, The resident is at risk for falls related to gait/balance problems. The goal for Resident #71 was to minimize the risk of falls. The care plan interventions included: be sure the resident's call light is within reach and encourage the resident to use it. Bed in low position. Ensure the resident is wearing appropriate foot ware/non-skid socks when ambulating or mobilizing in w/c(wheelchair). Review of the Fall Incident Reports: Fall #1 occurred on 1/10/24 at 3:00 a.m., documented Resident observed to a sitting position, onto her buttocks at the foot of the bed, while sleeping sitting on up on the edge of bed. Resident stated I just slipped down. No injuries were observed at the time of the incident. Review of the Post Fall Documentation (12 HR) dated 1/11/24 at 5:25 a.m., documented response to questions: Care plan changes/New interventions No. Fall related injuries, No. Fall interventions in place, Yes. Review of the care plan revealed no new care plan interventions were initiated to prevent Resident #71 from falling. Fall #2 occurred on 2/3/24 at 6:30 a.m., documented Resident observed sitting on the floor of her bathroom. Resident stated I fell asleep and slid off. No injuries observed at the time of incident. Review of the Post Fall Documentation (12 HR) dated 2/5/24 at 6:52 a.m., documented response to questions: Care plan changes/New interventions No. Fall related injuries, No. Fall interventions in place, Yes. Fall #3 occurred on 2/6/24 at 2:00 a.m., documented, Resident found on her side by CNA (certified nursing assistant), after she fell to her knees trying to use walker to walk. Patient states she locked the walker but then fell to her knees. No injuries observed at time of incident. Review of the Post Fall Documentation (12 HR) dated 2/7/24 at 5:13 a.m., documented response to questions: Care plan changes/New interventions No. Fall related injuries, No. Fall interventions in place, Yes. A Fall Risk Evaluation dated 2/6/24 documented a score of 65 indicating a high risk for falls. On 2/6/24 the care plan was updated with the intervention, Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility such as (park activities, music, dancing, movies or nail care). On 3/13/24 at 11:10 a.m., in an interview the Director of Nursing (DON) said she was the acting Risk Manager for the facility. The DON explained the process for reviewing falls was We do morning clinical and we look at the falls and the 24 hour report sheet, the risk management piece. Any new orders we review and someone from the Therapy Department does attend. The process is to review the incident report in morning clinical. We have a Registered Nurse Practitioner who attends our meeting Mondays to Fridays, and she will see the resident after a fall. During the meeting we make sure notifications have been completed with the family and the physician. We review any injuries. An interdisciplinary note is written, and we review what interventions are needed and add them to the care plan. The DON said the root cause of fall number one on 1/10/24 was, I don't know. I have not completed a root cause analysis. The DON said, I do not have a root cause analysis for any of Resident #19's 3 falls because I did not do that. The DON confirmed the care plan was not consistently updated after each fall and confirmed she did not have any interdisciplinary notes after Resident #19's falls. The DON said we review the falls in Quality Assurance Plan Improvement(QAPI). We review the total number over the month and the shift and figure out if they are at a particular time of day if the Pt has multiple falls. A request to review the QAPI minutes for falls and the DON said we have reviewed them in QA yet, because we have not had our meeting for this month. The DON said she was aware Resident #19's falls occurred during the night on the way to use the bathroom and said the resident was not on a bowel and bladder program. On 3/13/24 at 11:24 a.m., in an interview Resident #19 said, I fall because I have to go to the bathroom. When I have to go, I have to get there right away. I don't always use my call light because I like to do it myself. I seem to fall asleep on the toilet or sitting on the edge of the bed. I don't know why I'm so sleepy but sometimes I fall asleep when I'm trying to get up and go to the bathroom. The last fall I had my knees buckled and gave out and I fell . I think I forgot to lock the brakes on the walker because I was going to get something on my way to the bathroom. I wish I could tell you that I'll use the call light, but I probably won't. 2. The facility policy S-406, Smoking - Supervised, effective 11/30/14 (revised 2/7/20) documented The Center will provide a safe, designated smoking area for residents. For the safety of all residents the designated smoking area will be monitored by a staff member during authorized smoking times. The Center will retain and store matches, lighters, etc., for all residents. On 3/10/24 at 11:10 a.m., in an interview with Licensed Practical Nurse (LPN) Staff W said the residents were allowed to keep the cigarettes in their rooms but not the lighters. The smoking aide was responsible to light the cigarettes. Review of the clinical record revealed Resident #71 had an admitted [DATE] with diagnoses including Chronic obstructive pulmonay disease and nicotine dependence. The clinical record contained a Smoking Evaluation form dated 3/10/24 at 6:23 p.m., identified Resident #71 was determined to be a safe smoker requiring constant supervision while smoking. On 3/10/24 at 11:28 a.m., during an interview and observation, Resident #71 was sitting in his room in a wheelchair. He had a pack of cigarettes on his nightstand and said he had just come in from smoking. When asked if he had a lighter, he said yes it in the top drawer right there. Resident #71 opened the top nightstand drawer to show he had a green lighter. He said, no one ever told me I couldn't have it. Photographic evidence obtained. On 3/10/24 at 11:34 a.m., the Director of Nursing (DON), the Regional Nurse Consultant and Unit Manager Staff B were notified of Resident #71 having a lighter and cigarettes in his room. The Unit Manager went to the room and retrieved the lighter. The DON said the residents were able to have cigarettes in the room but no lighters. On 3/12/24 at 10:15 a.m., in an interview with Activity Assistant Staff C she said during the day she or the other activity person will be out in the smoking area to monitor the residents. We do not search them for lighters. When they come inside, we check them to make sure they are not hiding any lit cigarettes and they do not have any burn holes in their clothing. We have the lighter and we light the cigarette. At admission they review the smoking policy and ask if they have a lighter to please turn it over. There are metal ashtrays on the tables for the residents and if they need to be emptied, we empty them into the red, metal buckets with the lids. Staff C revealed the lighters are kept in a locked treatment cart on the smoking patio. She said once they leave for the day, a CNA is assigned to the smoking area. On 3/13/24 at 1:02 p.m., in an interview the DON, she said there were currently 25 residents in house who smoke.

Based on observation, interview, record review, and facility policy review the facility failed to maintain ongoing, effective communication with dialysis centers and failed to ensure 2 (Residents #176 and #63) of 2 sampled residents receiving dialysis received appropriate care and services before and after dialysis treatments. The facility failed to have documentation of an agreement with the dialysis centers providing treatment to Residents #176 and #63. The findings included: The facility policy N-1359, Coordination of Hemodialysis Services effective 11/30/14 and last revised 7/2/19 reads, Residents requiring an outside ESRD [end stage renal dialysis] facility will have services coordinated by the facility. There will be communication between the facility and the ESRD facility regarding the resident. The facility will establish a Dialysis Agreement/Arrangement if there are any residents requiring Dialysis Services. The agreement shall include how the residents care is to be managed. Procedure: 1. The Dialysis communication form will be initiated by the facility for any resident going to an ESRD center for hemodialysis. 2. Nursing will collect and complete the information regarding the resident to send to the ESRD Center . 4. Upon the resident's return to the facility, nursing will review the Dialysis Communication form and information completed by the dialysis center . 5. Nursing will complete the post dialysis information on the dialysis communication form and file the completed form in the Resident's Clinical record. Review of the clinical record revealed Resident #176 was admitted to the facility on [DATE] with a diagnosis of end stage renal disease. Resident #176 had a shunt (access site for dialysis treatment) in her left arm. Resident #176 had physician's orders to receive Dialysis at Dialysis Center A on Mondays, Wednesdays, and Fridays each week. On 3/12/24 Review of Resident #176's Dialysis treatment book showed two forms titled Dialysis Communication Record. The Dialysis Communication Record dated 3/11/24 was left blank as to the name phone and fax of Company A Dialysis facility. The Transport Company was also blank on the form. The location of the shunt site was blank. The time the resident left for dialysis was documented as AM. There was no documentation of an assessment of Resident #176 upon returning from Dialysis on 3/11/24. The Dialysis Communication Form dated 3/6/24 had a documented set of vital signs prior to dialysis but the other information required on the form was blank The time the resident left for dialysis was documented as AM. There was no documented assessment of Resident #176 when she returned from dialysis on 3/6/24. The facility provided two additional Dialysis Communication forms dated 2/26/24 and 2/21/24. The form dated 2/26/24 did not have the resident's name, and noted the dialysis access site (shunt) was located in the right hand. There was no post dialysis assessment documented on the forms. Review of the electronic documentation of vital signs in the resident's medical record showed no documented vital signs on 2/21/24 or 2/26/24. On 3/12/24 at 9:30 a.m., Resident #176 was observed lying in bed. An AV (arteriovenous) shunt was observed in Resident #176's left antecubital area. A pressure dressing was observed above the antecubital area. When asked how long the dialysis unit tells her to keep the dressing on her arm, Resident #176 said six hours. On 3/12/24 at 10:00 a.m., Licensed Practical Nurse, Staff A (Resident #176's assigned nurse) said she could not answer any question regarding Resident 176's assessments after her dialysis because she was never working on the days Resident #176 was scheduled for dialysis. On 3/12/24 at 10:03 a.m., Licensed Practical Nurse Staff O verified nursing staff had not completed the Dialysis Communication Forms and were not documenting a pre-treatment and post-treatment assessment of the resident. On 3/12/24 at 10:05 a.m., Licensed Practical Nurse, Unit Manager, Staff B verified there was missing documentation for Resident #176's Dialysis Communication forms. She stated she had attempted to contact the Dialysis Unit and she got a hold of a person at the dialysis facility company A who told her the facility was closed on Tuesdays. On 3/12/24 at 10:30 a.m., the Director of Nursing (DON) verified there was only two communication forms in the resident's dialysis folder and the two forms were missing information. The DON said she was told Resident #176's communication forms were being left at the dialysis facility. The DON said she did not know if the facility had a agreement with dialysis Company A. She stated the Administrator was working on it. The DON did not know how long the dressing from the access site should remain in place after dialysis treatment per the dialysis center policy. The DON verified the importance of removing the pressure dressing per the facilities policy to prevent the shunt (access site) from clotting. The DON verified the importance of a post dialysis assessment when Residents returned from dialysis to ensure their blood pressure was stable after receiving hemodialysis. On 3/13/24 at 2:00 p.m., the Administrator verified the facility did not have an agreement with dialysis center A who provided dialysis treatment to resident #176. Review of the clinical record revealed Resident #63 was readmitted to the facility on [DATE]. Diagnoses included End Stage Renal Disease. Resident #63's physician's order dated 8/3/23 was to receive Hemodialysis at dialysis center B at 11:00 a.m., on Mondays, Wednesdays, and Fridays. On 3/12/24 at 10:30 a.m., a request was made to the DON for the previous two months of completed dialysis communication forms for Resident #63. On 3/12/24 at 12:00 p.m., seven Dialysis Communication Forms were reviewed. The form dated 2/12/24 had no vital signs documented pre or post dialysis treatment. Four of the seven forms had no post dialysis assessment documented. The Dialysis Communication Form dated 2/19/24 documented Resident #63 had a shunt in her left arm. when Resident #63 had a Catheter in her chest for access on 2/19/24. The facility should have documented at a minimum sixteen Dialysis Communication Forms from the time Resident #63 had been readmitted on [DATE]. There was no documentation provided by the facility Resident #63 had received the appropriate number of dialysis treatments from 2/3/24 to 3/13/24. On 3/13/24 at 2:00 p.m., the Administrator said the facility did not have an agreement with dialysis center B where Resident #63 received dialysis treatments.

Based on record review, and interview the facility policy the facility failed to ensure nursing staff were competent to provide care and services to 2 (Residents #176 and #63) of 2 sampled residents receiving dialysis. The findings included: The facility policy N-1359, Coordination of Hemodialysis Services effective 11/30/14 and last revised 7/2/19 reads, Procedure: 1. The Dialysis communication form will be initiated by the facility for any resident going to an ESRD center for hemodialysis. 2. Nursing will collect and complete the information regarding the resident to send to the ESRD Center . 4. Upon the resident's return to the facility, nursing will review the Dialysis Communication form and information completed by the dialysis center . 5. Nursing will complete the post dialysis information on the dialysis communication form and file the completed form in the Resident's Clinical record. 1. Review of the clinical record revealed Resident #176 was admitted to the facility on [DATE] with a diagnosis of end stage renal disease. Resident #176 had a shunt (access site for dialysis treatment) in her left arm. The physician's orders included dialysis treatments at a local dialysis center on Mondays, Wednesdays, and Fridays. Review of the resident's dialysis binder where the facility keeps the communication forms used to document coordination between the facility and the dialysis center revealed the Dialysis Communication Record dated 3/11/24 the location of the shunt site was blank. There was no documentation of an assessment of Resident #176 upon returning from Dialysis on 3/11/24. The Dialysis Communication Form dated 3/6/24 had a documented set of vital signs prior to dialysis. There was no documented assessment of Resident #176 when she returned from dialysis on 3/6/24. The facility provided two additional Dialysis Communication forms dated 2/26/24 and 2/21/24. The form dated 2/26/24 noted the dialysis access site (shunt) was located in the right hand. There was no post dialysis assessment documented on the forms. Review of the electronic documentation of vital signs in the resident's medical record showed no documented vital signs on 2/21/24 or 2/26/24. 2. Review of the clinical record revealed Resident #63 was readmitted to the facility on [DATE]. Diagnoses included End Stage Renal Disease. Resident #63's physician's order dated 8/3/23 was to receive Hemodialysis at dialysis center B at 11:00 a.m., on Mondays, Wednesdays, and Fridays. On 3/12/24 at 10:30 a.m., a request was made to the DON for the previous two months of completed dialysis communication forms for Resident #63. On 3/12/24 at 12:00 p.m., seven Dialysis Communication Forms were reviewed. The form dated 2/12/24 had no vital signs documented pre or post dialysis treatment. Four of the seven forms had no post dialysis assessment documented. The Dialysis Communication Form dated 2/19/24 documented Resident #63 had a shunt in her left arm when Resident #63 had a Catheter in her chest for access on 2/19/24. On 3/13/24 at 10:00 a.m., in an interview Registered Nurse, Staff F said she had been regularly assigned to provide nursing care to Resident #63. Staff F said she was not aware Resident #63 had a chest catheter for dialysis access at that time. Staff F said she had worked at the facility since July of 2023 and had not received any training or competencies regarding pre and post assessments of residents receiving dialysis. On 3/13/24 at 10:10 a.m., in an interview Licensed Practical Nurse, Unit Manager Staff B said she had not received any in-services or competencies regarding caring for residents receiving dialysis. Staff B's date of hire at the facility was on 5/16/2023. On 3/13/24 at 10:25 a.m., in an interview Registered Nurse Staff K said she had never received any in-services or competencies on caring for a resident receiving dialysis treatments since she had started working at the facility. Staff K's date of hire was 7/21/20. On 3/13/23 The Director of Nursing stated she was not able to provide any documentation the licensed nurses were trained in the facility policy for assessing dialysis patients both pre and post dialysis treatments and in communication with dialysis units providing care to residents receiving dialysis at the facility.

Based on record review, review of facility's policy and procedure, and staff interviews, the facility failed to ensure the accuracy of a Pre-Admission Screening and Resident Review (PASRR) and make the necessary corrections for 1(Resident #37) of 1 resident with admitting diagnoses of mental illness. The findings included: The facility policy titled Preadmission Screening and Resident Review (PASSR) with a revision date of 11/8/2021 stated, The center will assure that all Serious Mentally Ill (SMI) and intellectually disabled (ID) residents received appropriate pre-admission screenings according to Federal/State guidelines. The purpose is to ensure that the residents with SMI or are ID receive the care and services they need in the most appropriate setting. It is the responsibility of the center to assess and assure that the appropriate preadmission screenings, either Level I or Level II, are conducted and results obtained prior to admission and placed in the appropriate section of the resident's medical record. Review of the Admission Record for Resident #37 revealed an admitted [DATE]. The documented medical history at the time of admission included a diagnosis of bipolar disorder, schizoaffective disorder, and dementia. The Minimum Data Set (MDS) revealed Resident #37 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. Resident #37 level I PASRR screen dated 9/4/23 documented no diagnosis or suspicion of serious mental illness or intellectual disability indicated. Level II PASRR evaluation not required. Review of Resident #37 Psychology Evaluation dated 9/28/2023 reason of referral/chief complaint states, Confused thinking/bipolar disorder and is currently on Zyprexa which is a brand name for olanzapine (an antipsychotic medication to treat mental disorders, including schizophrenia and bipolar disorder). Per staff the patient is displaying confused thinking and wandering behavior. Review of Psychiatry Subsequent Note dated 3/5/24 indicates that Resident #37 will continue with olanzapine for controlling schizoaffective disorder. On 3/11/24 at 3:57 p.m., in an interview the Director of Nursing (DON) revealed the process to fill out a PASRR falls to the DON when the resident enters the facility through the home. The facility reviews admission charts for accuracy the next day or on Monday, if falls on the weekend. If errors are made on the PASRR, it would get corrected and resent. The DON confirmed the level I PASRR was inaccurate and did not list the diagnoses of bipolar disorder, and schizoaffective disorder on the PASSR for Resident #37 dated 9/4/24. The DON said she will make the correction.

