Every finding on record at Awe Kualawaache Care Center

Based on observation, interview, and record review, the facility failed to implement a care plan intervention for foam heel protection intended to prevent skin breakdown for 1 (#3), which increased the risk for recurrence of pressure related skin breakdown for a resident with a history of pressure ulcers to both heels, and the facility staff failed to revise and implement a comprehensive, person-centered care plan to address the use of a high-risk anticoagulant medications, and interventions necessary to monitor for and minimize potential adverse consequences, which increased the risks for unrecognized adverse consequences, including bleeding complications associated with anticoagulant use, for 1 (#5) of 14 sampled residents. Findings include:1. During an observation on 6/1/26 at 4:34 p.m., resident #3 was observed lying in bed without foam heel protection boots on either foot.During a second observation on 6/3/26 at 1:25 p.m., resident #3 was again observed lying in bed without foam heel protection boots in place.During an interview on 6/3/26 at 12:58 p.m., staff member D said resident #3's previous open wounds on resident #3's heels were healed, and the foam boots were utilized as a preventative measure for the prevention of future wounds.During an interview with staff members K and L on 6/3/26 at 1:29 p.m., staff member K said foam boots were no longer being used for resident #3, because the open areas on resident #3's heels were healed, and the foam boots were not in the resident's room. Staff member L stated the foam boots were sometimes used as a preventative measure.Review of resident #3's diagnoses list showed a history of pressure injuries, including a Pressure Ulcer of Left Ankle, Unstageable (severity) (L89.520), dated 5/21/25; Pressure Ulcer of Left Heel, Unstageable (L89.520), dated 5/21/25; and Pressure Ulcer of Right Heel, Unspecified Stage (L89.619), dated 4/4/25.Review of resident #3's comprehensive care plan, last reviewed on 4/21/26, showed, . Focus: Pressure Ulcer: Potential for Impairment: (Resident #3) has pressure ulcers on her Skin (on admit), and she has a potential for pressure ulcer development on other boney [sic] prominences r/t disease process.7/23/25 Rt Heel (unstageable on admit) now a Stage 4 healed 11/19/25; . Lt Heel Stage 3 developed during stay healed 11/20/25; .10/23/25 Rt Heel healing. Revision on: 4/15/26Interventions: . Foam boots while in bed to protect bilateral heels. Date Initiated: 4/16/26. [sic]2. During an interview on 6/2/26 at 10:24 a.m., resident #5 said she was taking a blood thinner medication because staff suspected she had a blood clot.During an interview on 6/2/26 at 3:12 p.m., staff member D said that when a new high-risk medication (like the blood thinner) is initiated, the resident's care plan should be revised to reflect the medication's use and include how the resident should be monitored. Review of resident #5's physician's orders showed an order for Apixaban Oral Tablet 5 MG, dated 5/22/26, Give 5 mg by mouth two times a day for anticoagulant Take two tabs by mouth twice daily for 7 days, then 1 tab by mouth twice daily. [sic]Review of resident #5's comprehensive care plan, last reviewed on 5/26/26, failed to show the identification of the resident's use of Apixaban, the anticoagulant. Further review showed the care plan lacked measurable goals related to safe anticoagulant use, and the plan did not include interventions directing staff to monitor for or report potential adverse consequences such as bleeding, bruising, bleeding gums, nosebleeds, bloody or tarry stools, or other signs and symptoms associated with anticoagulant medication therapy.Review of the facility's policy, Care Plans, Comprehensive Person - Centered, revised May 2024, showed, Policy Statement, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation .7. The comprehensive, person-centered care plan: .b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, .

Based on the interview and record review, a facility staff member failed to notify nursing staff of a resident's initial fall for the immediate assessment to be completed by the nurse to determine the resident's clinical condition or if there were injuries after the fall, and the staff member failed to follow the fall program policies and procedures related to fall reporting, for 1 (#10) of 14 sampled residents. Findings include:Review of a facility-reported incident, submitted to the State Survey Agency on 4/23/26, showed resident #10 was found on the floor in his room by a nurse aide. Resident #10 stated he had a fall from his wheelchair. Nursing staff assessed resident #10 and transferred him via Hoyer lift to his wheelchair. The provider and director of nursing were notified, and the provider ordered that resident #10 be transported via ambulance to the local hospital's emergency room for evaluation. Review of the facility reported incident's investigative findings, dated 4/27/26, showed resident #10 was found on the floor after a fall in the morning on 4/22/26 at 9:02 a.m. Facility staff interviews showed resident #10 had a fall earlier that morning, on 4/22/26, around shift change. Facility staff interviews showed that the fall happened around shift change, but it was not reported immediately to the nurse by the nurse aides. The investigative findings showed that resident #10 was interviewed, as well as nurse aides and nurses. The findings showed that education was provided to all staff on the facility's fall protocol and reporting. The nurse aides involved in the incident were given disciplinary warnings for not following the facility's fall protocol(s) and reporting to the assigned nurse.During an interview on 6/4/26 at 10:42 a.m., staff member B stated resident #10 had two falls on 4/22/26. Staff member B stated the first fall in the morning happened around the time of shift change. Staff member B stated there was miscommunication with nurse aides who did not inform the assigned nurses of the first fall that day. Staff member B stated the nurse aides involved had been interviewed and had received education on informing the assigned nursing staff of a resident's fall as soon as they discovered a fall had happened.Review of resident #10's nursing progress notes, dated 4/22/26 at 10:59 a.m., showed: Note Text: CNA reported resident was on the floor and when asked what happened resident stated he fell out of his wheelchair. CNA reported incident to charge nurse at 0910. assessed resident, checked ROM, Neuro checks, vitals taken, hoyered into Chair, Provider notified, DON Notified and provider ordered resident be sent to ER via ambulance. Will continue neuro checks upon return. [sic]Review of resident #10's nursing progress notes, dated 4/23/26 at 12:46 p.m., showed: Note Text: [Resident #10] fell the morning of 4/22/26, hitting his head. He stated he fell out of his wheelchair. DON & [Physician] notified & order received to transfer to [Hospital] ER for evaluation. At the ER, he was found to be anemic & they transfused a unit of PRBC and then transferred him to [Hospital] for further evaluation & to be admitted . He was admitted with the diagnosis of acute on chronic anemia and closed head injury. [sic]Review of resident #10's electronic medical record showed his readmission to the facility on 4/27/26. Resident #10 received facial abrasions and an abrasion to his left leg stump (prior amputation) from the fall on 4/22/26.Review of a facility policy titled Falls - Clinical Protocol, revised March 2025, showed:Assessment and Recognition . c. While many falls are isolated individual incidents, a few individuals fall repeatedly. Those individuals often have an identifiable underlying cause.2. the nurse shall assess and document/report the following:a. Vital signs;b. Recent injury.;d. Change in cognition or level of consciousness;. f. Pain;. h. Precipitating factors, details on how fall occurred. 5. The staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the events, etc.

Based on observation, interview, and record review, the facility failed to ensure a fortified diet was implemented as ordered for a resident who was at risk for weight loss for 1 (#2) of 14 sampled residents. This failure increased the risk for the resident's continued weight loss and compromised nutritional status. Findings include:During an interview on 6/1/26 at 5:08 p.m., resident #2 reported she has lost weight since she was admitted to the facility. Resident #2 stated staff member D spoke to her regarding weight loss and encouraged her to eat foods she preferred.During an observation and interview on 6/3/26 at 8:14 a.m., resident #2's breakfast meal tray card did not identify the resident as requiring a fortified diet. Staff member H said he was unaware that resident #2 had experienced weight loss and was unaware of any interventions related to the resident's nutritional status.During an interview on 6/3/26 at 8:43 a.m., resident #2 said she was supposed to receive extra butter with meals due to her weight loss; however, staff frequently forgot to provide it.During an observation and interview on 6/3/26 at 8:53 a.m., resident #2's breakfast tray lacked additional butter. Staff member J stated that resident #2 was receiving a normal diet and was unaware that the resident required a fortified diet.During an observation and interview on 6/4/26 at 8:11 a.m., the meal service system had been changed from the previously observed tray card to a printed paper tray ticket that identified the resident's fortified diet order. Staff member H stated that the printed paper tray tickets were a new practice, and they provided more information and served as a better guide for meal service.During an interview on 6/4/26 at 8:16 a.m., staff member G said the printed paper cards were not implemented previously due to the printer not working properly. Staff member G stated examples of a fortified diet included adding milk to mashed potatoes, gravy added to meats, and butter added to foods.Review of resident #2's documented weights showed on 1/26/26, the resident weighed 114 lbs. On 5/25/26, the resident weighed 109 lbs., reflecting an approximate five-pound (-4.39%) loss over the four months.Review of resident #2's diet order showed, Regular Food and Fluids w/NO Restrictions diet Regular (L7) texture, Thin (0) No thickness restrictions consistency, Needs Fortified diet related to CHRONIC DIASTOLIC (CONGESTIVE) HEART FAILURE (I50.32). [sic]Review of resident #2's comprehensive care plan, last reviewed on 3/31/26, showed: .Focus: (Resident #2) has nutritional problem or potential nutritional problem r/t Dx of CHF on a mechanically altered diet and dependent on staff at meals Increased needs related to wound healing Significant weight loss, may be secondary to inaccurate weights on admit date Initiated: 12/23/2025, Revision on: 01/14/2026.Interventions: .Provide, serve diet as ordered. Monitor intake and record q meal. Regular, MM5, Thin, Fortified Date Initiated: 12/23/2025, Revision on: 01/14/2026. [sic]Despite a documented weight loss, a physician's order for a fortified diet, and a care plan intervention directing staff to serve the resident's diet as ordered, the facility failed to ensure resident #2 consistently received the fortified diet intended to address her nutritional risk and prevent further weight loss.

Based on interview and record review, the facility failed to ensure monitoring was in place for a resident for adverse consequences associated with the use of an anticoagulant medication that increased the risk of unrecognized adverse drug consequences and complications associated with anticoagulant therapy, for 1 (#5) of 14 residents sampled. Findings includeDuring an interview on 6/2/26 at 10:24 a.m., resident #5 said she was taking a blood thinner because staff suspected she had a blood clot.During an interview on 6/2/26 at 2:52 p.m., staff member P stated that when a resident received an anticoagulant medication, staff monitored for signs of bleeding and ensured the required laboratory work was completed. Staff member P stated that monitoring would be documented in the resident's medical record progress notes.During an interview on 6/2/26 at 2:55 p.m., staff member J said she was unsure what monitoring was required for a resident receiving an anticoagulant medication. After consulting staff member P, staff member J stated that staff should watch for signs such as bleeding gums and nosebleeds.During an interview on 6/3/26 at 2:02 p.m., staff member C stated that monitoring should have been implemented when the anticoagulant medication was initiated for resident #5. Staff member C stated that staff should monitor for adverse effects such as tarry black stools, and anticoagulant monitoring should have been added to the Medication Administration Record (MAR) and/or Treatment Administration Record (TAR).Review of resident #5's physician's orders showed the physician's order for Apixaban Oral Tablet 5 MG, dated 5/22/26, that included Give 5 mg by mouth two times a day for anticoagulant Take two tabs by mouth twice daily for 7 days, then 1 tab by mouth twice daily. [sic]Review of resident #5's progress notes showed a health status note dated 5/2/26, that included (Resident #5) up and about. Requested pain med after she had a nap. Left lower leg with swelling, red and warm to touch. No increased c/o pain. She was started on apixaban today. [sic] Further review of progress notes failed to show the identification of monitoring for adverse consequences associated with anticoagulant therapy, such as bleeding, bruising, bloody stools, tarry black stools, bleeding gums, nosebleeds or other signs and symptoms of hemorrhage.Review of resident #5's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for May and June 2026 lacked the monitoring for adverse side effects for the use of the anticoagulation medication ordered on 5/22/26.Review of the facility's policy, Anticoagulation - Clinical Protocol, revised March 2025, showed, Assessment and Recognition:1. As part of the initial assessment, the physician and staff will identify individuals who are currently anticoagulated; .a. Assess any signs or symptoms related to adverse drug reactions due to the medication alone or in combination with other medications.b. Assess for evidence of effects related to the subtherapeutic or greater than therapeutic drug level related to that particular drug (for example, a resident with an above therapeutic level of an anticoagulation medication should be assessed for bleeding).Monitoring and Follow-up: .5. The staff and physician will monitor for possible complications in individuals who are being anticoagulated, and will manage related problems. [sic]

Based on observation, interview, and record review, the facility failed to ensure staff kept a urinary catheter drainage bag off the floor for 1 (#35); and failed to ensure oxygen tubing was changed to prevent contamination of respiratory equipment for a resident who was dependent upon oxygen for 1 (#2) of 14 sampled residents. Findings include: 1. During an observation on 6/4/26 at 7:43 a.m., staff member N entered resident #35's room to administer morning medications. Resident #35 had urinary catheter tubing extending down from his bed ending in a covered bag, which was on the floor. Staff member N helped resident #35 adjust in bed to sit up for taking medications. Staff member N administered oral and ophthalmic medications. Staff member N was moving away from resident #35's bedside to exit the room when this surveyor pointed out the catheter bag on the floor, so the placement of the bag could be corrected. During an interview on 6/4/26 at 9:59 a.m., staff member M stated that nursing staff were to keep urinary catheter bags, used by residents, off the floor. Staff member M stated nurse aides knew to use a hook on the catheter bag to hang the bag from the bed, so the bag was off the floor. Review of resident #35's nursing progress notes, dated 6/1/26, showed a recent hospitalization with diagnoses including Benign prostatic hyperplasia (BPH) with urinary retention and obstruction, and chronic foley catheter use with asymptomatic colonized bacteremia (multidrug-resistant organisms including VRE and ESBL E. coli). Review of a facility policy titled Catheter Care, Urinary, revised August 2022, showed: . The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. Infection Control1. Use aseptic technique when handling or manipulating the drainage system.2. Be sure the catheter tubing and drainage bag are kept off the floor. [sic] 2. During an observation and interview on 6/1/26 at 4:33 p.m., resident #2 was observed receiving oxygen through nasal cannula tubing connected to an oxygen concentrator. The oxygen tubing was not dated to show when the tubing was last changed. Resident #2 said the staff did not change the oxygen tubing regularly. During an interview on 6/3/26 at 1:12 p.m., staff member D said oxygen tubing was changed weekly, and the change should be documented and tracked on either the Medication Administration Record (MAR) or Treatment Administration Record (TAR). During an interview on 6/3/26 at 1:17 p.m., staff member L said oxygen tubing should be changed every 72 hours and documented in the resident's electronic health record. Staff member L further stated she typically wrote the date of the tubing change on tape and affixed it to the tubing when the task was completed. During an interview on 6/4/26 at 8:00 a.m., staff member C said resident #2's oxygen tubing should have been dated with tape, and the tubing change should have been documented on the Medication Administration Record (MAR) or Treatment Administration Record (TAR). During an interview on 6/4/26 at 10:11 a.m., staff member M stated that nursing staff were expected to change a resident's oxygen tubing every week. Staff member M stated that if oxygen tubing was not dated, the nursing staff were supposed to change the tubing right away. Staff member M stated that if there was no sticker adhered to the tubing showing the date it was changed, then it would not be known when the tubing was last changed. Review of resident #2's physician orders for oxygen, dated 12/19/25, showed it was to be administered at 1-6 liters per minute via nasal cannula continuously, day and night, on every shift. Review of resident #2's Medication Administration Record (MAR) and Treatment Administration Records (TAR) for May and June 2026 failed to show any documentation that oxygen tubing changes had been completed.