Based on observation, record review, review of facility policy and procedure review, and interviews, the facility failed to develop and implement a comprehensive individualized care plan for 4 (Residents #37, #104, #18, and #102) of 26 residents reviewed. The findings included: Review of the facility policy titled, Plans of Care, with a revision date of 9/25/2017, specified, An individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and /or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements. The development of a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. Develop and implement an individualized person-centered baseline plan of care within 48 hours of admission that includes, but not limited to, initial goals based on the admission orders, physician orders, dietary orders, therapy services, social services, PASARR recommendations, if applicable, and other areas needed to provide effective care of the resident that meets professional standards of care to ensure that the resident's needs are met appropriately until the comprehensive plan of care is completed. Develop and implement an individualized person-centered comprehensive plan of care by the IDT that includes the attending physician, a registered nurse (RN) with responsibility for the resident, a nurse aide with responsibility for the resident, a member of food and nutrition services staff, and other appropriate staff or professionals in disciplines as determined by the residents' [NAME] or as requested by the resident, and, to the extent practicable, the participation of the resident and resident's representative(s), within seven (7) days after completion of the comprehensive assessment (minimum data set, MDS). A review of the Admission Record revealed Resident #37 was admitted to the facility on [DATE] with diagnoses including bipolar disorder, schizoaffective disorder, and dementia. The Admission Minimum Data Set (MDS) assessment noted Resident #37 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderate cognitive impairment. Review of Resident #37's Care Plan initiated on 9/21/2023, did not have a comprehensive person centered care plan for antipsychotic medication with interventions, elopement risk/wanderer, smoking, anticoagulation medications and interventions, activities of daily living (ADLs), congestive heart failure, risks for falls, risk for pain, chronic kidney disease and potential for fluid and electrolyte balance, incontinent of urine, potential for shortness of breath, potential for skin impairment, and use of diuretic and risk for fluid volume imbalance. On 3/10/24 at 10:40 a.m. observed resident in room, sitting on bed and a strong ammonia like smell in the room. During an interview on 3/13/24 at 9:32 a.m. with the MDS Licensed Practical Nurse (LPN) Staff H and MDS LPN Staff N stated, to be honest, we were covering social worker work and they have been behind. They are doing catch up work now. Nurses do the base line care plan on paper then the MDS nurse builds upon it. A base line care plan is about 4 pages. The MDS LPN build a care plan by looking at the orders and working with IDT. The MDS LPNs revealed that nurses monitor psychotropic medications and side effects by following the physician order and then it is in the MAR for charting. The MDS LPN confirmed there is no order for side effect monitoring and Resident #37 has not been monitored for side effects per the resident's electronic record. During an interview on 3/13/24 9:53 a.m., the DON revealed the admitting nurse does the baseline care plan. The MDS LPNs will enter information into Point Click Care (PCC) (electronic records). The DON is aware of being behind because they are trying to do catch up work. The staff have been covering floor nursing, social work, and wherever else needed and fell behind on the MDS work. The DON confirmed there is no order to monitor side effects of psychotropic medication. The DON confirmed the nurses are not monitoring or documenting side effects of psychotropic medications. The care plan was not patient centered care. A comprehensive care plan was not completed for six months. 25618 On 3/13/24 a review of Resident #104's medical record revealed she was readmitted to the facility on [DATE] from the hospital with a diagnosis of Cellulitis, Gout, Altered Mental Status, and a Stage 4 Sacrum Pressure Wound. Review of the initial care plan dated 11/07/23 noted it did not document the stage 4 pressure ulcer to Resident #104's sacrum and no goal(s) and/or interventions were initiated to address the stage 4 pressure ulcer. The Minimum Data Set (MDS) (a comprehensive clinical assessment tool), dated 11/12/23, identified in Section M - Skin Conditions, that Resident #104 had 1 stage 4 pressure ulcer. On 11/20/23 the initial wound care physician's progress note stated there was a stage 4 full thickness pressure ulcer to Resident #104's sacrum. The pressure ulcer measured 9 x 6.3 x 4.5 cm. A care plan for potential/actual impairment to skin integrity for a pressure wound to the sacrum was initiated on 3/05/24 with a goal and interventions listed to maintain or develop clean and intact skin. This care plan was not initiated until approximately 3 1/2 months after the pressure ulcer had been identified by the facility nursing staff. The Plan of Care policy and procedures #N-1015 with an effective date of 11/30/14 and revision date of 9/25/27 stated an individualized person-centered plan of care should be established by the interdisciplinary team (IDT) with the resident and/or representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements. The policy noted the Procedure was to: Develop a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs; Develop and implement an individualized person-centered comprehensive plan of care by the IDT . as determined by the resident's needs or as requested by the resident, and, to the extent practicable, . within 7 days after the completion of the comprehensive assessment (MDS); and The individualized person-centered plan of care may include but is not limited to the following: services to attain or maintain the resident's highest practicable physical, physical, mental, and psychosocial well-being. On 3/13/23 at 10:53 a.m., in an interview with the MDS Coordinator, she said, after she reviewed Resident #104's medical record, Resident #104 was readmitted with a stage 4 pressure ulcer to their sacrum on 11/07/24 and was currently being seen by the wound care physician. She confirmed the MDS IDT completed a 5-day MDS admission assessment on 11/12/23 and a quarterly MDS assessment on 1/03/24 but did not initiate a plan of care to address Resident #104's stage 4 sacrum pressure ulcer until 3/05/24 approximately 3 1/2 months after the pressure ulcer had been identified by nursing staff. She confirmed the facility did not develop and implement a comprehensive plan of care with measurable goals and interventions to address Resident #104's stage 4 sacrum pressure ulcer within 7 days after the completion of the 5-day admission assessment date 11/12/23 as required. 44307 Review of facility policy titled, Medication Management- Psychotropic Medications, revised 10/24/2022 which states Procedure: 4. Monitor behavior and side effects every shift utilizing the Behavior Monitoring Flow Record (BMFR) or electronic equivalent .11. Care plan to include person centered goals and non-pharmaceutical interventions. Update Care Plan as indicated. 12. Monitor resident's response to medication, including the effectiveness of the medication, and potential adverse consequences. 13. Monitoring should also include evaluation of the effectiveness of non-pharmacological approaches. Review of clinical records for Resident #18 initially admitted to the facility 9/8/23 and most recent readmission 11/7/23 documented diagnosis including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, and anxiety. Reviewed medication orders which included Diazepam 2.5 milligrams (MG) insert 20 mg rectally every 8 hours as needed for anxiety/ agitation. Insert 1 suppository as directed by Physician ordered 12/11/2023 discontinued 3/13/24; Diazepam 2.5 MG insert 20 mg rectally every 8 hours as needed for anxiety/ agitation. Insert 1 suppository as directed by Physician ordered 3/13/24; Lorazepam oral tablet 0.5 MG give 1 tablet by mouth every 4 hours as needed for anxiety ordered 11/20/23 discontinued 3/5/24; ; Lorazepam oral tablet 0.5 MG give 1 tablet by mouth one time only for increase agitation for 1 day ordered 3/11/24 discontinued 3/12/24; Quetiapine Fumarate oral tablet 50 MG give 1 tablet by mouth three times daily for mood stabilizer ordered 1/15/24 discontinued 3/5/24; Quetiapine Fumarate oral tablet 50 MG give 1 tablet by mouth three times daily related to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, and anxiety ordered 3/5/24; Temazepam oral capsule 15 MG give 1 tablet by mouth for insomnia ordered11/14/23 discontinued 3/13/24; Temazepam oral capsule 15 MG give 1 tablet by mouth for insomnia ordered 3/13/24; Ziprasidone HCl oral capsule 80 MG give 1 capsule by mouth twice daily for schizophrenia ordered 1/15/24 discontinued 3/13/24. Reviewed February 2024 and March 2024 Medication Administration Record (MAR) and Treatment Administration Records (TAR) with no behavior monitoring documented in clinical record. Reviewed resident's most recent care plan 10/23/23. Care plan does not address the use of psychotropic medications and to monitor behavior related to use of psychotropic medications. Reviewed of clinical records for Resident #102 initially admitted to the facility 8/2/23 and most recent readmission 10/8/23 documented diagnosis including dementia, depression, anxiety epilepsy and impaired balance. Reviewed medication orders which included the following psychotropic medications: Sertraline HCl oral tablet 25 MG give 1 tablet by mouth bedtime for MDD (Major Depressive Disorder) ordered 2/14/24; Trazadone HCl oral tablet 150 MG give 150 mg by mouth nightly for MDD related to insomnia ordered 2/13/24; Buspirone HCl oral Tablet 15 MG give 15 MG by mouth twice daily for anxiety ordered 10/4/23; Olanzapine oral tablet 2.5 MG give 1 tablet by mouth twice daily for delusions ordered 1/14/24. Reviewed February 2024 and March 2024 Medication Administration Record (MAR) and Treatment Administration Records (TAR) with no behavior monitoring documented in clinical record. Reviewed resident's most recent care plan 10/23/23. Care plan does not address the use of psychotropic medications and to monitor behavior related to use of psychotropic medications. On 3/12/24 at 8:52 a.m., interviewed Registered Nurse (RN) Staff F assigned to resident #18 who confirmed resident has dementia and is on medications to manage his behavior. On 3/12/24 at 11:16 a.m., RN Staff J interviewed who said resident #102 does not have any issues related to his medications. Asked if he monitored the resident for behaviors and RN said, We watch all of our residents. RN confirmed he does not chart behavior monitoring daily. On 3/12/24 at 1:55 p.m., interviewed Certified Nursing Assistant (CNA) Staff Y who confirmed resident has dementia saying, He can sometimes have behavior when he takes off his clothes or becomes agitated. On 3/13/24 at 8:29 a.m., interviewed RN Staff I who confirmed Resident #102 is stable and calm. RN Staff I said they only document if he acts up and if that happened, she would put a progress note in the record. She does not do daily monitoring documentation. On 3/13/24 8:57 AM interviewed assigned CNA Staff L caring for Resident #18 said he participates in activities but sometimes does stuff like taking off his clothing. On 3/13/24 at 9:21 a.m., during an interview with the Director of Nursing (DON) who confirmed when psychotropic medications are ordered the orders are reviewed to ensure there is an appropriate diagnosis and monitoring for side effects by assigned nurse each shift is initiated. The monitoring is documented on MAR. The DON reviewed clinical records for resident #18 and #102 and confirmed the order to monitor for side effects was never placed. DON said the order for monitoring would trigger the care plan to be updated. The DON said she was the person responsible for ensuring the medication orders and monitoring orders had been placed and that she had not done them as expected. Asked what the risks for not monitoring the use of psychotropic medications were. DON replied, there are a number of issues including anticholinergic effects, reaction to med itself tardive dyskinesia, over sedated, hypervigilant, exacerbation of behaviors. On 3/13/24 at 9:54 a.m., during an interview with Minimum Data Set (MDS) nurse Staff H who said that they have behind on care planning since she and the other MDS nurse were covering many roles for the social services department. Saying, Corporate knows we were behind in care planning, and we have been playing catch up and we started 2 weeks ago to get everything caught up. MDS nurse Staff H confirmed both Resident #18 and Resident #102 should have been care planned for behavior monitoring on admission. MDS nurse Staff H said, As a nurse I would have put the order in on admission. Confirmed comprehensive care plan for Resident #18 was not completed to include monitoring for behavior or medication response. Care plan for Resident #18 was updated accurately 3/8/24 and Resident #102 was updated 3/5/24. MSD nurse Staff H said not having accurate care plans can potentially cause harm since care and the care plan are driven by the entered orders. On 3/13/24 at 11:16 a.m., interviewed RN Staff K who confirmed Resident #18 was on psychotropics. Asked if she documented the resident's behavior each shift. RN Staff K replied, He is stable we only document if he has a problem. Confirmed she does not document each shift.

Based on observation, review of facility policy and procedure, review of the clinical record and staff interview, the facility failed to follow their policy and procedure and physician orders for the use of oxygen for 1 (Resident #273) of 1 resident reviewed for oxygen use. The facility failed to have a system in place to ensure the oxygen concentrator filters were removed and cleaned per the manufacturers recommendation. The facility had 19 residents with oxygen concentrators. The findings included: The facility policy N-1440 Oxygen effective 11/30/14 (revised 8/23/17) documented, Obtain Physician's order. Set flow at level ordered by the physician. Review of the manufacturers recommendation for the oxygen concentrator Cleaning the Cabinet Filter, specified Risk of danger. To avoid damage to the internal components of the unit, do not operate the concentrator without the filter installed or with a dirty filter . Remove the filter and clean as needed. On 3/10/24 at 9:55 a.m., Resident #273 was observed in bed, there was an oxygen concentrator in her room that was turned on and set on 3.5 liters per minute (LPM). The nasal cannula (NC) was on the floor. The concentrator filter was observed to have a thick layer of brown dust and debris. Photographic evidence obtained. On 3/10/24 at 10:00 a.m., in an interview Certified Nursing Assistant Staff O said, only the nurse touches the concentrator. I do not touch the dial; I will put the tube in her nose but that is all. On 3/10/24 at 2:18 p.m., Resident #273 was observed in bed, the oxygen tubing was on the floor and the concentrator was set at 4.5 LPM. On 3/10/24 at 2:21 p.m., a review of the clinical record revealed Resident #273 did not have a physician order for the use of the oxygen. On 3/11/24 at 8:49 a.m., Resident #273 was observed with the oxygen concentrator on and set at 3.5 liters. Resident #273 said she was often short of breath. On 3/11/24 at 1:15 p.m., the Director of Nursing provided a copy of a physician order dated 3/11/24 for oxygen at 3 Liters per minute via a nasal cannula. On 3/12/24 at 8:50 a.m., in an interview the Regional Nurse Consultant said the nurses and housekeeping would be responsible for cleaning the oxygen concentrators. When asked if the housekeeping staff had training in cleaning the concentrator filters, she replied no, that would be nursing. On 3/12/24 at 9:01 a.m., in an interview Licensed Practical Nurse (LPN) Staff H said nurses are responsible to change the tubing and ensure it is in a plastic bag when not in use. I have that room for rounds, we check to make sure the room is clean, the concentrator tubing has been changed. To be honest I have never thought about checking the filters. We will make sure we do rounds on all the machines; they are working on it now. On 3/12/24 at 9:09 a.m., in an interview LPN Staff A said any nurse can obtain an order for oxygen. It is universal that we can start oxygen on anyone who needs it at 2 LPM and then obtain a physician order. The process for cleaning the concentrator is once it is discontinued the nurse or the CNA takes it to the soiled utility room and then housekeeping cleans it and puts it in the clean utility room. The 7:00 p.m., to 7:00 a.m., nurse is responsible to change the oxygen tubing. I don't know about the filters; I know the Unit Manager and the Assistant Director of Nursing (ADON) are working on that now. I don't know why the resident did not have an order she uses it every day. On 3/12/24 at 9:15 a.m., in an interview the Assistant Director of Nursing (ADON) said she was aware of the concern with Resident #273's oxygen concentrator filters and cleaning them. She said we are working on that now. On 3/12/24 at 9:35 a.m., in an interview Housekeeping Staff R said once a concentrator is no longer in use, we clean the outside of the concentrator and put a plastic bag over it and move it to the clean utility room. We do not clean the filters, nursing does that, we don't touch the filters. On 3/12/24 at 12:57 p.m., the DON provided a copy of Resident #273's Treatment Administration Record, it confirmed the oxygen was not ordered until 3/11/24. The DON said she did not know why Resident #273 did not have an order for the oxygen used daily since admission. On 3/13/24 at 10:29 a.m., in an interview the DON she said she did know why the oxygen was not ordered when initiated for Resident #273. She said the oxygen concentrators were the facilities equipment but she did not know who was responsible to clean the filters. She said we are working on it now to get a program in place. She said she did not know who was responsible to fix the concentrators should a repair be necessary.