Based on observation, interview, and record review, the facility failed to ensure the infection preventionist was properly trained; failed to ensure the safety measures were in place to prevent the growth of a waterborne illness (such as Legionella); failed to identify appropriate Transmission-Based Precautions for a resident with Clostridioides difficile (C. diff) for 1 (#178); and staff member D failed to adhere to proper infection control practices related to not performing hand hygiene between doffing and donning gloves, while performing wound care for 1 (#22) of 20 sampled residents. These deficient practices had the potential to affect all residents in the facility increasing the risk for infections overall. Findings include: 1. Infection Prevention During an interview on 5/7/25 at 2:29 p.m., staff member E stated they did not feel they had received the proper education that was required for their position. Staff member E stated hand hygiene audits were completed weekly, but they did not keep record of these audits. Staff member E stated PPE audits were completed weekly as well, but they were not able to show documentation by the end of the survey. Staff member E stated they were unsure how often mandatory education was completed concerning infection control. They stated they were unsure what PPE precautions were needed for a resident with a Coronavirus-19 infection. Staff member E stated they did not have a sheet or a quick system in which they could refer to when trying to figure out which precautions were needed for specific infections. Staff member E stated they relied heavily on the public county health nurse for all of those types of questions. Staff member E stated they were unsure which diseases were reportable to the state, but would communicate with the public health nurse for this information as well. Staff member E stated a gown, gloves, and a mask were the required PPE for a C. diff infection. Staff member E stated alcohol was better than handwashing for a resident who had C. diff. The CDC refers to the C. diff spores as being very difficult to kill (Centers for Disease Control and Prevention, 2024). The CDC website also showed, Washing your hands with soap and water is the best way to prevent the spread of C. diff from person to person (Centers for Disease Control and Prevention, 2024). Review of a facility document titled, Monitoring Compliance with Infection Control, revised 8/2019, showed: . 2. Monitoring includes regular surveillance of adherence to hand hygiene practices and availability of hand hygiene supplies, and the availability of personal protective equipment and its appropriate use. Review of a facility document titled, Reporting Communicable Diseases, revised 7/2014, showed: . 1. All reportable infectious diseases (residents' or employees') must be reported to the Infection Preventionist as soon as a definite diagnosis is made or strongly suspected. 2. Legionella During an interview on 5/7/25 at 10:22 a.m., staff member H stated the [local entity] checked the water. Staff member H stated they did not keep a log of flushing toilets, but stated staff member E would maybe know more information regarding this topic. Staff member H stated they did complete a test for Legionella by swab testing the countertop in the kitchen. During an interview on 5/7/25 at 2:29 p.m., staff member E stated, Are we supposed to do that?, when referring to records and the weekly flushing requirement to prevent the growth of Legionella. Review of a facility policy, titled Legionella Water Management Program, revised 9/2022, showed: Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella. .e. Specific measures used to control the introduction and/or spread of Legionella (e.g., temperature, disinfectants); f. The control limits or parameters that are acceptable and that are monitored; . h. A system to monitor control limits and the effectiveness of control measures; . j. Documentation of the program. 49554 3. Transmission Based Precautions During an observation and interview on 5/6/25 at 8:32 a.m., staff member I entered resident #178's room to deliver her breakfast. A biohazard sticker, a sign that showed droplet/contact precautions, and a sign that showed EBP required were observed on the door of resident #178's room. A box of masks were observed on the handrail outside of the room. The door to the room was halfway open. Staff member I was observed with no mask, gown, or gloves and walked up to the sink and began washing her hands before exiting the room. The door to the room was left open when she walked out. Staff member I stated she thought it was ok to leave the door open. Staff member I stated, All of the PPE is in the room on the back of the bathroom door. The resident has C. diff and is on droplet precautions. We (staff) should be wearing gowns, gloves, and masks, which we put on after we enter the room. During an interview on 5/6/25 at 8:41 a.m., staff member D stated, Resident #178 is positive for C. diff and should be on contact precautions. The resident's door should be closed, and the staff should use the PPE on the inside of the room. 41951 4. Hand Hygiene During an observation on 5/5/25 at 3:08 p.m., staff member D removed the soiled bandage from resident #22's left hip. Staff member D removed (doffed) her dirty gloves, donned new gloves, but did not sanitize her hands before donning the new gloves. Staff member D cleansed resident #22's wound, doffed her gloves, donned new gloves, but did not sanitize her hands before donning new gloves. During an interview on 5/5/25 at 3:29 p.m., staff member D stated she should have sanitized her hands between glove changes. She stated she was upset with herself and was nervous, as she was the wound care nurse and knew the process. Review of the facility's policy titled, Standard Precautions, last revised 12/07, showed: - . 1. Hand hygiene - a. Hand hygiene refers to handwashing with soap (anti-microbial or non antimicrobial) OR using alcohol-based hand rubs (gels, foams, rinses) that do not require access to water, and - . d. Wash hands after removing gloves. References: Centers for Disease Control and Prevention. (2024, March 5). C. diff: Facts for Clinicians. Retrieved from Centers for Disease Control and Prevention: https://www.cdc.gov/c-diff/hcp/clinical-overview/index.html

Based on interview and record review, the facility failed to notify the State Ombudsman Office when a resident was transferred to the hospital and failed to provide the resident with contact information for the State Ombudsmans Office for 3 (#s 13, 127, and 177) of 20 sampled residents. This deficient practice left the residents without an advocate related to the transfers in the event there were concerns. Findings include: During an interview on 5/5/25 at 2:56 p.m., NF1 stated, I am concerned the facility is not notifying the Ombudsman Office when they transfer someone to the hospital or when a resident is discharged . This is leaving them without an advocate during that time. During an interview on 5/7/25 at 1:25 p.m., staff member G stated we did not let the ombudsman know resident #177 was discharged because the facility was not aware the local hospital sent him to a larger hospital. During an interview on 5/8/25 at 8:07 a.m., NF1 stated, I am not notified when someone is transferred or discharged from the facility. During an interview on 5/8/25 at 8:45 a.m., staff member G stated, The director of nursing or the charge nurse will fill out the transfer/discharge notice when someone leaves for the hospital. The form also includes the bed hold notice. They print it off and send it with the residents when they leave. I was not aware the form had to include contact information for the State Ombudsman Office. I only notify the ombudsman when we do an incident report in Bounds. I was unaware I had to notify the ombudsman when someone transferred or discharged . Review of resident #13's Transfer/Bed Hold Notice showed he was transferred to the hospital on 5/4/25 and on 5/6/25. The transfer notices did not contain contact information for the State Ombudsman Office. Review of resident #127's Transfer/Bed Hold Notice's showed she was transferred to the hospital on 1/10/25, 1/20/25, and 3/2/25. The transfer/discharge notices did not contain contact information for the State Ombudsman Office. Review of resident #177's Transfer/Bed Hold Notice showed he was transferred to the hospital on 3/4/25. The transfer/discharge notice did not contain contact information for the State Ombudsman Office. A request was made for documentation of notification of transfer/discharge to the State Ombudsman Office. The facility did not provide any further documentation prior to the end of the survey period. Review of a facility document titled, Transfer or Discharge, Facility Initiated, dated October 2022, showed: . Notice of Transfer or Discharge (Emergent or Therapeutic Leave) . 4. Notice of Transfer is provided to the resident and representative as soon as practicable before the transfer and to the long-term care (LTC) ombudsman when practicable (e.g., in a monthly list of residents that includes all notice content requirements).

Based on interview and record review, a resident was acting out aggressively, and the staff restrained the resident for a Period of Imminent Danger to the Safety and Well being of others, and failed to ensure the required steps were taken to address the emergency restraint immediately after it occurred, or for future events in which a restraint may have been needed for this resident, for 1 (#2) of 1 sampled resident. Findings include: A review of a facility-reported incident, dated 11/11/24, revealed the following: On 11/13/24, at approximately 4:30 p.m., a personal care attendant (PCA) reported to the administrator-in-training that she had sustained an injury on 11/11/24, while assisting the charge nurse and other staff in physically restraining resident #2. During the investigation staff reported on 11/11/24, around 10:00 a.m., the charge nurse directed staff to physically restrain resident #2, due to the resident exhibiting physical aggression toward staff, and other residents. This restraint was implemented to allow the charge nurse to administer an intramuscular injection of an antipsychotic medication. The charge nurse instructed staff to continue restraining the resident for an additional fifteen minutes after the injection to allow the medication to take effect. After fifteen minutes, the charge nurse directed three staff members who were physically restraining resident #2 to resume their other assigned duties, leaving the PCA and security staff member to continue restraining resident #2 for a total of one hour until the resident fell asleep. Steps were not taken to ensure future restraint use was addressed for the resident and his behaviors. During an interview on 12/3/24 at 12:03 p.m., staff member E stated, on 11/11/24, resident #2 had attempted to hit, kick, and spit at staff and other residents in the facility. Staff member E stated the charge nurse requested staff member E to physically restrain resident #2, by holding her hand under the resident's left ankle while the nurse administered an intramuscular injection in the residents left arm. Staff member E stated the charge nurse requested resident #2 be physically restrained by staff for an additional fifteen minutes for the medication to take effect. Staff member E stated she did not hold the residents left leg down continuously but did restrain the resident at times by holding his left ankle when resident #2 attempted to kick at staff. The staff failed to ensure the least restrictive restraint was used, and verify with the nurse it was safe to continue restraining the resident throughout the hour period. During an interview on 12/3/24 at 2:20 p.m., staff member G stated on 11/11/24 she was summoned by the charge nurse to assist in physically restraining resident #2's right lower leg, while the charge nurse administered an intramuscular medication to the resident. Staff member G stated resident #2 had been physically aggressive to staff and residents on the morning of 11/11/24, by attempting to hit, kick, and spit. Staff member G stated after the charge nurse administered the medication, she left the resident's room and continued her other assigned duties. The nurse did not verify with the staff the least restrictive method of restraint was to be used. During an interview on 12/4/24 at 2:51 p.m., staff member J stated, on 11/11/24, resident #2 was destructive and swung at and punched staff. Staff member J stated the charge nurse asked him and another staff member to hold resident #2 down, while she administered an intramuscular medication. Staff member J stated he held resident #2's wrist, off and on, when the resident was trying to hit staff. Staff member J stated when resident #2 would calm down he would let go of the resident's wrist and try to talk to the resident. Staff member J stated resident #2 attempted to get out of bed, and the charge nurse instructed him not to allow the resident to get out of bed because he was a fall risk. Staff member J stated, I was just kind of confining him to an area but not being forceful. The Appendix PP, of the State Operations Manual, addressing restraints, shows: . the order from the practitioner and supporting documentation for the use of a restraint must be obtained either during the application of the restraint, or immediately after the restraint has been applied. The failure to immediately obtain an order is viewed as the application of restraint without an order and supporting documentation . If application of a restraint occurs, the facility must: - Determine that a physical restraint is a measure of last resort to protect the safety of the resident or others; - Provide ongoing direct monitoring and assessment of the resident's condition during use of the restraint; - Provide assessment by the staff and practitioner to address other interventions that may address the symptoms or cause of the situation (e.g., identification of an infection process or delirium, presence of pain); - Ensure that the resident and other residents are protected until the resident's behavioral symptoms have subsided, or until the resident is transferred to another setting; - Discontinue the use of the restraint as soon as the imminent danger ends; and - Immediately notify the resident representative of the symptoms and temporary intervention implemented. Documentation must reflect what the resident was doing and what happened that presented the imminent danger, interventions that were attempted, response to those interventions, whether the resident was transferred to another setting for evaluation, whether the use of a physical restraint was ordered by the practitioner, and the medical symptom(s) and cause(s) that were identified. The steps identified as required in the Appendix PP, under F604 - Restraints, were not followed by the facility for the emergent restraint use for resident #2, or to address future potential episodes of imminent danger.

Based on observation, interview, and record review, the facility failed to update a resident's individualized care plan for personal preferences related to communication and the provision of ADL care from male staff who had the ability to speak the resident's native language. When male staff assisted the resident, and used the resident's native language when communicating, the resident would exhibit less agitation and aggression, for 1 (#2) of 7 sampled residents. Findings include: During an observation and interview on 12/3/24 at 2:45 p.m. resident #2 was observed sitting in his wheelchair speaking his native language with staff member H. Resident #2 appeared happy, smiling at times, and responsive during the interaction. Resident #2 stated he preferred male staff who spoke his Crow language to care for him stating, white people are okay. During an interview on 12/3/24 at 2:55 p.m., staff member H stated resident #2 preferred male staff to care for him who speak his native Crow language. Staff member H stated resident #2 was less aggressive and more compliant with daily care with male Crow-speaking staff. Staff member H stated resident #2's preferences should be reflected on his current care plan and was not sure why it was not listed under the care plan's interventions. During an interview on 12/4/24 at 12:08 p.m., staff member B stated resident behaviors were discussed each morning at stand up (the facility's daily meeting) and if updates were needed to a resident care plan, it would be assigned to herself or staff member D. Staff member B stated the morning meeting is how they determined resident #2 responded better with a male staff who spoke his native language. Staff member B stated the missing interventions on resident #2's care plan was an oversight, and they (the facility staff) were getting better at developing individualized resident care plans. Review of resident #2's care plan, with a revision date of 11/18/24, failed to show the resident preferred male staff who spoke his native language, during the provision of ADL, as it would decrease the resident's agitation and aggressive behavior towards others.

Based on interview and record review, facility failed to ensure all nursing staff working with a resident who exhibited aggressive behaviors towards others, was educated to the extent necessary and competent to provide services for the resident's needs to be met for behaviors and use of restraints; and to ensure restraint use was utilized properly for resident safety, in the event of an emergency situation; and failed to ensure all staff working with the resident when a restraint was applied had necessary training for physicial restraint use, for 1 (#2) of 7 sampled residents. The deficient practice resulted in a resident being physically restrained for up to one hour without nursing oversight. Findings include: A review of a facility-reported incident, dated 11/11/24, showed the following information: On 11/13/24, at approximately 4:30 p.m., a personal care attendant (PCA) reported to the administrator-in-training that she had sustained an injury on 11/11/24, while assisting the charge nurse and other staff in physically restraining resident #2. During the facility's investigation, staff reported on 11/11/24, around 10:00 a.m., the charge nurse directed staff to physically restrain resident #2, due to the resident exhibiting physical aggression toward staff and other residents. The restraint was implemented to allow the charge nurse to administer an intramuscular antipsychotic injection. The charge nurse instructed staff to continue restraining the resident for an additional 15 minutes after the injection to allow the medication to take effect. After 15 minutes, the charge nurse directed three staff members who were physically restraining resident #2, to resume their other assigned duties, leaving the PCA and a security staff member to continue restraining resident #2 for a total of one hour until the resident fell asleep. During an interview on 12/3/24 at 2:59 p.m., NF2 stated resident #2 had become aggressive with staff and residents at approximately 9:00 a.m. on 11/11/24. NF2 stated nursing staff had tried to redirect the resident, but interventions failed. NF2 stated she contacted the medical provider and received an order for the resident to have intramuscular antipsychotic injection to help with his aggressive behaviors. NF2 stated she gave resident #2 the injection at around 10:00 a.m., and requested staff physically restrain resident #2 for fifteen minutes until the medication would take effect. NF2 stated she returned to resident #2's room after fifteen minutes, and the resident was still aggressive and agitated. NF2 stated she had a male staff member stay with resident #2, and continue to physically restrain him for safety. NF2 stated she did not reassess or document the resident's condition every 15 minutes after her initial assessment. Review of resident #2's electronic medical record failed to show resident #2 was re-assessed at any time by nursing staff during the one hour period of physical restraint on 11/11/24. During an interview on 12/4/24 at 12:08 p.m., staff member B stated the nurse involved in the restraint incident was a brand-new graduate who had just passed her nursing boards. She stated after the incident management had reviewed the Haldol usage and interviewed other nurses about resident #2, and she believed it was the new nurse who was having the most difficulty. Staff member B stated there should be an assessment before resident #2 received the injection, a justification with exactly what he was doing, what interventions weren't working, and then the Haldol. Staff member B stated when giving the intramuscular shots the practice should be not holding him for any longer than it takes, just long enough to make sure he doesn't hit or kick, and then letting him go. During an interview on 12/4/24 at 2:51 p.m., staff member J stated on 11/11/24 resident #2 was destructive and swung at and punched staff. Staff member J stated the charge nurse asked him and another staff member to hold resident #2 down while she administered an intramuscular medication. Staff member J stated he held resident #2's wrist off and on when the resident was trying to hit staff. Staff member J stated when resident #2 would calm down he would let go of the resident's wrist and try to talk to the resident. Staff member J stated he did not receive any training from the facility on how to restrain a resident, and it was the first time he had any physical contact with a resident. Staff member J said prior to the incident on 11/11/24, he would call a CNA if a resident needed help. Staff member J stated he knew he was not to provide any hands-on care. Staff member J stated he was doing what he was told to do by the facility supervisor at the time. Review of staff member J's personnel file failed to show documentation of training or education regarding resident care or restraint use. During an interview on 12/4/24 at 3:00 p.m., Staff member C stated the aides would sometimes ask the nurse to get the resident a shot for behaviors, but it was up to the nurse to evaluate if it was appropriate not to just give it.

Based on interviews and record review, the facility failed to review and update the facility assessment to include the care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population for residents with behavioral health needs. This practice had the potential to affect residents with behavioral health needs admitted to the facility. Findings include: During an interview on 7/29/24 at 3:58 p.m., staff member H stated resident #2 required a one-to-one sitter related to behaviors. Staff member H stated the facility was waiting for a psychological evaluation to be done. Staff member H stated staff member J was responsible for setting up the psychological evaluations. Staff member H stated, [Resident #2] deserves to be in a place that is more equipped to take care of behavior patients. I'm afraid to say it, but if we don't get her somewhere, it's (staff to resident abuse) going to happen again. We are not equipped to care for her. During an interview on 7/30/24 at 9:06 a.m., staff member J stated, We are not equipped to take care of [resident #2]. I don't know why the facility assessment says we can take behavior patients, we really shouldn't. I'm new and didn't know anything about facility assessments until yesterday when it was requested (by surveyors). During an interview on 7/30/24 at 10:26 a.m., staff member E stated there were seven residents with aggressive behaviors on the unit that she was aware of. Staff member E reported the following behaviors included: hitting, kicking, pinching, yelling, throwing things, and cussing. Staff member E stated, They (CNAs) really don't have the skills to care for these behaviors. I don't even know how I would handle some of them in the moment. Review of the facility provided, Facility Assessment, dated 12/13/22, reflected: -Part 2: Services and Care We Offer Based on our Residents' Needs -Mental health and behavior: manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, other psychiatric diagnoses, intellectual or developmental disabilities.