Based on observation, record review and interview, the facility failed to ensure care according to industry standards by not following physician's orders for quarterly lab draws for 1 (Resident #31) of 1 resident reviewed for seizures. Not following physician's orders for quarterly lab values puts a resident with [CONDITION(S)] at risk of seizures and hospitalization by not ensuring therapeutic levels of the [CONDITION(S)] medication are within the bloodstream. The findings included: On 5/1/22 at 10:06 a.m., Resident #31 was observed lying in bed in her room. The resident did not respond to verbal stimulation, stared straight ahead, making unintelligible noises, like whimpering. Review of the Minimum Data Set, dated dated dated [DATE] indicated Resident #31 had a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. The active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #31 was originally admitted to the facility on [DATE]. Review of the active orders as of 4/1/22 for Resident #31 indicated orders for three different [CONDITION(S)] medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . The active orders also included an order dated 9/17/20 to draw lab values to monitor the blood levels of [MEDICATION(S)], [MEDICATION(S)] ([MEDICATION(S)]) and [MEDICATION(S)] ([MEDICATION(S)]) every three months. On 5/1/22 at 7:00 p.m. during a telephone interview with Resident #31's mother, she said Resident #31 had a [CONDITION(S)] a couple of weeks ago at the facility and was admitted to the hospital. She said Resident #31's blood level for the [CONDITION(S)] medication was checked when she got to the hospital and two of three [CONDITION(S)] medications were lower than the therapeutic range. Review of the nursing progress note dated 4/17/22 indicated Resident #31 was admitted to the hospital emergency department for [CONDITION(S)] symptoms and discharged back to the facility on [DATE]. Review of the hospital records for Resident #31 indicated Blood levels for [MEDICATION(S)] ([MEDICATION(S)]) collected by the hospital on 4/17/22 at 1:17 p.m. were 5.63, below the therapeutic range of 10 - 20. Blood levels for [MEDICATION(S)] collected by the hospital on 4/18/22 at 11:36 a.m. were 25.65, below the therapeutic range of 50 - 100. Review of the Medication Administration Records from January 2022 through April 17, 2022, indicated Resident #31 did not miss any doses of her [CONDITION(S)] medication at the facility. Review of the facility laboratory reports for Resident #31 indicated blood levels for [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] were done on 10/14/21. Lab values were due again in January 2022 and April 2022. Review of the facility laboratory reports for Resident #31 indicated there were no blood level results for [MEDICATION(S)], [MEDICATION(S)] ([MEDICATION(S)]), or [MEDICATION(S)] in the facility medical record for January 2022, February 2022, March 2022, or April 2022 before Resident #31 went to the hospital for the [CONDITION(S)] on 4/17/22. On 5/3/22 at 11:20 a.m., Unit Manager Staff J said all lab results are in the computer. She said she did not see the results for the [CONDITION(S)] medications in January 2022 or April 2022 before Resident #31 went to the hospital for the [CONDITION(S)]. On 5/3/22 at 11:50 a.m., Resident #31's mother said the resident does not go out for blood draws and has them done at the facility. On 5/3/22 at 11:58 a.m., Medical Records Staff K said there were no lab reports in the paper chart in the medical records department for Resident #31, and she did not possess the missing lab reports. On 5/3/22 at 12:24 p.m., the Director of Nursing (DON) said she did not see the lab results that were due for Resident #31 every 3 months after October 14, 2021, in the computer or paper chart. On 5/3/22 at 3:25 p.m., the DON said she called the laboratory, and she can only assume the labs were not done. On 5/4/22 at 10:19 a.m., Advanced Registered Nurse Practitioner Staff A said you want to keep the [CONDITION(S)] drugs in the therapeutic ranges to decrease the chance of seizures. She said the blood draws should have been done every 3 months. She said, It is a ding on her because she did not monitor the lab results.

Based on observation, record review, and interview, the facility failed to demonstrate effective coordination to ensure 1 (Resident #62) of 1 resident with a surgical incision received appropriate follow up care. This failure could cause delayed wound healing and infection and resulted is a higher level of care. The findings included: On 11/2/20 at 10:25 a.m., Resident #62 was observed in a wheelchair at the doorway of his room and was heard calling for help. The resident had a dressing to the right hip saturated with bloody drainage. The drainage was dripping from the wound, running down his leg onto the floor. Two puddles of bloody drainage were observed on the floor next to the wheelchair. Resident #62 stated he had staples to that area from a hip procedure in September. A review of clinical record for Resident #62 revealed an admission assessment dated [DATE] indicating the resident had a wound with wound vac to the right medial hip with staples intact. (Staples are generally placed for 7-10 days). On 11/2/20 the Nurse Practitioner (NP) documented in a progress note Reason for Visit: Patient seen today for assessment of right hip incision site. Currently has an area with mild dehiscence (splitting or bursting open of a wound), drainage and redness, afebrile. Several staples removed on well healed area today Needs ortho (orthopedic) F/U (follow up) ASAP (as soon as possible). On 11/2/20 at 11:45 a.m., during an interview Resident #62 reported some of the staples were removed that morning. On 11/3/20 at 3:07 p.m., Registered Nurse (RN) Staff H said Resident #62 had purulent (pus filled, indicating infection) drainage from the right hip incision and was sent to the hospital. RN Staff H said the process was if a resident was admitted from the hospital with staples and had no orders to remove the staples, the nurse would be responsible to contact the surgeon or the Nurse Practitioner (NP) and obtain orders. RN Staff H she said she completed the initial skin assessment for Resident #62 and verified the staples had been in place since admission on 9/17/20. RN Staff H verified Resident #62 was not scheduled for the necessary follow up care with the orthopedic surgeon. On 11/5/20 at 12:55 p.m., during an interview the NP, she said when residents come from hospital, they should have orders to follow up on when to remove staples. The NP said if orders were not included, hopefully someone would catch that, but she would not be aware of the lack of orders unless nursing brought that to her attention. The NP said she did not see Resident #62 on 11/2/20 when he was sent out. She said she relied on the assessment of the RN Supervisor and RN Staff H. She also stated she had been out for several weeks and would have to reference her notes on Resident #62. She said on Monday (11/2/20) the Resident's incision site was draining, red and was warm to touch (signs of infection). A review of the hospital emergency department notes dated 11/3/20, revealed Resident #62 was being evaluated for moderate, progressive worsening of the right hip wound. On 11/4/20, Resident #62 underwent a surgical debridement to the right hip wound.

Based on observation, record review, facility policy and procedure review, and interview, the facility failed to implement timely preventive measures and failed to alter the plan of care to include offloading of the area when a pressure ulcer developed for 1 (Resident #62) of 2 residents reviewed who developed a pressure ulcer at the facility. This lack of interventions resulted in Resident #62 developing an unstageable pressure ulcer. The facility also failed to coordinate the care and ensure 2 (Resident #55 and #3) received the necessary interventions to prevent the development of pressure ulcers and assist in wound healing. The findings included: The facility policy WC-100, Clinical Guideline Skin and Wound (effective 4/1/17) documented to provide a system for identifying skin at risk, implementing individual interventions including evaluation and monitoring as indicated to promote skin health, healing and decrease worsening of / prevention of pressure injury. The policy included, Licensed Nurse to complete skin evaluation weekly. 1. Review of the clinical record showed Resident #62 was admitted on [DATE]. The Minimum Data Set (MDS) assessment (tool used to assess and plan care) dated 9/20/20, documented Resident #62 had no pressure injuries, and noted the resident was at risk for pressure ulcers/injuries. Review of skin assessments documented on 9/24/20 and 10/7/20 stated skin to be intact. Subsequent weekly skin assessments were not documented. Review of physician orders [REDACTED].#62 included to apply skin prep to right heel topically every shift. On 11/2/07 at 11:45 a.m., Resident #62 was observed in his room. He was observed to have a reddened area to the right heel, with an approximate 2.0 centimeter round blackened area to the center. On 11/3/20 at 10:22 a.m., Resident #62 was observed sitting in a wheelchair in his room. During an interview at this time, he said he was not doing well. The resident complained of pain to his right heel and said it was leaking a lot. On 11/3/20 at 3:07 p.m., in an interview Registered Nurse (RN) Staff H stated they have been doing skin prep to Resident #62's heel. RN Staff H said she assessed the resident's right heel last week when brought to her attention by physical therapy. RN Staff H said at that time, the right heel was intact, and no fluid was noted. RN Staff H said she did not document a skin assessment then, but the nurse assigned to Resident #62 should have charted it. On 11/5/20 at 8:55 a.m., in an interview Occupational Therapy Assistant (OTA) Staff V stated he noticed the resident was walking on the ball of his foot last week and appeared to be in pain. OTA Staff V said he removed Resident #62's right sock and the heel looked different. OTA Staff V said he reported his observation to the nurse caring for the resident. On 11/5/20 at 9:10 a.m., in an interview Physical Therapy Assistant (PTA) Staff W stated he observed Resident #62 limping last week and informed the assigned nurse. PTA Staff W stated he did not notice any drainage but believed the heel was reddened. On 11/5/20 at 9:18 a.m., in an interview RN Staff B said she administered medications to Resident #62 on 11/2/20 but did not assess the condition if his skin. On 11/5/20 at 10:18 a.m., in an interview RN Staff H said she was somewhat familiar with resident #62 but did not do the initial skin assessment. RN Staff H said the resident only had a surgical site on admission. RN Staff H said at the time Resident #62 was transferred to hospital, he did have not fluid filled area on right heel. RN Staff H said the nurse assigned to the hallway should be assessing the residents daily. On 11/5/20 at 12:55 p.m., during an interview, the Nurse Practitioner stated she was unaware that Resident #62 had a pressure ulcer and would have to reference her previous assessment. A review of the hospital emergency department admission record for 11/3/20 revealed Resident #62 had a round silver dollar sized blister that is scabbed over to the right heel. A nursing clinical note dated 11/4/20 noted right heel with an unstageable pressure injury. Stable eschar (dead tissue) to wound bed, no signs and symptoms of infection noted. 2. The wheelchair seating pocket guide from the National Pressure Injury Advisory Panel (NPIAP) notes The number one factor in common among all wheelchair users is impaired mobility . A number of contributing or compounding factors are associated with pressure injuries; the primary of which is impaired mobility . Use a pressure redistribution cushion for preventing pressure injuries in people at high risk who are seated in a chair/wheelchair for prolonged periods, particularly if the individual is unable to perform pressure relieving maneuvers. Source: https://cdn.ymaws.com/npiap.com/resource/resmgr/events/NPIAP_Permobil_WC_Seating_Po.pdf A review of the clinical record revealed Resident #55 was admitted from the hospital on [DATE] with a pressure areas on the left and right buttocks which were documented as resolved on 9/6/19. The most recent quarterly MDS assessment dated [DATE] noted Resident #55 had impaired cognition, generalized weakness and required extensive physical assistance of 2 persons for transfer. Resident #55 was only able to stabilize with staff assistance when moving from a seated to standing position. The assessment also noted the resident was frequently incontinent of bowel, always incontinent of bladder and was at risk of developing a pressure ulcer. The assessment indicated the resident had a pressure reducing device for his chair. The most recent Braden Scale for predicting Pressure Sore Risk evaluation dated 10/30/20 noted Resident #55 was at moderate risk for developing a pressure ulcer. The resident made occasional slight changes in body or extremity position but was unable to make frequent or significant changes independently. The care plan revised on 7/1/20 noted the resident has a potential for pressure injury development related to activities of daily living deficits. The interventions in the care plan did not include a pressure reducing device to the wheelchair. On 11/2/20 at 10:45 a.m., Resident #55 was observed in a wheelchair in his room. Resident #55 was not able to answer questions but was attempting to get out of the wheelchair while complaining his bottom hurts. On 11/2/20 at 12:05 p.m., Resident #55 remained in the wheelchair in his room. He continued to complain his bottom and neck hurt while attempting to get up. Observation of the wheelchair failed to reveal the presence of a pressure reducing or relieving cushion. On 11/3/20 at 2:22 p.m., observation of Resident #55's skin with Certified Nursing Assistant (CNA) Staff Y and Unit Manager Staff A revealed mild redness to the right buttock. On 11/3/20 at 2:38 p.m., during an interview CNA Staff Y said she had been taking care of Resident #55 since his return from the hospital on [DATE]. She said she relied on the information on the Kardex (CNA information) and would use whatever intervention was listed on the Kardex. She said Resident #55 had not had a pressure reducing cushion in his wheelchair since at least 10/30/20. The CNA Kardex failed to include a pressure reducing cushion listed as a preventive measure for Resident #55. On 11/3/20 at 3:38 p.m., during an interview the Director of Nursing (DON) said the pressure ulcer prevention interventions for Resident #55 included barrier cream, pressure reducing cushion in the wheelchair and repositioning. On 11/3/20 at 4:22 p.m., the DON verified Resident #55 did not have a pressure reducing cushion in his wheelchair. She said: I don't know if it matters, but we found his wheelchair in the other room with a nice cushion. 3. A clinical record review revealed Resident #3 was admitted to the facility on [DATE] with right sided weakness and a wound to the right plantar area. The admission data collection form completed by a RN noted the resident was alert and oriented to person, place, and time. Resident #3 was incontinent of bowel and had excoriation to the perineal area. The facility determined Resident #3 had a potential for impairment to skin integrity related to [DIAGNOSES REDACTED]. The care plan was updated on 8/12/20 to note area to the upper left buttock and on 8/24/20 to note pressure ulcer to gluteal fold and upper left buttock. An event report completed on 8/12/20 noted pressure ulcers to the left gluteal fold and left buttock measuring respectively 1.5 x 0.7 x 0.7 and 0.1 x 0.5 x 0.1 centimeter. On 10/13/20 when RN Staff Q documented the left gluteal fold, the pressure ulcer measured 0.3 x 0.1 x 0 centimeter. There was no weekly measurement of the pressure ulcer on 10/20/20. On 10/27/20 RN Staff Q documented the left gluteal fold pressure ulcer measured 0.6 x 0.5 x 0.1 centimeter. On 11/2/20 at 2:59 p.m., during an interview Resident #3 said he developed a pressure ulcer at the facility. He said he did not know if it was getting better. On 11/4/20 at 12:50 p.m., observation of the pressure ulcer with Resident #3's permission revealed a stage II pressure ulcer to the left gluteal fold and left buttock. RN Staff Q applied treatment as ordered but did not measure the wounds. On 9/10/20 the Registered Dietician (RD) documented in a nutrition consult note Resident with two stage II pressure ulcers under treatment . Recommend add Prostat 30 ml (milliliters) once daily and add Zn-220 (zinc) one tablet daily to support wound healing. The clinical record lacked documentation the facility followed through on the RD's recommendation and administered the supplements to support the healing of the pressure ulcers acquired at the facility. On 11/5/20 at 3:07 p.m., during an interview the Director of Nursing (DON) said the RD sent her dietary recommendations to her via email. She verified and printed the RD's recommendation dated 9/10/20 for Resident #3 that read Add Zinc-220 one tablet daily and add Prostat 30 ml daily. The DON said she usually called the Advanced Practice Registered Nurse (APRN) to discuss the recommendations but could not find documentation the APRN was notified of the dietician's recommendations. On 11/5/20 at 3:28 p.m., during an interview RN Staff Q said she was responsible to measure the resident's wounds every Tuesday but did not do it this week. She said, before it was a line, now it is bigger. On 11/5/20 at 3:45 p.m., the DON said the facility used to have weekly wound meetings where they would discuss residents with wounds. She said sometimes she looked at the wounds herself but could not remember the last time she made wound rounds. The DON admitted they had not had a wound meeting in a while.

Based on record review, observation, and staff interview the facility failed to prevent the development and worsening of a pressure ulcer for 1 (Resident #2) of 3 residents sampled for pressure ulcers. Resident #2 was admitted without a pressure ulcer but developed one during his stay. The facility failed to adequately assess and treat the wound. The findings included: On 10/28/16 review of Resident #2 record showed he was readmitted from the hospital 8/26/16 with no pressure ulcers. Weekly skin integrity reviews through 10/14/16 showed no pressure ulcers. Review of progress note showed a pressure ulcer was discovered on 10/18/16 by Licensed Practical Nurse (LPN) Staff C who notified the Director of Nursing (DON). There was no documentation in the resident record to indicate the physician or the Physician Assistant (PA) was notified of the wound. Review of the pressure ulcer record showed the wound was located on the coccyx. It was dated 10/18/16. Length 4.5 centimeters (cm) x width 1.8 cm x depth 0.1 cm. Tissue type was [MEDICATION NAME], color was red, wound edges were firm/no redness, no drainage, no odor and surrounding area was red. It was signed by LPN Staff C. The care plan for skin and wound did not address assisting the resident with turning and positioning. The resident has a history of a stroke with left sided weakness and was unable to reposition or turn himself. The pressure ulcer record dated 10/25/16 showed length 8 cm x width 8 cm. There was no depth and no other information indicated on the form. Progress note dated 10/25/16 at 3:00 p.m., noted black slough (dead tissue) and foul odor. Resident record review revealed a progress note written by the PA dated 10/27/16 that documented the sacral pressure wound as a stage II, no signs or symptoms of soft tissue infection. On 10/28/16 at 2:38 p.m., the resident was observed in bed laying on his back. At 3:15 p.m., the resident remained laying on his back; at 4:30 p.m., the resident continued to lay on his back in the bed. On 10/28/16 at 2:43 p.m., the old dressing was observed to have fresh blood on it and a grayish discharge. The sacrum wound had drained through the dressing dated 10/27/16. There was a foul odor coming from the wound. The wound was observed with dressing material in the middle of it. The wound bed extended into the tissue beneath the skin. Both the wound bed and surrounding tissue was dark red and dark purple. On 10/28/16 at 2:47 p.m., LPN Staff A said the floor nurses did the treatments. On Tuesdays we do wound rounds with the DON and /or ADON (Assistant Director of Nursing) and nurse practitioner. On 10/28/16 at 2:48 p.m., LPN Staff B said the treatment was to cleanse the wound, apply calcium alginate to wound bed, cover with 4 x 4 gauze, abdominal pad, change every 3 days, and as needed if it became soiled or dislodged. On 10/28/16 at 3:00 p.m., the Regional Clinical Services nurse said she had not personally seen the wound. On 10/29/16 at 1:00 p.m., wound care was observed. The dressing was removed by LPN Staff C with a foul odor coming from wound. A moderate amount of serous drainage was on the old bandage. Staff C was asked if any of the supervisors had seen the wound, she replied The DON had seen it on Tuesday (10/25/16). During wound care, the surveyor observed the wound: beefy red and surrounded with dark purple tissue in color and there was a foul odor. On 10/29/16 at 2:15 p.m., the physician said his PA discussed the case with him yesterday. My mid-level saw it. I had not personally seen it. They had a sick patient with an unavoidable pressure wound. A debilitated patient with unavoidable wounds. The facility was following the protocol for the wound. If eschar developed, we would get him out to wound care. My mid-level will be in the building Monday to see the resident. With a pre-[MEDICATION NAME] as low as it was, it would be difficult for the wound to heal. On 10/29/16 at 2:45 p.m., the ADON stated she had not personally seen the wound. She said the DON was the one who made rounds and did the measurements. In an interview on 10/29/16 at 3:11 p.m., the PA said she had not actually seen the wound. The wound appeared last week. The PA explained when she was in again, the resident was not in a state for her to see the wound, he had a fever and was not feeling well and I did not want to turn him. She said the nurses did not tell her the wound was infected. The PA put him on Linezolid (an antibiotic, prescribed for a urinary tract infection), so if it was infected, that would cover it. The PA was planning on seeing the wound this coming week. As of 10/29/16 the physician had not seen the wound. As of 10/29/16 the PA had not seen the wound. As of 10/29/16 the ADON had not seen the wound.

Based on record review and staff interviews, the facility failed to implement their policy to assess the use of a motorized device. The lack of assessment resulted in the facility not providing the supervision needed to prevent injury for 1 (Resident #1) of 5 residents using motorized wheelchairs / scooters. The facility's systemic failure resulted in Resident #1 being injured a fracture to her ankle, in an accident involving her electric wheelchair. Findings include: 1. Review of facility policy #S-332, titled, Motorized Wheel Chairs - Scooters effective 11/30/14 revealed: 1. Assessments for resident operating motorized wheelchairs/scooters will be the responsibility of the Physical or Occupational Therapist, with assistance of the MDS (Minimum Data Set) Coordinator, Social Services Director, and care plan coordinator for the facility. 2. Residents requesting use of a motorized wheelchair/scooter will be assessed for the ability to safely operate the motorized device using the Motorized Wheelchair/Scooter Assessment tool. 2. Record review on 6/8/16 revealed Resident #1 was admitted to the facility 5/10/16. The Minimum Data Set of 5/17/16 includes a history of Guillain-Barre' Syndrome that can cause weakness and abnormal sensations spread to the arms and legs. No documentation of a motorized wheelchair/scooter assessment in the medical record was found for Resident #1. 3. An occurrence report dated 5/24/16 indicated Resident #1 was on the smoking patio and attempted to come inside the building. The report indicated using an electric wheelchair she turned too close to the window and caught her foot. The resident's statement on this report indicated the resident said she was on the smoking patio trying to push the button to open the door and turned too close to the window and the ledge and caught her foot bending it sideways before she could stop the chair. 4. Review of an x-ray report dated 5/24/16 showed Resident #1 sustained a non-displaced fracture to her right distal tibia (the ankle bone). 5. On 6/9/16 at 10:33 a.m., during an interview, the Director of Rehabilitation said no formal therapy evaluation was conducted for Resident #1. 7. On 6/9/16 at 11:06 a.m., the Director of Social Services said she thought therapy was going to assess the resident but did not know if this occurred. 8. On 6/9/16 at 11:19 a.m., the MDS Coordinator said he did not specifically care plan Resident #1's motorized wheelchair as a potential risk because the resident is alert and oriented.

Based on record review and interview the facility failed to assess the functional capacity of 1 (Resident #1) of 5 residents sampled who used motorized wheelchairs/scooters. Resident #1 was not assessed for ability to use a motorized wheelchair and subsequently sustained a fracture of her ankle. The findings included: 1. Review of facility policy #S-332, titled, Motorized Wheel Chairs - Scooters effective 11/30/14 revealed: 1. Assessments for resident operating motorized wheelchairs/scooters will be the responsibility of the Physical or Occupational Therapist, with assistance of the MDS (Minimum Data Set) Coordinator, Social Services Director, and care plan coordinator for the facility. 2. Residents requesting use of a motorized wheelchair/scooter will be assessed for the ability to safely operate the motorized device using the Motorized Wheelchair / Scooter Assessment tool. 3. All motorized wheelchairs/scooters will be inspected by the facility maintenance staff upon initial use by a resident and annually to ensure the unit is in proper operating condition and does not pose any safety concern for the operator, facility and the residents of the facility. In addition the resident must meet the following preliminary criteria before the use of he motorized device will be considered by the facility, a. The resident is unable to operate a manual wheelchair, b. The resident is capable of safely operating the controls of the wheelchair/scooter and c. The resident can be safely transferred in and out of the wheelchair/scooter and has trunk stability to be able to safely operate and ride in the wheelchair/scooter. 2. Record review on 6/8/16 revealed Resident #1 was admitted to the facility 5/10/16. The Minimum Data Set of 5/17/16 includes a history of Guillain-Barre' Syndrome that can cause weakness and abnormal sensations spread to the arms and legs. No documentation of a motorized wheelchair/scooter assessment was found in the medical record for Resident #1. 3. On 6/9/16 at 10:33 a.m., the Director of Rehabilitation said no formal therapy evaluation was conducted for Resident #1. 4. On 6/9/16 at 10:45 a.m., the Regional Director said all other residents had been evaluated for motorized wheelchair safety, but he did not know why this resident was not assessed. 5. On 6/9/16 at 11:06 a.m., the Director of Social Services said she thought therapy was going to assess the resident but did not know if this occurred. She said she thought they were waiting on insurance verification. She said she was not aware of her role in the assessment of the wheelchair safety for residents. She said she told staff in the morning stand up meeting the resident had a motorized wheelchair. 6. On 6/9/16 at 11:19 a.m., the MDS Coordinator said he was unaware he had a role in the assessment for residents in motorized wheelchairs. He said he did not specifically care plan Resident #1's motorized wheelchair as a potential risk because the resident was alert and oriented. He said he thought physical therapy was waiting on insurance verification before working with the resident. 7. An occurrence report dated 5/24/16 indicated Resident #1 was on the smoking patio and attempted to come inside the building. The report indicated using an electric wheelchair she turned too close to the window and caught her foot. The resident's statement on this report indicated the resident said she was on the smoking patio trying to push the button to open the door and turned too close to the window and the ledge and caught her foot bending it sideways before she could stop the chair. 8. Review of an x-ray report dated 5/24/16 showed Resident #1 sustained a nondisplaced fracture to her right distal tibia (the ankle bone).

Based on record review and interview the facility failed to provide assessment according to the standards set by their internal policies to prevent injury for 1 (Resident #1) of 5 residents using motorized wheelchairs / scooters. The facility failed to follow their standard of care to assess for safe use of a motorized wheelchair for Resident #1. The resident subsequently sustained [REDACTED]. Findings included: 1. Review of facility policy #S-332, titled, Motorized Wheel Chairs - Scooters effective 11/30/14 revealed: 1. Assessments for resident operating motorized wheelchairs/scooters will be the responsibility of the Physical or Occupational Therapist, with assistance of the MDS (Minimum Data Set) Coordinator, Social Services Director, and care plan coordinator for the facility. 2. Residents requesting use of a motorized wheelchair/scooter will be assessed for the ability to safely operate the motorized device using the Motorized Wheelchair/Scooter Assessment tool. 2. Record review on 6/8/16 revealed Resident #1 was admitted to the facility 5/10/16. No documentation of a motorized wheelchair/scooter assessment in the medical record was found for Resident #1. 3. On 6/9/16 at 10:33 a.m., during an interview, the Director of Rehabilitation confirmed no formal therapy evaluation was conducted for Resident #1. 4. On 6/9/16 at 11:06 a.m., the Director of Social Services said she thought therapy was going to assess the resident but did not know if this occurred. She said she thought they were waiting on insurance verification. She said she did tell staff in the morning stand up meeting the resident had a motorized wheelchair. She said nursing and therapy attended this meeting. 5. An occurrence report dated 5/24/16 indicated Resident #1 was on the smoking patio and attempted to come inside the building. The report indicated using an electric wheelchair she turned too close to the window and caught her foot. The resident's statement on this report indicated the resident said she was on the smoking patio trying to push the button to open the door and turned too close to the window and the ledge and caught her foot bending it sideways before she could stop the chair. 6. Review of an x-ray report dated 5/24/16 showed Resident #1 sustained a non-displaced fracture to her right distal tibia (the ankle bone).

Based on record review and interview the facility failed to coordinate care and services to prevent injury for 1 (Resident #1) of 5 residents using motorized wheelchairs/scooters. The failure to coordinate care resulted in a lack of assessment and subsequent [MEDICAL CONDITION]'s ankle. Findings included: 1. Review of facility policy #S-332, titled, Motorized Wheel Chairs - Scooters effective 11/30/14 revealed: 1. Assessments for resident operating motorized wheelchairs/scooters will be the responsibility of the Physical or Occupational Therapist, with assistance of the MDS (Minimum Data Set) Coordinator, Social Services Director, and care plan coordinator for the facility. 2. Residents requesting use of a motorized wheelchair/scooter will be assessed for the ability to safely operate the motorized device using the Motorized Wheelchair/Scooter Assessment tool. 2. Record review on 6/8/16 revealed Resident #1 was admitted to the facility 5/10/16. The Minimum Data Set of 5/17/16 includes a history of Guillain-Barre' Syndrome that can cause weakness and abnormal sensations spread to the arms and legs. No documentation of a motorized wheelchair/scooter assessment in the medical record was found for Resident #1. 3. On 6/9/16 at 10:33 a.m., the Director of Rehabilitation said no formal therapy evaluation was conducted for Resident #1. 4. On 6/9/16 at 11:06 a.m., the Director of Social Services said she thought therapy was going to assess the resident but did not know if this occurred. She said she thought they were waiting on insurance verification. She said she was not aware of her role in the assessment of the wheelchair safety for residents. She said she did tell staff in the morning stand up meeting the resident had a motorized wheelchair. She said nursing and therapy also attended this meeting. 5. On 6/9/16 at 11:19 a.m., the MDS Coordinator said he was unaware he had a role in the assessment for residents in motorized wheelchairs. He said he did not specifically care plan Resident #1's motorized wheelchair as a potential risk because the resident is alert and oriented. He said he had observed her in her wheelchair and she was able to back the wheelchair into the care conference room to attend the conference. He said he thought physical therapy was waiting on insurance verification before working with the resident. 6. An occurrence report dated 5/24/16 indicated Resident #1 was on the smoking patio and attempted to come inside the building. The report indicated using an electric wheelchair she turned too close to the window and caught her. The resident's statement on this report indicated the resident said she was on the smoking patio trying to push the button to open the door and turned too close to the window and the ledge and caught her foot bending it sideways before she could stop the chair. 7. Review of an x-ray report dated 5/24/16 showed Resident #1 sustained a non-displaced fracture to her right distal tibia (the ankle).

Based on observation and interview conducted during review of the Quality Assurance (QA) program, the facility failed to identify bedrails utilized in the facility posed an immediate risk for head and neck entrapment of the residents who were using bed rails. This resulted in the QA committee's failure to develop a system-wide process to ensure bedrails were being safely used in the facility. The failure to have a QA program in place contributed to loose fitting side rails on resident beds and bedrails with spaces between the metal bars of the bed rails that were large enough for a resident's head to fit poses imminent risk of entrapment, serious harm, physical impairment or death to all residents using bedrails in the facility. It is unknown how long the hazardous side rails had been in use. The facility put corrective actions in place after the Immediate Jeopardy was identified by the survey team. On 8/26/14 after 5:00 p.m. a meeting was held with the Administrator and Regional Clinical Consultant informing them of the immediate jeopardy. The immediate jeopardy was abated on 8/26/14. Deficient practice continues as the facility has not demonstrated complete assessments, monitoring, auditing, or implementation of their newly developed tool. The facility has not had the input from the Quality Assurance Committee to develop a systematic process to ensure regulatory compliance is maintained. The corrective actions did reduce the scope and severity to E (pattern of no actual harm with potential for more than minimal harm). The findings include: 1. Observation during tour of the facility on 8/25/14 between 9:15 a.m. and 3:30 p.m., verified the bedrails of 19 of the 120 beds in the facility with spaces within the rails or between the bedrail and mattress which created risk for entrapment. During this observation, side rails had 8 in. x 8 ? in. spaces on each side of the rail and a 16 in. x 8 in. space in the middle of the side rails. Several of the side rails were loosely attached to the beds. Observations verified beds with these types of rails were occupied by residents in rooms #232, #233, #26, #72, #76, #83, #176, #111, #234, #235, #73, #147, #133, #120, #59, #164, and #146. 2. In an interview with the Executive Director (ED) and Regional Director of Clinical Services (RDCS) on 8/25/14 at 4:20 p.m., they were not aware of the types of side rails used in the facility. Neither were aware of the potential entrapment risk of the rails. Neither were aware the side rails did not meet the U.S. Department of Health and Human Services Food and Drug Administration's Dimensional Limits to reduce entrapment zones for beds with side rails (document issued on: March 10, 2006). The ED and RDCS said the facility did not have a policy specific to side rail use and the Director of Maintenance is responsible for checking the side rails and is to check there are no gaps more than 4 inches between the mattress and the side rails. 3. During an interview with the ED and Assistant Director of Nurses on 8/29/14 at 10:58 a.m., they confirmed the facility was using 4 different types of side rails in the facility and the quality assessment and assurance committee failed to identify the facility's use of loose fitting side rails that were attached to resident beds as well as rails that were not in accordance with the U.S. FDA's "Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment" issued on March 10, 2006. The ED she said the facility must continue to develop its process for bedrail safety. The maintenance department was given an in-service on 8/26/14 to include using a measuring tape to check for spaces in the side rails. The facility had loosely attached side rails and side rails that did not fall within the parameters listed in the guidance of the U.S. Department of Health and Human Services Food and Drug Administration's Dimensional Limits to reduce entrapment zones for beds with side rails. This failure posed an immediate threat to the health and safety of all residents using bedrails within the facility.

Based on observations, personnel record review and staff interviews, facility leadership failed to ensure bed rails on residents beds were safe and prevented the risk of head and neck entrapment. Facility administration, including the Executive Director, failed to ensure a systematic process was in place to identify safe use of side rails which resulted in inadequate assessments of the bedrails by the Director of Maintenance. This failure contributed to loose-fitting side rails on resident beds and bed rails and with spaces between the metal bars of the bed rails that were large enough for a resident's head to fit through. This situation poses an imminent risk of entrapment, serious harm, physical impairment or death to residents using bedrails in the facility. Immediate Jeopardy with side rail hazards was identified by the survey team on 8/25/14. It is unknown how long the hazardous side rails had been in use. This situation required immediate corrective action on the part of the facility. On 8/26/14 at 5:00 p.m. a meeting was held with the Administrator and Regional Clinical Consultant informing them of the immediate jeopardy. The facility put corrective actions in place after the immediate jeopardy was identified by the survey team. The Immediate Jeopardy was abated on 8/26/14. Deficient practice continues as the facility has not demonstrated complete assessments, monitoring, auditing, or implementation of the newly developed tool. The facility has not had the input from the Quality Assurance Committee to develop a systematic process to ensure regulatory compliance is maintained. The corrective actions did reduce the scope and severity to E (pattern of no actual harm with potential for more than minimal harm). The findings included: Review of the U.S. FDA's "Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment" issued on March 10, 2006 may be found at: : <http://www.fda.gov/downloads/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/ucm 9.pdf> "The guidance provides recommendations intended to reduce life-threatening entrapments ... It characterizes the body parts at risk for entrapment, identifies the locations of (facility) bed openings that are potential entrapment areas, and recommends dimensional criteria for these devices. " 1. Observation during tour of the facility on 8/25/14 between 9:15 a.m. and 3:30 p.m., verified the bed rails of 19 of the 120 beds in the facility with spaces within the rails or between the bed rail and mattress which created risk for entrapment. During this observation, side rails had 8 in. x 8 ? in. spaces on each side of the rail and a 16 in. x 8 in. space in the middle of the side rails. Several of the side rails were loosely attached to the beds. Observations verified the beds with this type rail were occupied by Residents #26, #59, #72, #73, #76, #83, #111, #120, #133, #146, #147, #164, #176, #234, and #235. The bed in room [ROOM NUMBER]A had the same type of bed rail and had recently been occupied by Resident #233. Three beds were observed to have bed rails that were partially detached or loose creating gaps between the mattress and the rail. Resident #235's right bed rail was partially detached and had a 6.5 inch gap between the bed and the rail. Resident #158's right bed rail was loose and leaning away from the mattress, creating a 5 inch gap. Resident #50's left bed rail was loose and leaned away from the mattress, creating a 5 inch gap at the top. 2. On 8/25/14 at 4:20 p.m., a meeting was held with the Executive Director (ED) and Regional Director of Clinical Services (RDCS) informing them of the risk of harm related to the bed side rails being used in the facility. Neither were aware of the potential entrapment risk of the rails. Neither were aware the side rails did not meet the U.S. Department of Health and Human Services Food and Drug Administration's Dimensional Limits to reduce entrapment zone for bed with side rails (Document issued on: March 10, 2006). The ED and RDCS said the facility did not have a policy specific to side rail use. They said the Director of Maintenance (DoM) is responsible for checking the side rails and is to check there are no gaps more than 4 inches between the mattress and the side rails. 3. During an interview on 8/26/14 at 10:39 a.m. with the ED, DoM and RDCS, the DoM stated, "I do a unit a week for bed side rail check going from room to room. We do not measure the gaps in the rails, do not measure the gaps between the mattress and the rail it is eyeballed; a tape measure is not used." 4. A review of the job description for " Executive Director I " showed signature by the ED, a hire date of 8/15/14, and included the following: Purpose of Job Position: The primary purpose of the Executive Director is to direct the day-to-day functions of the facility in accordance with federal, state, and local standards, guidelines, and regulations that govern nursing facilities to ensure the highest degree of quality care can be provided to our residents at all times. Job Functions (include, but are not limited to): Supervise Director of Clinical Services ...Director of Resident and Family Services ...Director of Environmental Services ...You will also provide leadership to all facility staff in meeting the goal of providing quality resident care. Duties and Responsibilities: Schedule regular meeting with direct report staff to provide supervision, ensure communication and to monitor facility operations ...Ensure a safe, clean and comfortable environment for residents, visitors and staff ...Maintain a file for and monitor incident reports. 5. During the meeting on 8/26/14 at 10:30 a.m., the RDCS stated, "We went to look at the rooms identified, approximately 18-20 sets (of bed rails). We did new assessments to determine if they (residents) needed them. If they needed or wanted rails they were provided with different rails. There are 4 different rails in the house. We are trying to make sure all of the rails will be the same. We think we took the risk out of those identified. (We are) going to one type of rail. Did education to staff CNAs (certified nursing assistants), nursing and maintenance and report any issues. Spoke to corporate to see if this can be streamlined so purchase can be made." 6. During an interview on 8/26/14 at 12:08 a.m., the Executive Director said the facility must continue to develop its process for bedrail safety. The maintenance department was given an in-service on 8/26/14 to include using a measuring tape to check for gaps. The facility also provided the team with a four-point plan for side rail/mattress/bed checks as well as one for raising and lowering of beds. The Immediate Jeopardy was abated on 8/26/14. The facility has not demonstrated complete assessments, monitoring, auditing or implementation of the newly developed tool. The facility has not had the input from the Quality Assurance Committee to develop a systematic process to ensure regulatory compliance is maintained.