Based on observation, interview and record review, the facility failed to provide behavioral health training for staff; consistent with the needs of the residents in the facility for 2 (#s 2 and 3) of 4 sampled residents. Findings include: During an observation and interview on 7/29/24 at 1:17 p.m., resident #2 was lying in bed diagonally, watching the television. Staff member C was sitting in a chair next to resident #2's bed looking at a personal cell phone. Staff member C stated she was the sitter for resident #2. Staff member C stated she was to document every 15 minutes what resident #2 was doing, and follow her if she left her room. Staff member C stated she was not aware of any behaviors resident #2 had in the past, and no one told her what she should do if resident #2 had behaviors. Staff member C stated she, . would try to go find the Director of Nursing if something happened. Staff member C stated she had not been trained on how to handle behaviors. During an interview on 7/29/24 at 1:25 p.m., staff member D stated she did not know about the care plan or the interventions for resident #2's behaviors. During an interview on 7/29/24 at 1:32 p.m., staff member E stated resident #2 was very fast and strong. Staff member E stated resident #2 had a sitter, and all the sitters could do was stay with her. Staff member E stated the facility had medication for resident #2's behaviors, and the only trigger she was aware of was if someone sat in her favorite chair in the common area. Staff member E stated she did not know if resident #2 had other triggers and stated resident #2 frequently had behaviors for no reason. Staff member E stated resident #2 had frequent outbursts of aggressive behavior toward staff and residents. Staff member E did not know what the care plan interventions were other than a sitter and medication. Staff member E stated, Truthfully, I don't know what I'd do when she gets aggressive, attacking people. Staff member C stated she had not been trained on how to handle behaviors. During an interview on 7/29/24 at 1:41 p.m., staff member F stated resident #2 was quick. Staff member F stated, I usually tell her, 'Don't do that' and try to get her back in her room. Staff member F stated she had not had training on managing behaviors specifically, and did not know what interventions were on resident #2's care plan. During an interview on 7/29/24 at 3:27 p.m., staff member G stated if a resident were to become aggressive toward her, she would yell for a nurse, and they would take care of it. We (staff) were told not to fight back, just go get a nurse. During an interview on 7/29/24 at 3:58 p.m., staff member H stated resident #2 required a one-to-one sitter related to behaviors. Staff member H stated, [Resident #2] deserves to be in a place that is more equipped to take care of behavior patients. I'm afraid to say it, but if we don't get her somewhere, it's (staff to resident abuse) going to happen again. We are not equipped to care for her. Staff member H stated the staff at the facility were not trained to care for the residents behaviors. Staff member H stated he had told staff to call for him when the behaviors occur so he could help them, but if he was not available the only thing the staff could do was to use the call light for a nurse to come help. During an observation and interview on 7/30/24 at 8:15 a.m., resident #2 finished her breakfast in the dining room and immediately returned to her room. Staff member I was following resident #2 to her room and left a trainee in the room with her while staff member I remained in the hallway. Staff member I stated resident #2 did not like her, and would become angry if she entered her room so she was staying back and allowing the trainee to stay with her. Staff member I stated she did not know what the care plan stated for the resident's behaviors or interventions. Staff member I stated the only trigger she knows of is resident #2 did not like her. Staff member I stated she completed the 15-minute checks form, and returned them to the nurse on duty. Staff member C stated she had not been trained on how to handle behaviors. During an interview on 7/30/24 at 8:18 a.m., staff member E stated she did not know where the 15-minute check forms were going, and they were probably filed away somewhere. Staff member E stated she had not reviewed the 15-minute check forms in the three weeks she had been at the facility. During an interview on 7/30/24 at 9:06 a.m., staff member J stated, The behaviors have been a learning process. We took [resident #2] back from [hospital name] because they said her behaviors were better. [Resident #2's] behaviors came right back when she returned, and we are not equipped to handle it (behaviors). Staff member J stated, We should review the 15-minute checks, but we haven't so I don't think anyone really looks at them. Staff member J stated none of the CNAs like being the sitter for the residents with behaviors, and she had to have a meeting to tell all CNAs they were to take turns, and all share the sitter time. During an interview on 7/30/24 at 10:26 a.m., staff member E stated there were seven residents with aggressive behaviors on the unit that she was aware of. Staff member E reported the residents on the unit exhibited behaviors which included: hitting, kicking, pinching, yelling, throwing things, and cussing. Staff member E stated, They (CNAs) really don't have the skills to care for these behaviors. I don't even know how I would handle some of them in the moment. During an interview on 7/30/24 at 10:44 a.m., staff member N stated resident #3 hits, kicks, cusses, and yells when staff try to change his brief. Staff member N stated, We just hope for the best, and get it done. It's hard and all they (management) say is we have to do it (check and change). During an interview on 7/30/24 at 11:37 a.m., staff member K stated, I feel burned out with all this aggressiveness. I don't even want to come in. I try to get someone to cover. During an interview on 7/30/24 at 11:38 a.m., staff member L stated she felt overwhelmed at times by the behaviors. Staff member L stated most days the staff dealt with more behaviors than ADL cares. Staff member L stated she had not received training on managing aggressive behaviors. Review of resident #2's Care Plan, updated 7/1/24, reflected: -I have the potential to be a safety risk to self and others due to my paranoid like schizophrenia and aggressive history of unprovoked behaviors towards others. - I would benefit from clinical medical management in a geriatric psych setting. Review of resident #2's CNA Kardex, dated 4/15/24, reflected: -Provide 1:1 staff to resident monitoring when resident is up out of bed and in common areas by keeping resident in line of sight. -Redirect to her room if resident appears agitated or aggressive or vocalizes threatening statements. -Attempt non-pharmacologic interventions when resident exhibits behaviors such as agitation, pacing, wandering, disorganized thoughts. Encourage walking, offer emotional support, allow her to watch a movie, provide a snack and/or fluids, sit with her, provide a calm, quiet environment with decreased stimuli. There was no documented indications of triggers. Review of resident #2's Nursing Progress notes, dated 6/29/24 - 7/30/24, showed the resident had a pattern of agitation, cursing, and kicking at other residents and staff. There was no identification of triggers or attempts to determine the root cause the behaviors. Review of resident #3's Care Plan, revision date of 12/31/24, reflected: -New Behavior Potentially Causing Harm to self of others (Episodic). Resident was in physical altercation with another resident causing harm to other resident on 11/30/23. -If Resident poses a potential threat to injure self or others notify provider - If safe, allow Resident personal space - If wandering or pacing, initiate visual supervision during acute episode - Minimize environmental stimuli - Monitor Resident for signs / symptoms of agitation - Provide verbal feedback to Resident regarding behavior - Utilize diversion techniques as needed Review of resident #3's Progress Notes, dated 7/16/24, reflected: Social services were asked to assist with the resident having aggressive behaviors when nursing staff is trying to change his pants and underwear, which the resident soiled. The resident began to be combative and swinging at CNAs and DON. The resident was transferred from the commons couch to wheelchair while still combative. Staff was able to get the resident to his room, where he tried to hit and bite staff. Staff eventually changed the resident and the resident calmed down.

Based on observation, interview, and record review, the facility failed to prevent resident abuse in the form of a physical altercation with a staff member for 1 (#2) of 4 residents sampled. Findings include: Review of resident #2's nursing progress notes, dated 7/22/24, showed, Resident and her assigned one on one CNA in the door way to the dining room. CNA has residents hands behind her back pulling on her in an aggressive manner. Holler for CNA and security to help. CNA pulled resident to the floor with her hands still behind her back . [sic] During an interview on 7/29/24 at 1:20 p.m., staff member A stated when the staff to resident altercation had been reported to her, she came to the facility to review the security footage and began investigating the incident. Staff member N was removed from the shift, and later terminated. Staff member A stated through interviews the facility learned staff member N was easily angered and had been a bully. During an observation on 7/29/24 at 2:45 p.m., the security camera footage, dated 7/22/24, showed resident #2 walking into the dining room with her walker. Staff member N was the assigned 1:1 following the resident at a distance. Resident #2 turned and left the dining room, aggressively pushing her walker towards staff member N. Staff member N grabbed the resident by her arms, turned her around with her arms behind her back, and pulled her to the ground, despite other staff coming to help de-escalate the situation.

Based on interview and record review, the facility failed to assess for the root cause or triggers of behavioral outbursts for 1 (#2); and failed to provide the behavioral health services outlined in a PASRR Level II for 1 (#4) of 4 sampled residents. Findings include: 1. Review of resident #2's nursing progress notes, dated 6/29/24 - 7/30/24, showed the resident had been assigned a 1:1 sitter after a pattern of agitation and aggression towards other residents and staff including: - 6/29/24 Assaulting another resident and being sent to [Clinic Name 2] emergently for a psychiatric evaluation. - 7/1/24 Pacing and agitation resulting in a phone call to the physician for a one-time medication order. - 7/2/24 Cursing and yelling at her 1:1. - 7/11/24 Kicking at another resident seated in her recliner. - 7/22/24 Charging and punching her 1:1. During an interview on 7/30/24 at 9:11 a.m., staff member A stated there were no root cause assessments done to identify trends or triggers related to resident #2's incidents. Staff member A stated it did not appear anyone was looking at the documentation on the 1:1 sitter sheet to determine if there were patterns associated with resident #2's behaviors. During an interview on 7/30/24 at 10:00 a.m., staff member J stated the facility had been told by [outside behavioral health clinic 2] to not send a referral to have resident #2 seen, but to send her through the E.R during a crisis. Staff member J stated this was difficult because the drive to this clinic was an hour, and the resident was calm by the time she arrived at the clinic. Staff member J stated the facility had sent out many referrals and requests for new placements with every place declining to take resident #2, due to her behaviors. 2. Review of resident #4's PASRR Level II, dated 6/2/22, showed the resident had a history of schizophrenia and institutionalization that required the specialized services of Outpatient Mental Health. Review of resident #4's EMR failed to show any documentation the resident was receiving or refusing any form of outpatient mental health services. During an interview on 7/30/24 at 12:00 p.m., staff member B stated it was a near weekly conversation with [outside clinic 1] to have the residents at the facility seen for behavioral health services. Staff member B stated [outside clinic 1] was the only provider in the area, and had been difficult to work with. During the exit conference on 7/30/24 at 1:00 p.m., staff member A stated the intention was to send the requested behavioral health documentation to the State Survey Agency. No documentation was received.