Based on observations, record reviews and interviews, the facility failed to ensure bed rails were properly secured to resident beds and failed to ensure the vertical bars of the bed rails were mechanically structured to prevent the risk of head and neck entrapment for 19 (Residents #26, #50, #59, #72, #73, #76, #83, #111, #120, #133, #146, #147, #158, #164, #176, #232, #233, #234, and #235) of 48 sampled residents of the 120 bed facility. In addition, the facility failed to assess the continued use of bed rails as an entrapment risk for a resident (Resident #164) dependent on staff for bed mobility and transfers, with a known history of falls and falling from the bed. The facility failed to ensure an electrical outlet was covered to prevent possible electric shock in room 332 B. The facility failed to develop, implement and maintain a policy and procedure for bed rail assessments to evaluate the use of bedrails and the potential risk of entrapment if used by residents. The identified side rails were able to move providing a gap between the side rail and the bed or mattress. The identified side rails had enough room for a resident to engage their head between or inside the rails. Both conditions, coupled with the neglect of having a facility-wide system in place, posed an immediate jeopardy for entrapment with a substantial probability that serious physical harm, impairment, or death to the residents to occur. On 8/26/14 after 5:00 p.m. a meeting was held with the Administrator and Regional Clinical Consultant informing them of the immediate jeopardy. It is unknown how long the hazardous side rails had been in use. The facility put corrective actions in place after the immediate jeopardy was identified by the survey team. The immediate jeopardy was abated on 8/26/14. Deficient practice continues as the facility has not demonstrated complete assessments, monitoring, auditing, or implementation of their newly developed tool. The facility has not had the input from the Quality Assurance Committee to develop a systematic process to ensure regulatory compliance is maintained. The corrective actions did reduce the scope and severity to E (pattern of no actual harm with potential for more than minimal harm). The findings included: 1. Review of the U.S. Food and Drug Administration (FDA) Safety Alert dated 8/23/1995 may be found at http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/PublicHealthNotifications/UCM 4?sms_ss=email This alert documented discussion of hazards related to bed side rails. The Alert noted that "reported entrapments occurred in one of the following ways: 1. through the bars of an individual side rail; 2. through the space between split side rails; 3. between the side rail and the mattress; or between the headboard or footboard, side rail, and mattress." It continued that "all deaths involved entrapment of the head, neck or thorax..." 2. On 8/25/14 between 9:15 a.m. and 3:30 p.m., observation verified 19 of the 120 beds in the facility had bed rails with spaces within the rail or gaps between the bed rail and mattress (photographic evidence in the file). The spaces and gaps created entrapment areas which had the potential to cause injury to residents. 3. Sixteen of the beds had spaces between the metal bars of the bed rails that were large enough for a resident's head to fit through. The space between the metal bars on the ends of the rail measured 8 inch by 8 inch, and the space in the middle section of the rail measured 16 inch by 8 inch. The beds with this type rail were occupied by Residents #26, #59, #72, #73, #76, #83, #111, #120, #133, #146, #147, #164, #176, #232, #234, and #235. The bed in room 207A had the same type of bed rail and had recently been occupied by Resident #233. 4. Three beds were observed to have bedrails that were partially detached or loose creating gaps between the mattress and the rail. Resident #50's left bed rail was loose and leaned away from the mattress, creating a 5 inch gap at the top. Resident #158's right bed rail was loose and leaning away from the mattress, creating a 5 inch gap. Resident #235's right bed rail was partially detached and had a 6.5 inch gap between the bed and the rail. 5. The Food and Drug Administration (FDA) "Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment" issued on March 10, 2006 can be found at <http://www.fda.gov/downloads/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/ucm 9.pdf> Page 15 noted the majority of the reported bed rail entrapments have occurred in Zone 1-4. Zone 1 is any open space within the perimeter of the rail. Openings in the rail should be small enough to prevent the head from entering and the recommended space be less than 4 3/4 inches, representing head breadth. A loosened bar or rail can change the size of the space. Pages 18 and 19 of this guidance notes Zone 3 (between the rail and the mattress) ... " is the space between the inside surface of the rail and the mattress compressed by the weight of a patient's head. The space should be small enough to prevent head entrapment when taking into account the mattress compressibility, any lateral shift of the mattress or rail, and degree of play from loosened rails. "HBSW (Hospital Bed Safety Workgroup) and IEC (International Electrotechnical Commission) recommend a dimension of less than 120 mm (4 ? inches) because the head is presumed to enter the space before the neck. FDA is recommending a dimensional limit of less than 120 mm (4 ? inches) for the area between the inside surface of the rail and the compressed mattress. Although seven potential zones of entrapment have been identified by HBSW, FDA is recommending dimensional limits for zones 1-4 because these zones were most frequently reported as having entrapments." The bedrails in the facility were verified to fall under Zone 1 and 4. 6. In an interview on 8/26/14 at 10:39 p.m., the Executive Director (ED) said the Director of Maintenance is responsible for evaluating bed safety, but there was no policy or procedure for how he was to do this. She confirmed there was also no policy in regards to a bed rail assessment that would evaluate if the use of the device was a possible hazard for a resident. The ED provided information confirming 12 of the 19 residents (identified by surveyors as having bed rails with potential entrapment zones) had cognitive impairment, and 15 of the 19 residents required some assistance with bed mobility. During an interview on 8/26/14 at 10:45 a.m., the Director of Maintenance acknowledged he was responsible for bed and bed rail safety. He stated he checks the beds monthly to be sure there is no gap greater than 4-3/4 inches between the mattress and the headboard, footboard, or bed rail. The Director of Maintenance stated he only views the bed for gaps and did not use a measuring tape. He stated he does not measure the spaces within the perimeter of the bed rails. 7. Observation of Resident #164's bed on 8/25/14 at 9:10 a.m. showed the bed equipped with bed rails that had potential entrapment zones. The resident was in bed with both half side rails up. The bed rails had spaces between the metal bars that measured 8 inch by 8 inch on each end and had a 16 inch by 8 inch space in the middle section of the rail. The spacing between the rails was large enough for the resident's head to fit through. A Minimum Data Set assessment, dated 7/15/14, noted Resident #164 had severely impaired cognitive skills and was dependent on staff for bed mobility and transfers. The resident's clinical record revealed a physician's orders [REDACTED]. Nurse's notes documented Resident #164 had a fall from the bed on 1/7/14 and 1/20/14 with no apparent injuries. On 3/23/14, the resident slid to the floor from his wheelchair with no apparent injury. A nursing entry dated 7/31/14 at 3:30 a.m., noted Licensed Practical Nurse (LPN) Staff K, was called to Resident #164's room by the Certified Nursing Assistant (CNA), and Resident #164 was observed on the floor "hanging from bed." Staff K noted the resident did not have any injuries from the fall. In a phone interview on 8/29/14 at 9:36 a.m., Staff K said when she was called to the resident's room by the CNA, she observed the resident hanging from the left side of the bed, holding onto the side rail with his hands. She stated the resident's head was on the mattress and his bottom and legs were on the floor. Staff K stated the resident was also kicking the roommate's bedside table with his feet. She stated the resident was not injured and that both side rails were in the raised position. During an interview on 8/29/14 at 10:40 a.m., CNA Staff L stated she observed Resident #164 on the floor the night of 7/31/14 and immediately went to get the nurse. Staff L stated the resident is "always trying to get out of bed" and the nurse instructs her to monitor him closely because of that. Staff L stated the side rails are always up. On 8/29/14 at 11:00 a.m., during an interview with the Regional Director of Clinical Services (RDCS), he was informed there was no documented assessment to determine if the bed rails posed a risk to Resident #164 before or after the resident fell out of bed on 7/31/14. The RDCS stated he was going to be looking at the side rail assessment form and process, and would probably be making some changes. On 8/29/14 at 2:15 p.m., the RDCS confirmed there was no evidence of an assessment after the resident's fall on 7/31/14 to determine if continued use of the side rails was safe. 8. Observation on 8/25/14 at 11:43 a.m. of Room 332 B showed the electrical outlet uncovered and with a hole around it (photographic evidence in the file). A 1/2 inch gap at top of air conditioning unit was also observed. In an interview at the time of the observation, the resident stated the electric outlet has been like that since he arrived 2 months ago. He said the exterminator was here the other day to spray for sugar ants and he informed the maintenance man that he needed to close it up or he would continue to have problems with the ants. 9. During an interview on 8/26/14 at 12:08 a.m., the Executive Director said the facility must continue to develop its process for bedrail safety. The maintenance department was given an in-service on 8/26/14 to include using a measuring tape to check for gaps. The facility also provided the team with a four-point plan for side rail/mattress/bed checks as well as one for raising and lowering of beds. The Immediate Jeopardy was abated on 8/26/14. The facility has not demonstrated complete assessments, monitoring, auditing or implementation of the newly developed tool. The facility has not had the input from the Quality Assurance Committee to develop a systematic process to ensure regulatory compliance is maintained.

Based on record review, observation, interviews and review of facility policies and procedures, the facility failed to ensure 2 (Residents #16 and #51) of 3 residents reviewed for pain management were adequately assessed, reassessed and received timely interventions to manage their signs and symptoms of pain and/or distress. Nursing failed to follow accepted standards of clinical practice as it relates to administering medications through a Gastrostomy tube for Resident #16. This failure contributed to the resident's prolonged distress, pain and discomfort and inability to tolerate the tube feeding procedure. Direct care staff failed to acknowledge visible signs and symptoms of pain expressed by the resident during morning care. Staff failed to develop a comprehensive plan of care and implement interventions to prevent the resident from pulling out her tube and was subsequently transferred to the hospital for a reinsertion of the Gastrostomy tube. The facility failed to medicate Resident #51 for pain after he notified staff of complaints of pain. The findings include: 1. Clinical record review on 8/21/2013 documents Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The clinical record dated and signed by the physician on 5/21/2005 documents the resident is incapable of making an informed decision and consent about providing, withholding or withdrawing medical treatment. An attestation by the physician the resident is terminally ill or has an end-stage condition of [MEDICAL CONDITION] is dated for 9/11/2009. An "enteral feeding necessity physician's progress note" is in the clinical record for the date of 5/20/2013 related to a [DIAGNOSES REDACTED]. Documentation in the clinical record reveals Resident #16 was admitted to Hospice Services on 8/25/2006 for an end stage [DIAGNOSES REDACTED]. Review of the August 2013 physician's orders [REDACTED]. PEG TUBE: Check for residual and notify physician if more than 60 cubic centimeters (cc); water flushes 50 cc before and after [MEDICATION NAME] feed (feed); flush with 50 milliliter (ml) of water before and after medications; flush with 250 ml water four times daily, change as needed (prn) if dislodged or occluded. Review of the nursing progress notes dated 5/10/2013 at 11:00 p.m. documents the "...resident pulled the peg tube out at approximately 4:00 p.m. The Advanced Registered Nurse Practitioner (ARNP) was notified and ordered to re-insert a new peg and change prn if dislodged or occluded. [MEDICATION NAME] give at 7:00 p.m. for pain. PEG feedings tolerated well, tube is patent, easy to flush bowel sounds present x 4 quads, lungs are clear bilaterally." Nurses notes dated 6/02/2013 and not timed, documents, "...3-11 shift- resident pulled out PEG tube, MD notified through answering service." Nursing notes on 6/03/2013 document, "...nurse reactionary called back and was notified. New order received to follow up with Gastrointestinal (GI) doctor in the am. and hold [MEDICATION NAME] feeding and medication until the PEG tube was replaced." The resident was transferred to the hospital for peg tube reinsertion. Review of the most recent comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/05/2013 documents Resident #16 with a Brief Interview for Mental Status (BIMS) of "99" - Resident unable to complete the interview. Resident #16 is with unclear speech; sometimes is understood; (ability is limited to making concrete requests; usually understands-misses some part/intent of message but comprehends most conversation). The resident has short and long term memory problems and is moderately impaired in decision making; decisions poor; cues/supervision requires. Resident has difficulty focusing attention (easily distracted, out of touch or difficulty following what was said and fluctuates, comes and goes, changes in severity. The assessment documents the resident as feeling down, depressed or hopeless; feeling tired or having little energy, trouble concentrating on things, moving or speaking so slowly that other people have noticed; or the opposite-being so fidgety or restless that she has been moving around a lot more than usual. Resident #16 is totally dependent on 1-2 staff for Activities of Daily Living (ADLs). The resident is noted to have impairment on both sides of her upper and lower extremities. The resident was documented as receiving scheduled pain medication as well as "prn" pain medication and during this assessment period, she indicated she did not have any pain or was hurting at any time in the last 5 days. The nutritional assessment reveals a height of 60 inches and 103 lbs. The resident requires a feeding tube (abdominal PEG) and mechanically altered diet; receives 51% or more of her total calories through the tube feeding and 501 cubic centimeters (cc)/day or more for average fluid intake per day by tube feeding. Observation of Resident #16 on 8/21/2013 at 8:44 a.m. reveals the resident in her room, positioned on her left buttock while seated in a geri chair. The resident is none communicative; however, will look at the speaker when name is called. A sign above her bed entitled "please don't water the flowers" is observed posted on the wall above her bed. During this observation, Resident #16's face became red, her eyebrows furrowed and she grunted. Her eyes began to water and she was observed rolling her tongue and putting her hand up to her cheek while profusely grimacing. During an interview on 8/21/2013 at 8:48 a.m., Staff X, an LPN, confirmed Resident #16 was in pain and she was going to medicate her prior to administering her medications through her tube. She stated the resident is able to tell you when she's in pain when she does what "you just saw" and she will also make grunting noises. She stated the "girl from medical records also told me she is making sounds and that's another way we know she's in pain". The nurse stated, "She will also tell you though some times. I know (Resident #16) for a long long time". Review of the August 2013 physician's orders [REDACTED].. (10 milligrams (mg)) by mouth (po) every 1 hour as needed (prn) for pain. Review of the August Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"jaw pain" at a pain intensity of an "8" and documents she "positioned" the resident as a non-med intervention; there was no reassessment of the intensity of the pain after medicating the resident. The area on the MAR indicated [REDACTED]. Observation on 8/21/2013 at 9:20 a.m. revealed Staff nurse X preparing to administer medications through the Gastrostomy tube of Resident #16. The nurse crushed and placed [MEDICATION NAME] 50 mg., [MEDICATION NAME] 20 mg., [MEDICATION NAME] CL ER 5 mg. into individual pill cups, and then poured [MEDICATION NAME] 15 cc and Prostat AWC sugar free supplement 15 cc into individual pill cups. She marked each of the medications with a black marker and indicated she did this to know what medications she was administering. Observation revealed "Do Not Crush" on the label of [MEDICATION NAME]. The nurse then placed a paper towel on top of the narcotic binder, placed each of the pill cups on top of the paper towel and carried the medications into the resident's room. While holding the binder and medications in one hand, she entered the bathroom, filled two plastic cups of water and placed all of the items on top of a paper towel resting on the resident's bedside table. After washing her hands, the nurse walked back over to the resident who was seated in a geri chair. The resident's legs were contracted up and her torso was partially twisted to the left and she was resting on her left buttock. The nurse removed the Gastrostomy tube from under the resident's shirt and after removing her stethoscope from around her neck, inserted a syringe into the Gastrostomy tube and inserted 30 cc of air through the tube. She did not check for residual fluids. The nurse then placed 5 cc of water into each pill cup, and measured 50 cc of water into 2 cups. She donned a pair of gloves, inserted the syringe back into the tube and poured 50 cc of water into the syringe. Stomach contents were observed coming up through the syringe and then the fluid drained down through the tube. At 9:40 a.m. the nurse checked for residual and after no residual was observed, she removed the syringe, then reinserted the syringe and poured the [MEDICATION NAME] mixture into the tube. She then poured 40 cc's of water into the syringe, poured the [MEDICATION NAME] mixture into the syringe, it began to drain slowly and then an additional 50 cc of water. The resident's face turned red, her eyebrows furled and her face was grimacing. The nurse failed to stop and acknowledge the resident's facial grimacing. Clumps of white medication were observed swirling around in the syringe as the mixture failed to drain down into the tube. The nurse "milked" the tubing several times and shook the syringe. Because the medication mixture failed to drain, she poured the mixture back into a plastic cup, swirled the mixture around in the cup and poured this same mixture of clumped medication back into the syringe. The nurse continued to vigorously squeeze the Gastrostomy tube and clumps of white medication were observed clinging to the inside of the syringe. She then removed the syringe and poured the medication mixture into a plastic cup and using the pressure of the syringe, plunged the mixture back and forth, in and out of the syringe and into the cup. The mixture could be observed splashing out of cup. She reinserted the syringe and poured the medication mixture back into the syringe leaving clumps of medication on the sides of the plastic cup. Residents #16 was observed with facial grimacing, her face was red, and she pressed her head tightly against the top of the chair, bringing her hand up to her jaw and moving her head side to side as she pressed it against the top of the chair. The nurse failed to stop the procedure and assess Residents #16 for signs and symptoms of pain, distress, discomfort or inability to tolerate the procedure. She then poured 30 cc of the Prostat into the medication mixture, "milked" the tubing and due to the failure of the contents to drain through the tube, she again poured this mixture back into a plastic cup. She removed her gloves, went into the bathroom and indicated she was pouring "warm, not hot" water into a plastic cup. The nurse stated, "when she (Resident) gets tense, it's harder to get in". The nurse did not stop the procedure and assess Residents #16's signs and symptoms of discomfort and inability to tolerate the procedure, she walked over to the resident, inserted the syringe into the tube, and poured 40 cc of the "warm" water into the syringe. She then pulled back 40 cc's of pink curdled solution mixed with water and air bubbles and withdrew the syringe. She did not continue to pull back on the syringe to determine if anymore residual could be obtained. The nurse was unable to administer the Prostat, [MEDICATION NAME] or [MEDICATION NAME]. Remnants of [MEDICATION NAME] was observed in the cup on the bedside table. Residents #16 showed visible signs of discomfort and distress as well as inability to tolerate the procedure for approximately 20 minutes. At 9:47 a.m., and due to the inability to administer the medications, the nurse walked over to the bathroom sink and the surveyor verified she poured the [MEDICATION NAME], Prostat and [MEDICATION NAME] into the sink drain. The nurse was asked how she knows when Residents #16 is in pain and stated the resident will tense up and show facial grimacing. She stated she pre-medicated the resident for the same symptoms prior to tube feeding and "did you see when I started she wasn't making that face? She stated Residents #16 tenses up, her face grimaces and her jaw starts to hurt her when she is in pain. She stated, "See how she is now that I stopped?" The resident did not exhibit facial grimacing or wincing. The nurse walked over to the resident and asked Residents #16 if she was in pain and the resident then shook her head no. The nurse stated she was going to tell the Advanced Registered Nurse Practitioner (ARNP) she could not administer all of the medications through the tube. At 10:23 a.m., the nurse carried a solution of [MEDICATION NAME] sulfate on top of a plastic spoon into Residents #16's room. She asked the resident if she was in any pain and the resident shook her head "no". She asked the resident a second time and the resident shook her head, "no". At 10:24 a.m., Staff nurse X walked into Residents #16's room and inserted the syringe into the resident's Gastrostomy tube. She pulled back on the syringe and 5 cc of curdled brownish pink residue was observed. The nurse reinserted the material back through the tube and removed the syringe. At 10:26 a.m., the ARNP entered the resident's room and assessed the resident. After assessing the resident, the ARNP stated, "She does get a lot of muscle contractions" and exited the room. She informed staff nurse "X" she could continue with medication pass. However, staff nurse "X" failed to inform the ARNP of the resident's signs and symptoms of distress during the tube feeding procedure and failed to inform her of the consistency, amount and type of residual that she had pulled back through the tube. At 10:41 a.m., staff nurse "X" was observed crushing [MEDICATION NAME] 5 mg and [MEDICATION NAME] 20 mg and placing into individual pill cups. She poured 20 cc of [MEDICATION NAME] and 30 cc of Prostat into pill cups. She locked her cart and was about to proceed into the resident's room to administer the medications. She did not realize she had already administered the [MEDICATION NAME]. The surveyor stopped the nurse and reconciled the medication she had already administered and she stated she thought it was the [MEDICATION NAME]. The nurse was going to administer the [MEDICATION NAME] until surveyor intervention. She then discarded the [MEDICATION NAME], crushed [MEDICATION NAME] 50 mg., crushed [MEDICATION NAME] 5 mg, and poured 30 cc of Prostat and 15 cc of [MEDICATION NAME] mg. into pill cups. She gathered all of the medications, including the 20 cc of [MEDICATION NAME] and carried them into Resident #16's room, placing them on the bedside table. She filled plastic cups with water. She stated she was administering 50 cc of water before and after each medication. The nurse turned to the resident and stated, "I hope you will not be in any pain". The resident did not display any facial grimacing or twitching. The nurse stated, "She's usually in bed which makes a big difference...now she's in the chair in this position". Without repositioning Resident #16, she inserted the syringe and injected 30 cc of air into the tube and pulled back approximately 20 cc of brown liquid. She removed the syringe, then reinserted the syringe and poured 50 cc of water, into the tube. She "milked" the tubing, then poured the [MEDICATION NAME] into the syringe, paused, then an additional 50 cc of water, paused, then the [MEDICATION NAME], paused, then 50 cc of water, then [MEDICATION NAME], then 50 cc water, and then, the [MEDICATION NAME]. The [MEDICATION NAME] mixture did not flow through the tube. It failed to dissolve and "clumped" inside of the tube. Because it did not flow down into the tube, she poured it back into a pill cup and mixed it with 5 cc of water, tried to dissolve it, inserted into the syringe. It remained undissolved and she tried a second time by mixing the medication with an additional 5 cc of water and inserted it back into the syringe. She then added 50 cc of water and then the Prostat and stated, "I think I should've waited longer after giving her that [MEDICATION NAME] 'cuz now you can see she's better". The Prostat and [MEDICATION NAME] mixture failed to adequately drain through the tube and she added an additional 20 cc of water as the fluid "thickened" inside of the syringe. She began milking the tubing, shook the syringe back and forth and due to the failure of the medications to flow freely through the tube, poured the Prostat/medication mixture out of syringe and into a plastic cup. She poured 10 cc of water back into the syringe and Resident #16's face turned red, her brows furled and she grimaced. The nurse failed to assess the resident's grimacing. She pulled back on the syringe and withdrew brown solution into the syringe. The resident moaned. The nurse failed to acknowledge the resident's moaning. She then poured 10 cc of the Prostat/medication mixture back into the syringe without any regard to the resident's moan and then 50 cc of water. After the water drained through the tube, she withdrew the syringe and stated, "Next time I need to make sure she's not in any pain." During an interview with the Director of Nurses (DON) on 8/21/2013 following this observation, she stated she was new to the facility and had already identified Staff Nurse X required re-education and in-servicing related to medication pass. She stated the intent of the physician's orders [REDACTED]." medication given. She stated she was going to discuss this concern with the administrator and suspend the nurse pending investigation. She stated she would have expected the nurse to stop the tube feeding procedure if the resident exhibited s/s of pain or discomfort. During an interview on 8/21/2013 at 12:30 p.m., the Registered Dietitian (RD) confirmed the nurses are to flush the Gastrostomy tube with 50 cc of water before the start of medications through the Gastrostomy tube and after the last medication has been given; "not" before and "after" each of the medications. She stated she would immediately start in-servicing the nurses on proper procedures to be followed during tube feeding. During an interview on 8/21/2013 at 1:00 p.m., the 3 p.m.-11 p.m. shift supervisor stated "The resident is able to tell you when she's in pain or not. She will also show facial grimacing and make sounds when she is in pain." She stated she "felt pretty confident that the resident will tell or show you when she's in pain. She stated the "resident used to eat in the past but now she isn't (eating) and will refuse to eat her pleasure foods as well and will not drink. Total nutrition and hydration come from her tube feeding." During an interview on 8/21/2013 at 1:37 p.m., the primary Certified Nursing Assistant (CNA) Staff "M" stated Resident #16 is able to indicate to you when she is in pain due to her facial grimacing and "sometimes she will actually tell you that she is in pain". She stated her "face will also change color as well, that it will get red. If she is not in pain, she will tell you no in a whisper or shake her head no that she is not in pain." She stated she has tried to offer her thickened liquids; she will not drink them. During an interview on 8/22/2013 at 8:27 a.m., the Health Care Surrogate (HCS) who is Resident #16's daughter, stated she was not informed of the nurse experiencing difficulty getting medications through the tube yesterday. She stated that her mother has pulled out her tube twice in the recent past because she will "fidget" and has asked the facility to make sure she has something in her hand or the tube is covered to prevent her from "fooling around" with it. She was not aware the facility was not providing items to place in Resident #16's hands. She stated Hospice is involved with her mother and that they are also managing her pain; "at least that's what they have told me". She was not sure how her mother reacted to pain. She stated, "I have never seen them tube feed my mother in the chair, it's always in the bed." During an interview on 8/22/2013 at 10:30 a.m., the DON stated she was not aware the facility had been informed by the daughter to ensure "something" is in her mother's hands as she fidgets and tends to pull on her tube. During an interview on 8/22/2013 at 11:16 a.m., the Hospice Case Manager, who is an RN (Registered Nurse), stated the resident has terrible [DIAGNOSES REDACTED] related to MS and is declining. When asked how Resident #16 is assessed for pain, she stated the resident "...can't always report verbally, has generalize muscle spasms, her face gets all contorted, she cries out. She will guard. Sometimes she can appropriately tell you, sometimes she will be showing all signs of pain and she will verbally say no but she will be in pain because it's obvious; she will be crying and yelling out, she will grimace or pat her jaw." The observation of Resident #16 during tube feeding was described to the Hospice nurse and she indicated in knowing this resident, the nurse should have stopped what she is doing. She stated,"When the resident started exhibiting the symptoms, whatever they might have been, anxiety, pain or distress, the nurse should have stopped at that point." Review of the July and August 2013 Medication Administration Records (MARs) documenting Resident #16's pain intensity averages between 8-10 (0-no hurt, 10-hurts worst). The nurses used the resident's "facial expressions"; "non-verbal sounds"; "restlessness" and "vocal complaints of pain" to assess the intensity. Review reveals the same non-medicinal interventions used for 2 months (positioning, support) prior to administering pain medication. There were no other alternative interventions documented prior to the use of the pain medication. Review of the care plans developed include the following: 1. 3/21/2013-At risk for aspiration r/t thickened liquids, enteral feeding, chewing and swallowing problems; resident will not exhibit s/s of aspiration, elevate HOB (head of bed) "BLANK" degrees; upright at 90 degrees during/after meals, alternate sips and bites; observe for s/s of aspiration, frequent oral care, verbal cues to swallow and/or chin tuck as appropriate. 2. 6/04/2013-Nutritional Risk related to therapeutic diet, mech (mechanically) altered diet, variable po (by mouth) intake, enteral nutrition, dysphagia/dementia/HTN (hypertension); resident will maintain acceptable nutritional parameters as evidenced by labs improved; no significant weight loss; anticipate wt. fluctuations r/t var (variable) po; no s/s (signs/symptoms) of choking or aspiration related to NTL (nectar thickened liquids). 3. 6/08/2013-Enteral tube feeding related to: Dysphagia; will be free of signs/symptoms of aspiration; will be free of signs/symptoms of dehydration; check placement and residual prior to use of tube as ordered; monitor ostomy site for complications; medications and flush via Tube as ordered. 4. 6/08/2013-Comfort care measures/t end stage disease process, MS, resident has a Do Not Resuscitate (DNR) order, resident is under hospice care; goal-resident comfort needs will be anticipated/met by staff, hospice thru next review; interventions include- observe for pain s/s; provide pain relief measures; medicate as ordered; reposition to provide comfort. 5. 6/08/2013-Resident needs emotional,physical and spiritual support during the terminal phase of illness, Terminal/End stage Diagnosis (DX): MS; goal-resident will receive emotional physical and spiritual support during this terminal phase of illness; interventions include-observe for other s/s of distress (i.e. SOB, N/V, increased anxiety and restlessness) medicate as ordered and monitor effectiveness. 6. 6/08/2013-PAIN: Risk for unmanaged pain secondary to neuralgia, MS-acute, breakthrough, neuropathic or [MEDICAL CONDITION], persistent pain or chronic pain, episodic, intermittent; goal-left BLANK, complete pain flow record; review pain flow record; medications as ordered by physician; notify physician regarding new onset of pain; ineffective pain relief; attempt nonpharmacologic interventions; determine resident's normal responses regarding pain; monitor effectiveness of medication/nonpharmacologic interventions; pain management specialist/clinic. Review of all of the care plans provided by the facility failed to address the health care surrogate's concerns related to her mother's "fidgeting" and need to have something in her hands to prevent the resident from pulling out her Gastrostomy tube. The facility failed to develop a specific plan of care to address the known signs and symptoms of pain the residents exhibits (i.e. facial grimacing, grunting, verbal complaints) with a specific goal to effectively manage the resident's pain. During an interview on 8/22/2013 at 10:02 a.m., the ARNP stated she "went home last night and did research" as she thinks the residents symptoms are "MS related and about 10% of MS patient are tonic spasms. They can happen spontaneously, through visual stimuli or movement." She stated she feels Resident #16 is "having more spasms and does not see them every time she rounds on her; that she has had 3 spasms yesterday and from a nursing judgement standpoint, "we have all been taught the non verbal signs of pain. I don't' think they are in error for medicating for pain." "What I have to wonder is if she is accurate about pain anymore or if she's having these spells...they appear painful to me..." and that she has "to monitor in the future with her". She stated, "I do not think the nurses are in error for medicating her for pain and that these muscles spasms are painful." She stated, "I do think what happened yesterday with the tube feeding was her having the episode of spasm. I think it was spontaneous and that it may have been triggered by the movement. I do not think the extra fluid caused the pain. Our stomach can handle 4 liters." She confirmed Staff Nurse X failed to inform her of the inability to administer all of the medications through the tube on 8/21/2013 as well as failed to inform her of Resident #16's signs and symptoms during the procedure. Review of the facility's policies and procedures for enteral feedings includes the following: Policy "statement"-It is the policy of Consulate Health Care that the resident can expect medication to be administered properly via an enteral tube. Procedure-"...(medication) Consistency of solution should be able to pass easily through a tube...NOTE: If medication cannot be crushed and is unavailable in liquid form, notify the physician...place disposable underpad or towel around area of tube to limit spillage...To confirm proper placement attach syringe to end of tube and place stethoscope over left upper quadrant of the resident's abdomen. Instill approximately 20 cc of air using the syringe while listening or a "swooshing" sound in the stomach...AND/OR...aspirate by gently pulling back on plunger of syringe to check for stomach contents. Note: replace contents by gently pushing plunger...pour at least 15 cc of clear liquid into the syringe and allow to drain into tube prior to medication administration...Pour one, individual liquefied medication in the syringe, and allow gravity to drain medication into the stomach. Followed by at least 15 cc (or physician order [REDACTED].e. physician notified, medication held, resident unable to tolerate, etc.) Staff nurse X failed to ensure Resident #16 was properly positioned during the tube feeding procedure. She failed to ensure the consistency of all of the medications were able to pass easily through the tube. She failed to ensure all medications were "crushable" and failed to notify the physician the "[MEDICATION NAME]" was not able to be crushed and failed to request whether the medication was available in liquid form. She failed to remember which cardiac medication she had administered until surveyor intervention. She failed to follow the facility policy as it relates to inserting "20" cc of air as she inserted "30" cc of air into the tube. She failed to follow physician's orders [REDACTED]. There is no indication in the facility's policies and procedures or physician's orders [REDACTED]. The nurse failed to stop the tube feeding procedure and acknowledge the resident's facial grimacing and moaning as potential indicators of distress, discomfort or inability to tolerate the procedure. She failed to report a detailed assessment of the occluded tube to the physician and/or ARNP as well as the resident's signs and symptoms of pain and discomfort and inability to tolerate the tube feeding procedure. Observation on 8/23/2013 at 7:35 a.m. revealed Staff Y, who is a Certified Nursing Assistant (CNA), in the room with Resident #16. The resident was in bed in a 45 degree position. Staff Y stated she "just finished bathing the resident". Bathing supplies were observed at the bedside. The resident was observed with a furled brow, moving her head side to side, grunting and patting her stomach. The aide was unaware of the resident's s/s of discomfort. The aide continued to arrange the sheet under the bed, empty the water basins and gather trash out of the area. The resident continued to writhe in the bed, moving her head from side to side, grunt and pat her stomach and then jaw. At 7:40 a.m. the surveyor asked the resident if she was in any pain. The resident shook her head up and down, patted her stomach and grunted and mouthed "yes". The surveyor asked the resident if her stomach hurt her. The resident's face became red, she grunted and with furled brows, shook her head "yes". Staff X, who was at the bedside, did not acknowledge Resident #16's signs and symptoms (s/s) of pain and continued to position the resident in bed, place pads between the resident's knees and while grabbing the sheets to cover the resident, the surveyor informed the aide that the resident's face was red, that she was moving her head side to side, grunting and patting her stomach. The aide ignored the surveyor and proceeded to grab the covers at the end of the resident's bed and cover the resident. The aide was asked if she should tell her nurse that the resident is in pain. The aide stated, "I finish what I am doing first". The aide continued to cover the resident, adjust the bed controls, put away the bathing materials, empty trash and left the room at 7:45 a.m. The resident was observed with increased grunting and head moving side to side while in bed. The aide came back into the room and again adjusted the bed controls. At 7:46 a.m., as the surveyor was about to exit the side of Resident #16's bed, a nurse came into the room and the surveyor informed her of the observed signs and symptoms (s/s) of Resident #16 being in pain. Resident #16's eyes were reddened, her head was moving back and forth and the nurse asked the resident if she was in pain. The resident shook her head yes and patted her stomach. The nurse asked if the resident's stomach was hurting her and the resident shook her head yes. The nurse apologized for Staff X's failure to act upon the s/s Resident #16 was exhibiting and medicated Resident #16 for pain. 2. During an interview on 8/20/13 at 9:57 a.m., Resident #51 answered "yes" to the question:" Do you have any discomfort now or have you been having discomfort such as pain, heaviness, burning, or hurting with no relief?" Resident # 51 stated stated stated he has a wound on the left leg that is painful. The nurse gives him a pain pill every 4 hours. The problem is the medication only lasts for 2-3 hours. When the pain comes back he asks for another pain pill and the nurse tells him he has to wait for 4 hours. Review of the clinical record for Resident # 51 documented an admitted to the facility of 11/28/10. The resident developed a left leg venous ulcer. During an interview on 8/22/13 a