Based on interview and record review, the facility failed to ensure prn psychotropic drugs were limited to 14 days or had documented rationale for extended prn usage; and failed to ensure prn anti-psychotic drugs were limited to 14 days and not renewed unless the attending physician or prescribing practitioner evaluated the resident for the appropriateness of the medication for 1 (#2) of 4 sampled residents. Findings include: Review of resident #2's MAR, dated July 2024, showed the resident had prn orders for: 1. Ativan 1mg give 1 tablet by mouth every 8 hours as needed for agitation. There was a start date of 7/1/24. The resident had received this dose seven times for the month of July. There was no physician documentation detailing the resident's need for continued prn dosing of this medication. There was no stop date listed. 2. Olanzapine 2.5mg give 2.5mg by mouth every 6 hours as needed for depression. There was a start date of 7/1/24. The resident had received this dose twice for the month of July. There was no physician documentation of an evaluation to extend the prn dosage period of this medication. There was no stop date listed. During an interview on 7/30/24 at 12:00 p.m., staff member B stated the physician was at the facility once per month, otherwise available by phone. They did not have an onsite physician who could re-evaluate residents after the 14-day prn period for antipsychotics was met. Staff member B stated pharmacy did the monthly reviews to catch stop dates, but had not yet done the reviews for the month of July 2024.

Based on interview and record review, the facility failed to revise and update a care plan for 1 resident (#26) of 17 sampled residents. Findings include: Review of resident #26's electronic medical record, dated 12/29/23, showed the resident had a chronic non-pressure ulcer of the right lower extremity. The physican order, dated 1/4/24, showed the right lower leg was to be cleaned with normal saline and patted dry, then staff were to apply Gentamicin ointment on the wound, and ABD pads and wrap with Kerlix, and cover with Tubi grip. Resident #26's care plan failed to show interventions related to any wound care treatment to resident #26's right lower extremity. Review of resident #26's nursing progress note, dated 1/31/24, showed the resident was seen in the emergency room due to excess fluid retention. The emergency room physician instructed the facility to weigh resident #26 daily. The facility failed to update the resident's care plan interventions to include daily weights. During an interview on 4/23/24 at 1:49 p.m., staff member D stated care plan conferences were not completed after the last Director of Nursing resigned and left the facility. The care plan meetings and updates for March and April 2024 were not completed. She stated staff are trying to get caught up with the care plan updates and also with conducting care plan meetings. During an interview on 4/24/24 at 10:58 a.m., staff member A stated care plans are updated by staff in the facility when necessary.

Based on interview and record review, the facility failed to ensure the nurse competencies and skills set was sufficient to provide services for resident care, which included wound care services, for 1 (#26) of 2 sampled residents with wounds. Findings include: Review of resident #26's electronic medical record showed an admission diagnoses of diabetes Type 2 with other skin ulcer, and non-pressure chronic ulcer of other part of right lower leg. The physician admission order, dated 12/29/23, included an order for Gentamicin Sulfate ointment to be applied to the affected area once a day. Resident #26's physician order did not show which skin wound was to be treated. Review of resident #26's treatment record for December 2023, showed there were initials showing the wound treatment was not completed on 12/29/23, 12/30/23, and 12/31/23. Resident #26's medical record failed to show why the treatments were not completed. Review of resident #26's medical records from 12/29/23 through 12/31/23, failed to show a medical provider was contacted to obtain or clarify wound care orders. Review of resident #26's late entry nursing progress note, dated 1/1/24, at 10:00 a.m., showed, Clarified orders with charge nurse regarding dates of wound changes, written orders hard to read and understand. Review of resident #26's progress note, dated 1/1/24 at 2:02 p.m., showed, Resident has a prescriber written order for RLE venous stasis ulcer/wound. The wound is be changed every day. The order is to remove previous dressing, apply Gentamicin, collagen powder, apply ABD pad, wrap kerlix guaze to keep dressing in place, then put a tubigrip over entire dressing. Will continue to monitor for excess drainage and infection. [sic] Resident #26's physician orders and treatment record s failed to show the order was transcribed onto the treatment record for the right lower leg wound treatment that was to be started on 1/1/24. Review of resident #26's nursing progress note, dated 1/1/24, showed Gentamicin antibiotic ointment had not been received from the pharmacy and was not available to be administered. During an interview on 4/24/24 at 3:36 p.m., staff member D said resident #26's admission orders did not include the complete wound treatment because the admitting physician was not the doctor that routinely took care of resident #26's wounds. Staff member D said, she was aware prior to admission resident #26 was treated by a wound clinic, and was unable to make contact with the wound clinic on 12/29/23. Staff member D said the wound clinic was closed for the weekend, and the holiday, and could not be reached for order clarification until Monday 1/1/24.

Based on interview and record review, the facility failed to accurately submit Payroll Based Journal (PBJ) data for RN coverage, eight consecutive hours per day for five days and 24-hour licensed nurse coverage for 25 days in Quarter One of Fiscal Year 2024. The failure to have a RN on duty increased the risk of negative resident outcomes for any resident needing RN services. Findings include: Review of the Quarter One, [NAME] report, for Fiscal Year 2024, dated 4/16/24, showed: No RN Hours for the following dates: 10/07/23, 10/15/23, 10/21/23, 11/11/23 and 12/31/23. Failed to have Licensed Nursing Coverage 24 Hours/Day for the following dates: 10/1/23, 10/7/23, 10/11/23, 10/21/23, 10/22/23, 10/28/23, 10/31/23, 11/3/23, 11/4/23, 11/10/23, 11/11/23, 11/12/23, 11/15/23, 11/17/23, 11/18/23, 11/25/23, 11/26/23, 12/3/23, 12/6/23. 12/7/23, 12/13/23, 12/14/23, 12/21/23, 12/30/23, and 12/31/23. Review of employee timecards showed RN hours for the following dates: 10/07/23, 10/15/23, 10/21/23, 11/11/23, and 12/31/23. Review of employee timecards showed Licensed Nurse coverage for the following dates: 10/1/23, 10/7/23, 10/11/23, 10/21/23, 10/22/23, 10/28/23, 10/31/23, 11/3/23, 11/4/23, 11/10/23, 11/11/23, 11/12/23, 11/15/23, 11/17/23, 11/18/23, 11/25/23, 11/26/23, 12/3/23, 12/6/23. 12/7/23, 12/13/23, 12/14/23, 12/21/23, 12/30/23, and 12/31/23. During an interview on 4/24/24 at 10:32 a.m., staff member H stated the data submitted was from a schedule provided by the ADON to the business office at the beginning of every month. Staff member H stated if changes were made to the schedule during the month, the business office did not receive an updated schedule. Staff member H stated she did not use employee timecards to enter data submitted for the PBJ was not always accurate. During an interview on 4/24/24 at 10:58 a.m., staff member A stated during a QAPI meeting it was identified from the [NAME] report that licensed staff were not submitted correctly to the PBJ. Staff member A stated the facility was working to develop a new process to report actual working hours for licensed staff to submit data to the PBJ.

Based on interview and record review, the facility failed to have an RN working at least eight hours per twenty-four hour period, seven days per week. This deficient practice had the potential to affect all residents who received skilled nursing services. Findings include: Record review of the October, November, and December 2022 schedules, for licensed nursing, showed the following dates did not have eight hours of RN coverage documented in a twenty-four hour period: - 10/22/22, 10/23/22, 10/29/22, 10/30/22, - 11/5/22, 11/6/22, 11/12/22, 11/13/22, 11/19/22, 11/20/22, 11/26/22, 11/27/22, - 12/4/22, 12/11/22, 12/17/22, 12/18/22. During an interview with staff member D, on 4/27/23 at 9:21 a.m., the facility staffing schedule and [NAME] PBJ report were reviewed and discussed, for the period of October to December, 2022. Staff member D stated there were no RN hours within a twenty-four hour period on the weekend dates, as noted in the prior paragraph. During an interview on 4/27/23 at 11:13 a.m., staff member A reported facility administration had addressed prior staffing deficiencies, and in the current year they have had RN coverage, for eight hours every day. The facility had not applied for an RN Nursing Waiver.