Based on record review, observation, interviews and review of enteral feeding policies and procedures, the facility failed to ensure nursing provided accepted standards of clinical practice as it relates to tube feeding for 1 (Resident #16) of 3 residents who rely on enteral support. The staff nurse failed to ensure the resident was properly positioned during the tube feeding procedure; failed to follow physician's orders [REDACTED]. The failure to follow the standard of practice for tube feeding caused the resident to exhibit signs and symptoms of pain, distress and discomfort as well as inability to tolerate the procedure. Because the nurse failed to stop and assess the resident for these symptoms, the resident sustained [REDACTED]. The findings include: 1. Clinical record review on 8/21/2013 documents Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The clinical record dated and signed by the physician on 5/21/2005 documents the resident is incapable of making an informed decision and consent about providing, withholding or withdrawing medical treatment. An attestation by the physician the resident is terminally ill or has an end-stage condition of [MEDICAL CONDITION] is dated for 9/11/2009. An "enteral feeding necessity physician's progress note" is in the clinical record for the date of 5/20/2013 related to a [DIAGNOSES REDACTED]. Documentation in the clinical record reveals the resident was admitted to Hospice Services on 8/25/2006 for an end stage [DIAGNOSES REDACTED]. Documentation in the clinical record reveals 2 speech therapy screens dated 8/02/2012 and 2/11/2012 reflecting the resident has a regular diet consistency with nectar thickened liquids and is appropriate for the resident at this time with tube feeding. There was no current documentation related to whether the resident was able to safely swallow oral foods and liquids. Review of the August 2013 physician's orders [REDACTED]. PEG TUBE: Check for residual and notify physician if more than 60 cc's; water flushes 50 cc before and after [MEDICATION NAME] feed (feed); flush with 50 ml of water before and after medications; flush with 250 ml water four times daily, change prn (as needed) if dislodged or occluded. Review of the nursing progress notes dated 5/10/2013 at 11 p.m. documents the "...resident pulled the peg tube out at approximately 4 p.m. The ARNP (Advanced Registered Nurse Practitioner)was notified and ordered to re-insert a new peg and change prn if dislodged or occluded. [MEDICATION NAME] give at 7:00 p.m. for pain. PEG feedings tolerated well, tube is patent, easy to flush bowel sounds present x 4 quads, lungs are clear bilaterally." Nurses notes dated 6/02/2013 and not timed, documents, "...3-11 shift- resident pulled out peg tube, MD notified through answering service." Nursing notes on 6/03/2013 document, "...nurse practitioner called back and was notified. New order received to follow up with GI (Gastrointestinal) doctor in the am. and hold [MEDICATION NAME] feeding and medication until the peg tube was replaced." The resident was transferred to the hospital for peg tube reinsertion. Review of the most recent comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/05/2013 documents the resident with a Brief Interview for Mental Status (BIMS) of "99"-Resident unable to complete the interview. The resident is with unclear speech; sometimes is understood; (ability is limited to making concrete requests; usually understands-misses some part/intent of message but comprehends most conversation). The resident has short and long term memory problems and is moderately impaired in decision making; decisions poor; cues/supervision requires. Resident has difficulty focusing attention (easily distracted, out of touch or difficulty following what was said and fluctuates, comes and goes, changes in severity. The assessment documents the resident as feeling down, depressed or hopeless; feeling tired or having little energy, trouble concentrating on things, moving or speaking so slowly that other people have noticed; or the opposite-being so fidgety or restless that she has been moving around a lot more than usual. The resident is totally dependent on 1-2 staff for Activities of Daily Living (ADLs). The resident is noted to have impairment on both sides of her upper and lower extremities. The nutritional assessment reveals a height of 60 inches and 103 lbs. The resident requires a feeding tube (abdominal PEG) and mechanically altered diet; receives 51% or more of her total calories through the tube feeding and 501 cubic centimeters (cc)/day or more for average fluid intake per day by tube feeding. Observation of the resident on 8/21/2013 at 8:44 a.m. reveals the resident in her room, positioned on her left buttock while seated in a geri chair. The resident is non communicative; however, will look at the speaker when name is called. A sign above her bed entitled, "please don't water the flowers" is observed posted on the wall above her bed. During this observation, the resident's face became red, her eyebrows furrowed and she grunted. Her eyes began to water and she was observed rolling her tongue and putting her hand up to her cheek while profusely grimacing. Interview with Staff "X", who is an LPN, on 8/21/2013 at 8:48 a.m. confirmed the resident was in pain and she was going to medicate her prior to administering her medications through her tube. She stated the resident is able to tell you when she's in pain when she does what "you just saw" and she will also make grunting noises. She stated the "girl from medical records also told me she is making sounds and that's another way we know she's in pain". The nurse stated, "She will also tell you though some times. I know (Resident #16) for a long long time". Review of the August Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"jaw pain" at a pain intensity of an "8" and documents she "positioned" the resident as a non-med intervention; however, there was no reassessment of the intensity of the pain after medicating the resident. The area on the MAR indicated [REDACTED]. Observation on 8/21/2013 at 9:20 a.m. revealed Staff nurse X preparing to administer medications through the Gastrostomy tube of Resident #16. The nurse crushed and placed [MEDICATION NAME] 50 mg, [MEDICATION NAME] 20 mg, [MEDICATION NAME] CL ER 5 mg into individual pill cups, and then poured [MEDICATION NAME] 15 cc's and Prostat AWC sugar free supplement 15 cc into individual pill cups. She marked each of the medications with a black marker and indicated she did this to know what medications she was administering. Observation revealed "Do Not Crush" on the label of [MEDICATION NAME]. The nurse then placed a paper towel on top of the narcotic binder, placed each of the pill cups on top of the paper towel and carried the medications into the resident's room. While holding the binder and medications in one hand, she entered the bathroom, filled two plastic cups of water and placed all of the items on top of a paper towel resting on the resident's bedside table. After washing her hands, the nurse walked back over to the resident who was seated in a geri chair. The resident's legs were contracted up and her torso was partially twisted to the left and she was resting on her left buttock. The nurse removed the Gastrostomy tube from under the resident's shirt and after removing her stethoscope from around her neck, inserted a syringe into the Gastrostomy tube and inserted 30 cc of air through the tube. She did not check for residual fluids. The nurse then placed 5 cc of water into each pill cup, and measured 50 cc of water into 2 cups. She donned a pair of gloves, inserted the syringe back into the tube and poured 50 cc's of water into the syringe. Stomach contents were observed coming up through the syringe and then the fluid drained down through the tube. At 9:40 a.m. the nurse checked for residual and after no residual was observed, she removed the syringe, then reinserted the syringe and poured the [MEDICATION NAME] mixture into the tube. She then poured 40 cc's of water into the syringe, poured the [MEDICATION NAME] mixture into the syringe, it began to drain slowly and then an additional 50 cc of water. The resident's face turned red, her eyebrows furled and her face was grimacing. The nurse failed to stop and acknowledge the resident's facial grimacing. Clumps of white medication were observed swirling around in the syringe as the mixture failed to drain down into the tube. The nurse "milked" the tubing several times and shook the syringe. Because the medication mixture failed to drain, she poured the mixture back into a plastic cup, swirled the mixture around in the cup and poured this same mixture of clumped medication back into the syringe. The nurse continued to vigorously squeeze the Gastrostomy tube and clumps of white medication were observed clinging to the inside of the syringe. She then removed the syringe and poured the medication mixture into a plastic cup and using the pressure of the syringe, plunged the mixture back and forth, in and out of the syringe and into the cup. The mixture could be observed splashing out of cup. She reinserted the syringe and poured the medication mixture back into the syringe leaving clumps of medication on the sides of the plastic cup. The resident was observed with facial grimacing, her face was red, and she pressed her head tightly against the top of the chair, bringing her hand up to her jaw and moving her head side to side as she pressed it against the top of the chair. The nurse failed to stop the procedure and assess the resident for signs and symptoms of pain, distress, discomfort or inability to tolerate the procedure. She then poured 30 cc of the Prostat into the medication mixture, "milked" the tubing and due to the failure of the contents to drain through the tube, she again poured this mixture back into a plastic cup. She removed her gloves, went into the bathroom and indicated she was pouring "warm, not hot" water into a plastic cup. The nurse stated, "when she (Resident) gets tense, it's harder to get in". Instead of stopping the procedure and assessing the resident's signs and symptoms of discomfort and inability to tolerate the procedure, she walked over to the resident, inserted the syringe into the tube, and poured 40 cc's of the "warm" water into the syringe. She then pulled back 40 cc's of pink curdled solution mixed with water and air bubbles and withdrew the syringe. She did not continue to pull back on the syringe to determine if anymore residual could be obtained. The nurse was unable to administer the Prostat, [MEDICATION NAME] or [MEDICATION NAME]. Remnants of [MEDICATION NAME] was observed in the cup on the bedside table. The resident showed visible signs of discomfort and distress as well as inability to tolerate the procedure for approximately 20 minutes. At 9:47 a.m., and due to the inability to administer the medications, the nurse walked over to the bathroom sink and the surveyor verified she poured the [MEDICATION NAME], Prostat and [MEDICATION NAME] into the sink drain. The nurse was asked how she knows when the resident is in pain and stated the resident will tense up and show facial grimacing. She stated she pre-medicated the resident for the same symptoms prior to tube feeding and "did you see when I started she wasn't making that face?. For approximately. 20 minutes during the procedure the resident exhibit the symptoms for which she was medicated and the nurse did not stop until she determined all of the medications could not be administered. She stated the resident tenses up, her face grimaces and her jaw starts to hurt her when she is in pain. She stated, "See how she is now that I stopped?" The resident did not exhibit facial grimacing or wincing. The nurse walked over to the resident and asked the resident if she was in pain and the resident then shook her head no. The nurse stated she was going to tell the ARNP (Advanced Registered Nurse Practitioner) she could not administer all of the medications through the tube. At 10:23 a.m., the nurse carried a solution of [MEDICATION NAME] sulfate on top of a plastic spoon into the resident's room. She asked the resident if she was in any pain and the resident shook her head "no". She asked the resident a second time and the resident shook her head, "no". At 10:24 a.m., Staff nurse "X" walked into the resident's room and inserted the syringe into the resident's Gastrostomy tube. She pulled back on the syringe and 5 cc's of curdled brownish pink residue was observed. The nurse reinserted the material back through the tube and removed the syringe. At 10:26 a.m., the ARNP entered the resident's room and assessed the resident. After assessing the resident, the ARNP stated, "She does get a lot of muscle contractions" and exited the room. She informed staff nurse "X" she could continue with medication pass. However, staff nurse "X" failed to inform the ARNP of the resident's signs and symptoms of distress during the tube feeding procedure and failed to inform her of the consistency, amount and type of residual that she had pulled back through the tube. At 10:41 a.m., Staff nurse "X" was observed crushing [MEDICATION NAME] 5 mg and [MEDICATION NAME] 20 mg and placing into individual pill cups. She poured 20 cc of [MEDICATION NAME] and 30 cc of Prostat into pill cups. She locked her cart and was about to proceed into the resident's room to administer the medications. She did not realize she had already administered the [MEDICATION NAME]. The surveyor stopped the nurse and reconciled the medication she had already administered and she stated she thought it was the [MEDICATION NAME]. The nurse was going to administer the [MEDICATION NAME] until surveyor intervention. She then discarded the [MEDICATION NAME], crushed [MEDICATION NAME] 50 mg, crushed [MEDICATION NAME] 5 mg, and poured 30 cc of Prostat and 15 cc of [MEDICATION NAME] mg. into pill cups. She gathered all of the medications, including the 20 cc of [MEDICATION NAME] and carried them into the resident's room, placing them on the bedside table. She filled plastic cups with water. She stated she was administering 50 cc of water before and after each medication. The nurse turned to the resident and stated, "I hope you will not be in any pain". The resident did not display any facial grimacing or twitching. The nurse stated, "She's usually in bed which makes a big difference...now she's in the chair in this position". Instead of repositioning the resident, she inserted the syringe and injected 30 cc of air into the tube and pulled back approximately 20 cc of brown liquid. She removed the syringe, then reinserted the syringe and poured 50 cc of water, into the tube. She "milked" the tubing, then poured the [MEDICATION NAME] into the syringe, paused, then an additional 50 cc of water, paused, then the [MEDICATION NAME], paused, then 50 cc's of water, then [MEDICATION NAME], then 50 cc water, and then the [MEDICATION NAME]. The [MEDICATION NAME] mixture did not flow through the tube. It failed to dissolve and "clumped" inside of the tube. Because it did not flow down into the tube, she poured it back into a pill cup and mixed it with 5 cc of water, tried to dissolve it, inserted into the syringe. It remained undissolved and she tried a second time by mixing the medication with an additional 5 cc of water and inserted it back into the syringe. She then added 50 cc of water and then the Prostat and stated, "I think I should've waited longer after giving her that [MEDICATION NAME] 'cuz now you can see she's better". The Prostat and [MEDICATION NAME] mixture failed to adequately drain through the tube and she added an additional 20 cc's of water as the fluid "thickened" inside of the syringe. She began milking the tubing, shook the syringe back and forth and due to the failure of the medications to flow freely through the tube, poured the Prostat/medication mixture out of syringe and into a plastic cup. She poured 10 cc's of water back into the syringe and the resident's face turned red, her brows furled and she grimaced. The nurse failed to assess the resident's grimacing. She pulled back on the syringe and withdrew brown solution into the syringe. The resident moaned. The nurse failed to acknowledge the resident's moaning. She then poured 10 cc's of the Prostat/medication mixture back into the syringe without any regard to the resident's moan and then 50 cc's of water. After the water drained through the tube, she withdrew the syringe and stated, " Next time I need to make sure she's not in any pain." During an interview with the Director of Nurses on 8/21/2013 following this observation, she stated she was new to the facility and had already identified Staff Nurse "X" required re-education and in-servicing related to medication pass. She stated the intent of the physician's orders [REDACTED]. the completion of the medication pass; not 50 cc's of water before and after "each" medication given. She stated she was going to discuss this concern with the administrator and suspend the nurse pending investigation. She stated she would have expected the nurse to stop the tube feeding procedure if the resident exhibited s/s of pain or discomfort. Interview with the RD (Registered Dietitian) on 8/21/2013 at 12:30 p.m. confirmed the nurses are to flush the Gastrostomy tube with 50 cc's of water before the start of medications through the Gastrostomy tube and after the last medication has been given; "not" before and "after" each of the medications. She stated she would immediately start in-servicing the nurses on proper procedures to be followed during tube feeding. In an interview with the 3 p.m.-11 p.m. supervisor on 8/21/2013 at 1:00 p.m., she stated "The resident is able to tell you when she's in pain or not. She will also show facial grimacing and make sounds when she is in pain." She stated she "felt pretty confident that the resident will tell or show you when she's in pain. She also stated the "resident used to eat in the past but now she isn't (eating) and will refuse to eat her pleasure foods as well and will not drink. Total nutrition and hydration come from her tube feeding." Interview with the primary CNA (Certified Nursing Assistant), Staff "M", on 8/21/2013 at 1:37 p.m. revealed the resident is able to you when she is in pain due to her facial grimacing and "sometimes she will actually tell you that she is in pain". She stated her "face will also change color as well, that it will get red. If she's not in pain, she will tell you no in a whisper or shake her head no that she is not in pain." She stated she has tried to offer her thickened liquids, however, she will not drink them. In an interview with the health care surrogate, who is also the resident's daughter, on 8/22/2013 at 8:27 a.m., revealed she was not informed of the nurse experiencing difficulty getting medications through the tube yesterday. She stated that her mother has pulled out her tube twice in the recent past because she will "fidget" and has asked the facility to make sure she has something in her hand or the tube is covered to prevent her from "fooling around" with it. She was not aware the facility was not providing items to place in the resident's hands. She stated Hospice is involved with her mother and that they are also managing her pain; "at least that's what they have told me". She wasn't sure how her mother reacted to pain. She stated her "mother hasn't been eating anything for a long time, that she stopped eating and drinking". She stated, "I have never seen them tube feed my mother in the chair, it's always in the bed." Review of the care plans include the following: 1. 3/21/2013-At risk for aspiration r/t thickened liquids, enteral feeding, chewing and swallowing problems; resident will not exhibit s/s of aspiration, elevate HOB (head of bed) "BLANK" degrees; upright at 90 degrees during/after meals, alternate sips and bites; observe for s/s of aspiration, frequent oral care, verbal cues to swallow and/or chin tuck as appropriate. 2. 6/04/2013-Nutritional Risk related to therapeutic diet, mech (mechanically) altered diet, variable po (by mouth) intake, enteral nutrition, dysphagia/dementia/HTN (hypertension); resident will maintain acceptable nutritional parameters as evidenced by labs improved; no significant weight loss; anticipate wt. fluctuations r/t var (variable) po; no s/s (signs/symptoms) of choking or aspiration related to NTL (nectar thickened liquids). 3. 6/08/2013-Enteral tube feeding related to: Dysphagia; will be free of signs/symptoms of aspiration; will be free of signs/symptoms of dehydration; check placement and residual prior to use of tube as ordered; monitor ostomy site for complications; medications and flush via Tube as ordered. Review of all of the care plans provided by the facility failed to address the health care surrogate's concerns related to her mother's "fidgeting" and need to have something in her hands to prevent the resident from pulling out her Gastrostomy tube. The facility failed to develop a specific plan of care to address the signs and symptoms the residents exhibits when in distress, discomfort or in pain (i.e. facial grimacing, grunting, verbal complaints). In an interview with the ARNP on 8/22/2013 at 10:02 a.m. she stated she "went home last night and did research" as she thinks the residents symptoms are "MS related and about 10% of MS patient are tonic spasms. They can happen spontaneously, through visual stimuli or movement." She stated she feels the resident is "having more spasms and doesn't see them every time she rounds on her; that she has had 3 spasms yesterday and from a nursing judgement standpoint, "we have all been taught the non verbal signs of pain. I do not' think they are in error for medicating for pain." "What I have to wonder is if she is accurate about pain anymore or if she's having these spells...they appear painful to me..." and that she has "to monitor in the future with her". She stated, "I don't think the nurses are in error for medicating her for pain and that these muscles spasms are painful." She confirmed Staff Nurse "X" failed to inform her of the inability to administer all of the medications through the tube on 8/21/2013 as well as failed to inform her of the resident's signs and symptoms during the procedure. During an interview with the DON on 8/22/2013 at 10:30 a.m., she was not aware the facility had been informed by the daughter to ensure "something" is in her mother's hands as she fidgets and tends to pull on her tube. In an interview with the Hospice Case Manager, who is an RN (Registered Nurse), on 8/22/2013 at 11:16 a.m., she stated the resident has terrible [DIAGNOSES REDACTED] related to MS and is declining. When asked how the resident is assessed for pain, she stated the resident "...can't always report verbally, has generalize muscle spasms, her face gets all contorted, she cries out. She will guard Sometimes she can appropriately tell you, sometimes she will be showing all signs of pain and she will verbally say no but she will be in pain because it's obvious; she will be crying and yelling out, she will grimace or pat her jaw". Review of the facility's policies and procedures for enteral feedings includes the following: Policy "statement"-It is the policy of Consulate Health Care that the resident can expect medication to be administered properly via an enteral tube. Procedure-"...(medication) Consistency of solution should be able to pass easily through a tube...NOTE: If medication cannot be crushed and is unavailable in liquid form, notify the physician...place disposable underpad or towel around area of tube to limit spillage...To confirm proper placement attach syringe to end of tube and place stethoscope over left upper quadrant of the resident's abdomen. Instill approximately 20 cc of air using the syringe while listening or a "swooshing" sound in the stomach...AND/OR...aspirate by gently pulling back on plunger of syringe to check for stomach contents. Note: replace contents by gently pushing plunger...pour at least 15 cc of clear liquid into the syringe and allow to drain into tube prior to medication administration...Pour one, individual liquified medication in the syringe, and allow gravity to drain medication into the stomach. Followed by at least 15 cc (or physician order [REDACTED].e. physician notified, medication held, resident unable to tolerate, etc.) Staff nurse "X" failed to ensure the resident was properly positioned during the tube feeding procedure. She failed to ensure the consistency of all of the medications were able to pass easily through the tube. She failed to ensure all medications were "crushable" and failed to notify the physician the "[MEDICATION NAME]" was not able to be crushed and failed to request whether the medication was available in liquid form. She failed to remember which cardiac medication she had administered until surveyor intervention. She failed to follow the facility policy as it relates to inserting "20" cc of air as she inserted "30" cc of air into the tube. She failed to follow physician's orders [REDACTED]. There is no indication in the facility's policies and procedures or physician's orders [REDACTED]. The nurse failed to stop the tube feeding procedure and acknowledge the resident's facial grimacing and moaning as potential indicators of distress, discomfort or inability to tolerate the procedure. She failed to report a detailed assessment of the occluded tube to the physician and/or ARNP as well as the resident's signs and symptoms of pain and discomfort and inability to tolerate the tube feeding procedure.