Based on interview and record review, the facility failed to ensure residents' records displayed the correct code status, correct physician orders, and correct staff notification of code statuses for three (#s 9, 10, and 17) of eighteen sampled residents. Findings include: 1. Review of the facility document titled, 24 Hour Shift Report, showed a list of the residents, their room numbers, and their CPR or DNR statuses. During an interview on [DATE] at 3:13 p.m., staff member A stated the resident code status, on the resident dashboard in the facility's electronic medical record (PCC), were the same as those on the report sheet the CNAs used. Review of resident #10's document, Montana Provider Orders for Life-Sustaining Treatment (POLST), dated and signed [DATE], showed the resident was a code status of DNR. Review of resident #10's code status, documented on the 24 Hour Shift Report, and on the resident dashboard in PCC, showed she was incorrectly identified as a code status of CPR. 48262 2. During an interview on [DATE] at 3:00 p.m., staff member I stated the residents' code status on the dashboard, was generated by a physician order, and it was the same as the 24 Hour Shift Report the Nurse and CNAs used during their scheduled shift. Staff member I said the 24 Hour Shift Report sheet was not generated by the electronic medical record, but was created by a staff member. Staff member I said that she was not aware of who created or updated the 24 Hour Shift Report sheet used by the nursing department. Review of resident #9's code status, documented on the 24 Hour Shift Report sheet, and on residents #9's dashboard in the electronic medical record, showed the resident's code status was Cardiopulmonary Resuscitation (CPR). Review of resident #9's Montana Provider Orders for Life-Sustaining Treatment (POLST), dated and signed [DATE], by the resident and provider, showed the resident's code status was Do Not Resuscitate (DNR). Resident #9's medical record and the facility's 24 Hour Shift Report was not consistent with the resident's signed POLST form. 48268 3. Record review of the facility document titled, 24 Hour Shift Report, showed the resident names, room numbers, and CPR or DNR status under the resident names. During an interview on [DATE] at 3:48 p.m., staff member A stated the facility document titled, 24 Hour Shift Report was not part of the medical record, but was something the staff developed to give shift report with. Resident #17 was listed on the 24 Hour Shift Report as a code status of CPR. Review of Resident #17's medical record included a completed Montana POLST form indicating No CPR. The POLST form was signed and dated by the resident on [DATE], and signed and dated by the healthcare provider, on [DATE]. Resident #17's medical record also included a code status of No CPR on resident's EHR dashboard. The resident's No CPR status was noted as reconfirmed with the resident on [DATE]. The resident's code status was accurately reflected in the medical record, but was inaccurately reflected on the 24 Hour Shift Report. During an interview on [DATE] at 3:10 p.m., staff member H reported if she needed to determine a resident's resuscitation status (CPR or DNR), she would look at the 24 Hour Shift Report.

Based on observation, interview, and record review, the facility failed to timely assess, identify, implement, monitor, and revise nutritional interventions for 2 (#s 5 and 10) of 6 sampled residents. Resident #5 had a weight loss of - 10.36% in six months. Resident #10 had a weight loss of - 12.57% in six months. Findings include: IMMEDIATE JEOPARDY On 4/28/2022 at 9:33 a.m., the facility Administrator and Director of Nursing was notified that an Immediate Jeopardy existed in the area of F692 - Nutritional Services. The Severity and Scope identified for the Immediate Jeopardy was identified to be at the level of J, and upon removal of immediacy lowered to a G. The IJ was called because of a facility wide system failure regarding failures to monitor, assess, and implement nutritional interventions for resident #10 that resulted in a severe weight loss. Immediate action was needed by the facility to prevent further harm or death related to the resident's weight loss. 1. During an observation on 4/27/22 at 12:45 p.m., resident #10 had appeared to have consumed less than 25% of her meal. During an interview on 4/26/22 at 10:01 a.m., resident #10 stated she had lost a lot of weight and wanted to gain weight. During an interview on 4/26/22 at 1:49 a.m., staff member D stated there had not been anything done for resident #10's weight loss other than putting in a request for a dietician consult for her. He stated he was not sure when the dietician came to the facility. During an interview on 4/27/22 at 7:47 a.m., staff member B stated resident #10's weight loss had been reported to her physician. She said resident #10's intake was monitored, and they offered the resident ensure with her meals. Staff member B stated the facility had not had a dietician since June of 2021, and they really needed one. Staff member B stated resident #10 may not have a nutritional care plan. During an observation and interview on 4/27/22 at 12:28 p.m., staff member G stated resident's who were ordered a 2 gram sodium diet usually got the same meal, just in smaller portions than the rest. She said the menu had come from another facility. Staff member G stated when serving, the staff utilized the dietary care cards. Resident #10's diet care card was blank. Staff member G stated she did not see what resident #10's diet order was on her electronic health record. Staff member G stated there were no special interventions in place for resident #10, but she was thinking about giving her boost. However, it was not in place and would not show in her electronic health record. Staff member G stated nursing never read the weights, but she had been inputting the weights for all residents on the fourth of the month. During an interview on 4/27/22 at 12:59 p.m., staff member D stated resident #10 was on a carb controlled diet. He said he would have given the diet order to the dietary manager to input into the electronic health record. Staff member D stated he had told the bus driver to schedule the resident a dietician consult upon her admission to the facility in November 2021. During an interview on 4/27/22 at 3:15 p.m., resident #10 stated her doctor told her she needed to gain weight, and was not sure why she lost it. Resident #10 stated she had not seen a dietician at the facility. During an interview on 4/27/22 at 3:31 p.m., staff member B stated there was no notification to the physician for resident #10's weight loss, and no physician notes for physician involvement in her weight loss. Staff member B stated she had no dietician notes because of the lack of a dietician since June 2021. She stated a dietician from the hospital came over last June three times and never came back. During an interview on 4/27/22 at 4:12 p.m., staff member B stated resident #10 was a really picky eater. Staff member B stated there were no doctor notes on the weight loss, but she could call the doctor and speak with him. During an interview on 4/27/22 at 5:00 p.m., staff member N stated he was aware of the residents weight loss and she had not been eating at times. Staff member N stated he could not even guess when he had been notified of resident #10's weight loss. Staff member N stated he was not confident in the intake monitoring of the residents meals due to having contracted staff in the building coming and going. Staff member N stated resident #10 should be on a regular diet. Staff member N stated resident #10 did have recent labs and everything looked good on those. Staff member N stated resident #10 should have been on a supplement of ensure, but he did not see those ordered in the electronic medical record either. Staff member N stated he and the facility had talked about resident weights about three weeks ago and resident #10 was one of them. During an interview on 4/28/22 at 9:29 a.m., staff member A stated resident #10 did not have any nutritional assessments, and staff member A was still looking for doctors notes. Review of resident #10's weights, showed on 11/25/21, the resident weighed 138.4 pounds. On 4/4/22, resident #10 weighed 121 lbs, which was a -12.57% loss in 6 months; a severe weight loss. Review of resident #10's diet card, undated, showed the residents name, and the rest of the card was blank. Review of resident #10's Order Recap Report, from 1/1/22 to 4/30/22, showed no order for a dietary supplement. Review of resident #10's pharmacy Consultation Report, dated 2/16/22, showed, [Name] medical record lacks documentation that a recent weight has been obtained as directed by the prescriber or facility policy/procedures. Review of resident #10's progress note, dated 3/18/22, showed, Resident is in the dining room eating supper when she began choking. [Staff member] was in the dining room and responded doing the Heimlich maneuver .[sic] Review of resident #10's Care plan, dated 12/28/21, showed: - On 11/20/21, weekly weights were initiated for resident #10. - On 11/20/21, Diet consult as necessary. - On 12/28/2021, Diet CCHO diet for diabetes. - No new interventions were care planned for resident #10's weight loss or choking. Review of resident #10's diet order, dated 12/29/21, showed, CCHO (controlled Carbohydrate) diet, regular texture, 2 gram Sodium (low sodium)[sic]. Review of resident #10's Quarterly MDS, with an ARD of 2/28/22, showed under K0300, resident #10 had weight loss, and it was not on a physician prescribed weight-loss regimen. A request for resident #10's meal intake monitoring for the last 6 months was made on 4/27/22. No documentation was provided by the facility. On 4/27/22 at 3:14 p.m., staff member B stated they did not have meal intake monitoring due to not having a dietician. A request for notification of resident #10's weight loss to the doctor was made on 4/27/22. No documentation was received by the facility. A request for physician notes for resident #10 was made on 4/27/22. No documentation was received by the facility. A request for resident #10's nutritional assessments was made on 4/27/22. No documentation was received by the facility. A request for dietician notes for the last six months was requested on 4/26/22. No documentation was received from the facility. The facility failed to take timely action on ensuring the resident's severe weight loss was addressed. 2. During an interview on 4/28/22 at 10:37 a.m., staff member D stated he was not sure if resident #5 had a weight loss. NF2 calculated the weight loss for resident #5 with staff member D at 11%. Staff member D stated resident #5's weight loss was not identified. The 11% would be a severe weight loss. During an interview on 4/28/22 at 10:48 a.m., staff member G stated she put the weights in the electronic health record on the third of every month. Staff member G stated she filled out forms for the doctor that rounded in the facility, but she had never received any information for the resident back. Staff member G stated she had filled one out for resident #5, because there were notifications in the electronic health system when she put the weights in, but never got any information back. During an interview on 4/28/22 at 10:52 a.m., staff member B stated resident #5 had lost a little weight but not much. Staff member B stated she had been notified by staff of the weight loss a few weeks ago. Staff member B stated they monitored resident #5 by her meal intakes that the staff completed every meal. Staff member B stated she believed resident #5 had a nutritional supplement given to her called boost. Review of resident #5's weights, showed, on 11/25/21, she weighed 117.8 lbs. On 4/4/22 resident #5 weighed 105.6 pounds, which is a -10.36 % loss in six months; a severe weight loss. Review of resident #5's care plan, reviewed on 12/28/21, showed: - Provide, serve diet as ordered. Monitor intake and record q meal. Date initiated: 10/13/21. - RD to evaluate and make diet change recommendations PRN. Date initiated: 10/13/21. - Monitor/record/report to MD PRN of s/sx of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3 lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. Date initiated: 10/31/21. Review of resident #5's meal intakes from 3/30/22 to 4/28/22, showed: -She ate 76-100% of her meals 27 times. -She ate 51-76% of her meals 12 times. -She ate 26-50% of her meals 18 times. -She ate 0-25% of her meal 2 times. -59 out of 84 meals were documented on the intake monitoring form. Review of resident #5's diet order, dated 7/20/21, showed, Regular Diet, Regular texture, Thin consistency [sic]. Review of resident #5's progress notes, dated 10/27/21-4/27/22, showed no doctor notification for weight loss and no dietician notes. A request was made for resident #5's nutritional assessments on 4/28/22. No documentation was provided from the facility. A request was made for resident #5's dietician notes on 4/28/22. No documentation was provided from the facility. A request was made for resident #5's physician notes on 4/28/22. No documentation was provided from the facility.