Based on observation, interview, record review and review of the facility's policies and procedures for Abuse, the facility failed to ensure a resident with impaired cognition and swallowing difficulties was not mistreated during medication administration for one (Resident #57) of 12 residents observed during medication pass. This failure resulted in the resident's display of verbal and non-verbal indicators of physical distress as the nurse willfully and forcefully continued to administer medications despite the resident's refusals. The findings include: 1. Resident #57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 6/01/11, documents the resident has short and long-term memory problems and is severely impaired in decision-making skills. The MDS also documents the resident is sometimes able to express ideas and wants, usually understands intent of message, but comprehends most conversation and has adequate hearing. The resident is totally dependent on staff for Activities of Daily Living (ADLs) to include eating. The resident requires two (2) people to assist with transfers and is transported by wheelchair for mobility. The resident has no functional limitations in range of motion (ROM) of upper and lower extremities. The MDS also documents that the resident is on a mechanically-altered, thickened-liquids diet. 2. Observation during medication pass conducted on 7/12/11 at 9:41 a.m. with LPN #1, revealed the LPN aggressively tapping on the resident's chin several times, with her finger, to get the resident to open her mouth and take her medicine. The LPN kept calling the resident's name - and while tapping aggressively on her chin at the same time - stated, "(Resident, resident) open your mouth, resident (calling her by name)! Take your medicine." The resident opened her mouth slightly and the nurse inserted the spoon of medicine immediately into the resident's mouth. The resident did not swallow immediately. Her mouth remained open and observation revealed the medicine sitting in her mouth. The nurse continually tapped on her chin and stated, "Take your medicine resident (name of resident)!" Before she could swallow, the nurse spooned in thickened water and tapped aggressively on her chin again, in succession, for the resident to swallow. As the resident swallowed, the nurse continued to spoon the liquid into the resident's mouth hurriedly, until all the thickened water was gone. The nurse would spoon the liquid, tap aggressively on the resident's chin, roughly wipe the overflow off the resident's mouth, with the paper towel, and then placed the wet, soiled paper towel on the resident's chest; repeating the process until all the fluid was gone. The nurse did not encourage, ask, or use presentation skills to gain the resident's cooperation. A second observation of medication administration was conducted with LPN #1 on 7/12/11 at 11:13 a.m. The nurse entered the resident's room and immediately started moving the resident's hi-back wheelchair (w/c) using sharp, jerky movements to position the resident to face the door and the medication cart. The resident was resting in her high-back w/c with her eyes closed, facing the TV, when she was awakened and startled by the sudden movement. The resident opened her eyes immediately, and raised her arms in a startled expression and slowly looked around to see what was going on. The nurse never alerted the resident or informed her that she was going to move her. The nurse retrieved the thickened water and medication from the medication cart and re-entered the resident's room. The nurse called the resident's name and said, "(Calling her by name), here's your medicine. Take your medicine (calling her name)." The resident's mouth was already open. The nurse spooned the medicine into the resident's mouth. Before the resident could swallow fully and breathe, the nurse inserted another spoonful of thickened water with the residual medication left on the spoon. It took the resident time to swallow, but the nurse kept repeating hurriedly, "Take your medicine. Come on, swallow." The resident swallowed and was slow to open her mouth again. The nurse put the spoon down, picked up the cup with her left hand and put her right hand around the back of the resident's neck and pulled her head forward (the resident was already seated in an upright, neutral position). Getting in close proximity to her face and with the cup close to her mouth, the nurse stated, "(Calling her name), drink some more!" She called her name twice and poured more thickened water into the resident's mouth; not allowing the resident time to breathe adequately between swallows. The water was observed flowing out of the sides of the resident's mouth. The nurse wiped the resident's mouth roughly of the overflow with paper towels, and put the soiled, wet paper towels back on the resident's chest and repeated the process all over again. At one point, the nurse stuck a paper towel in the resident's mouth while wiping it. The resident's head moved with the cleaning motion and she frowned her brows. The resident was heard moaning and lifted her right arm slowly toward her mouth, but the nurse's arm blocked it with the cup she was holding to the resident's mouth. The nurse was rushing the resident to swallow the thickened water. The nurse repositioned her hand on the back of the resident's neck and the resident's head nodded forward. The resident looked at the nurse with a distressed look. At this point, the surveyor intervened and stopped the nurse. The nurse stopped and said, "Ok, then I can take this time to do her eye drops." The resident burped immediately, twice in succession. The nurse did not stop forcing the resident to drink the thickened water. The nurse failed to recognize the resident's moaning, the shaking of her head back and forth, facial grimacing, frowning and raising her hands in an effort to stop the nurse from forcefully giving her the liquids. After administering the eye drops, the nurse dabbed the resident's eyes forcefully with the tissue (the resident's head bobbed backwards), leaving a piece of tissue approximately 1 cm in length hanging out of the resident's right eye. The nurse removed the tissue and stated, "Oh my, I need to tell the facility to buy better tissues." The nurse never informed the resident of what she was going to do, asked or encouraged the resident's cooperation prior to administering the eye drops. 3. Record review of the Rehabilitation Discharge Summary from Speech Therapy, dated 8/9/10 - 8/20/10, documented, "Severe dementia-related Oropharyngeal dysphagia. Puree/NTL (nectar-thick liquid) (liquefied puree/NTL by spoon)." Review of the "Speech Therapy Screen, dated 7/12/11, documented, "Recommend non-oral nutrition. Current diet equals liquefied puree by spoon and nectar-thick liquids for optimal safety. Continues exhibition many of the same behaviors as at d/c (discharge) from last course of ST (Speech Therapy). Pt continues to require assistance to attain optimal, safe-swallow position ..." by SLP (Speech Language Pathologist). Record review of the "Dysphagia Medical Work-Up. dated 8/20/10 by the physician, documented resident is "high risk for aspiration, reverse aspiration, silent aspiration and aspiration pneumonia. Neuromotor disturbance(s) affecting Oropharyngeal abilities, which are necessary to close the buccaal cavity and or bite, chew, suck, shape and swallow the [MEDICATION NAME] while protecting the airway secondary to dementia and confusion." Review of the care plan, titled "Aspiration Risk Care Plan" updated on 6/7/11, documents the problem as: "At risk for Aspiration related to Dysphagia, Thickened Liquids, Chewing Problems and Swallowing Problems. Goal: Resident will not exhibit signs and symptoms of aspiration as evidenced by: No cough, clear lungs, and temperature within normal limits. Approach & Interventions: Speech Therapy evaluate and treat as indicated, thickened liquids, alternate sips and bites, observe for signs/symptoms of aspiration: coughing fever, shortness of breath, wheezing and congestion." 4. During an interview on 7/14/11 at 9:52 a.m., the SLP (Speech Language Pathologist) stated Resident #57's "swallowing disorder is so significant that several times in the past, she has recommended non-oral nutrition, medication, anything through an alternate means; but the family declined it. She is at high risk for aspiration, it's very significant. It's gotta be all done through positioning. She's not safe. Safe as you can keep her." When asked about administering nectar-thick liquids, the SLP stated, "She should not even be taking medications orally, I don't know how she swallows it." The SLP confirmed that the resident should be taking breaks when swallowing because you have to see what's going on. She stated, "She doesn't know that she has to start pursing her lips, the pre-oral things, I say to put the cup on the lip, so she feels it, so you get an auto response, stroke the face to stimulate her to know something is coming. Can tap lightly, use edge of cup, stroke the face. It goes back to the infantile thing, where they may root if you stroke their face." When asked about placing your hand behind the resident's neck, the SLP stated, "We encourage maintaining the neutral position. She's been seen for positioning. If something needs to be done, a lumbar pillow and a pillow behind her head (showing the flyer with positioning on it). If you put a pillow behind the neck, make sure the neck is not hyper extended (backward). If that isn't working, we suggest placing a hand on back of head to tilt forward, not on back of neck. Just from what I saw the other day, she's contracted, she may need that." The SLP stated further, "She is incognizant and needs a wide cup. At times I was teaching (called the aide by name), about feeding liquefied pureed from a spoon. She had a big time problem at the time of swallowing food. We decided she did better with sips of liquefied food from the spoon." The SLP indicated that suggesting the resident to take "bites" of food, as listed on the facility care plan, is unrealistic because the resident does not "bite" food and her diet is pureed. 5. Upon review of the new Speech Screen, dated 7/12/11, the SLP stated she was asked to see Resident #57, because they thought there might be a significant change. The SLP indicated the only change she saw was the resident still needs the same (current diet, same head back, etc.) interventions. The SLP said, "She still has the infantile tongue thrust." When asked to explain what "10/10 > 8 seconds" meant on her screen, the SLP stated, "10/10 trials means that from the time the food is introduced and enters the point where the tongue pushes it back, to the time the pharynx goes back, it took 8 seconds to close. In normal, geriatric population, it's five (5) seconds and general population it's three (3)." The SLP stated, "If she repeatedly consumes, in succession, enough of the liquids - and some is running over - she has potential to aspirate." Upon review of the Nutritional Risk Care Plan with the SLP, she confirmed the resident should have frequent rest periods. She stated, "It's like someone living on soup. It takes so long for her to eat a meal, everything is nectar thick." Review of the "Dysphagia TIPS" sheet that the SLP confirmed she used to teach the CNAs, documented for liquids reveals, "Verbalize what patient should do when drinking: 1. Head down 2. Suck in liquid in (small amount) 3. Swallow, and 4. Rest." The SLP stated she provided in-services to CNAs during dining. The SLP confirmed the nursing assistants received technique training, however, she did not provide training to the nurses. 6. During an interview with the Administrator (Adm) and Director of Nursing (DON) on 7/14/11 at 8:37 a.m., the Administrator stated the "LPN definitely used poor nursing technique." He also stated, "It's more about dignity. Dignity, we take a look at all the time. We have policies that look at dignity and we certainly wouldn't want to violate that in any way." The DON stated, "The Certified Nursing Assistants (CNAs) and Nurses are in-serviced on presentation techniques in the dining room." Surveyor requested The record of in-services to staff on "Presentation techniques," requested by the surveyor, were never provided.