Based on observation, interview, and record review, the facility failed to treat and identify a pressure ulcer after admission for 1 (#8), and failed to prevent and provide treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: During an observation and interview on 4/14/21 at 9:05 a.m., staff member J provided pericare for resident #8. An open area was observed below the resident's coccyx. Staff member J stated the area had always been there, and the CNAs put a barrier cream on it twice a day. After resident #8's care was completed, the resident was positioned on her back. Review of resident #8's Admission Screening, dated 3/11/21, showed the presence of a Stage II pressure area to the coccyx, and a Stage I pressure area to the left toe. Review of resident #8's Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The pressure area was identified upon admission, but no treatment was provided until 4/15/21. During an interview on 4/14/21 at 11:54 a.m., staff member A stated resident #8's treatment order from the physician might not have been implemented because of confusion regarding how the [MEDICATION(S)] was purchased. She was not aware resident #8's pressure area was open. Staff member A stated skin conditions are identified when the residents have a bath; the CNAs fill out a Comprehensive CNA Shower Review form. Review of resident #8's Comprehensive Review Form, dated 4/11/21, showed no concerns for the coccyx area. Review of resident #8's Comprehensive Review Form, dated 4/12/21, showed a circle around the coccyx area. The form had been signed by staff member C. During an interview on 4/14/21 at 12:59 p.m., staff member C stated when she signed the skin report on 4/12/21, she should have looked at the area on the coccyx and called the physician with an update. She did not know why the treatments for the wound had not been implemented. During an interview on 4/14/21 at 2:27 p.m., staff member D looked through the electronic record for resident #8, and stated there had been a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident #8's Care Plan, dated 3/29/21, showed, Assess/record/monitor wound healing daily. Review of resident #8's Nursing Progress Notes from the admitted [DATE] through 4/14/21 did not show documentation of the pressure ulcer. During an interview on 4/14/21 at 2:50 p.m., resident #8 stated her toe had healed. Review of resident #8's physician orders, dated 4/14/21, showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A dressing change was documented on 4/15/21. During an observation of resident #8's wound care on 4/15/21 at 9:58 a.m., staff member D did not use '[MEDICATION(S)]' during the wound treatment, as ordered by the physician. She stated she forgot, and the '[MEDICATION(S)]' was in her pocket. 2. During an interview on 4/14/21 at 9:52 a.m., staff member D stated the pressure ulcer for resident #10 had been discovered on 12/2020 and believed it was a Stage II. Staff member D stated a duoderm control gel dressing was applied every other day. Staff member D stated the wound on resident #10's coccyx measured 2.5 x 1 cm. on 4/14/21. Staff member D stated the resident had no interventions in place prior to the development of the wound because he had been able to move around the facility in his wheel chair on his own, and was able to reposition himself. He had been declining in the last six months, and his potential for pressure ulcers had increased. Staff member D stated resident #10 now had an air mattress on his bed, and a cushion in his wheel chair. Staff member D stated the resident was to be turned and repositioned every two hours when in bed. Staff member D stated the wound had originally been overlooked, but was now being treated. During an interview on 4/14/21 at 1:44 p.m., staff member A stated she had not measured the wound in awhile. Staff member A stated it is the expectation that wounds be measured according to the physician orders. Staff member A stated some of the orders were being sent to the pharmacy and were not ending up on the TAR. Review of resident #10's medical record did not show there was a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Review of resident #10's MAR for April 2021 showed wound care was completed on 4/6, 4/9, and 4/12. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply to coccyx one time a day every 3 days for wound. May change Duoderm patch as needed. Start date of 4/6/21. Discontinued date of 4/14/21. Review of resident #10's MAR for 3/1/2021-3/31/2021 did not show documentation for pressure ulcer care. Review of the Wound Clinic physician orders, dated 3/29/21, showed resident #10 had a Stage 2 pressure ulcer on the right buttock. It measured 1.8 cm x 1.7 cm x 0.2 cm, with the following wound care orders; 1. Remove old dressing. 2. Cleanse with NS. 3. Use collagen as the primary dressing. Use [MEDICATION(S)] Plain and [MEDICATION(S)] Gentle as the secondary dressing. 4. This order to be carried out two times per week for three weeks. 5. Patient up for meals only and while in bed turned and repositioned every 2 hours. The MAR/TAR for March and April did not have documentation for the orders written by the wound care clinic physician. Review of resident #10's most current care plan, dated 2/24/21, did not show problems, goals, or interventions for wound care to the coccyx. Review of resident #10's nursing progress notes showed the following: -On 12/24/20; during a shower the resident was noted to have a shallow wound to R buttock crease where buttock meets thigh. Wound bed is pink with yellow nonviable tissue present. No depth noted. Area cleansed thoroughly in shower and thick skin protectant cream applied in order to protect this area from shear. -On 1/11/21; Stage III pressure ulcer to right buttock. Wound bed pink granular tissue with yellow nonviable tissue intermixed to base of wound. Edges of wound intact and raised and light pink epithelial tissue observed. Wound and surrounding skin cleansed thoroughly and patted dry. Skin barrier applied to periwound and surrounding skin. DermaThin dressing applied. Dressing to be changed in 2-3 days and PRN. -On 1/13/21; Resident has a progressive pressure ulcer, cleaned, dried, and applied bandage. Will continue to monitor area, contact MD about further care. -On 1/30/21; Dressing change done as ordered. Removed old dressing with small-mod amount of whitish, yellowish drainage. Ulcer size 2 cm x 2 cm x 0.25 cm no redness noted. Med-honey applied to ulcer wound bed and covered with 4x4 [MEDICATION(S)] Foam dressing. -On 2/2/21; During resident's bath, nurse observed moderate amounts of bright red blood oozing from Resident's right buttock ulcer. Cleansed, and dressed with [MEDICATION(S)] and [MEDICATION(S)]. Will follow up on Resident's wound care appointment scheduling. -On 2/6/21; Dressing change to coccyx, removed old dressing with minimal drainage. No odors present, intact edges, sloughing and white macerated tissue in wound bed. 2cmx2cmx0cm, cleansed with normal saline, wiped with sterile gauze, placed [MEDICATION(S)] in wound bed and placed island dressing over wound. No s/sx infection. -On 2/11/21; Per order; changed dressing to left gluteus; washed with wound cleanser, dried with sterile gauze, placed [MEDICATION(S)] in wound bed, applied island dressing over top of wound. -On 2/20/21; Per order; changed dressing to left gluteus; measures 1.5cmx1.5cmx0cm. -On 3/25/21; Resident has new areas of pressure developing on lateral aspects of both of his knees. -On 3/27/21; Dressing change to left gluteal fold. Measures 1cm x 1cm x 0.5cm. Dpeth [sic] has increased. -On 4/5/21; DON [name] requested that [physician name] be called to change resident's current treatment regiment [sic] to coccyx to Duoderm patch every three days and as needed till healed. Call placed to [physician name] as requested and was informed about the DON's request as well as about the wound to residents left leg. Order received to apply Duoderm patch to coccyx every three days and as needed until healed .

Based on observations, interview, and record review, the facility failed to identify, implement interventions, and monitor a resident's weight to prevent significant weight loss for 1 (# 8) and severe weight loss for 1 (#12) of 3 sampled residents. Findings include: 1. During an observation on 4/14/21 during lunch, resident #8 was not able to eat more than 25 percent of the roast beef and none of the vegetable. A substitution was not provided by staff in place of the items not eaten. During an observation on 4/15/21 during breakfast, resident #8 was not able to eat the bacon, and was not provided a substitute by the staff. Review of resident #8's Care Plan, dated 3/29/21, showed The resident will comply with recommended diet for weight reduction [sic] . Interventions included: weigh every morning prior to breakfast . Administer medications as ordered . Provide and serve diet as ordered: controlled carb diet with mechanical soft texture and thin consistency. Review of resident #8's physician order, dated 4/4/21, showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview and observation on 4/13/21 at 2:08 p.m., staff member H took a supplement out of the medication cart and said it was for resident #8. The supplement was [MEDICATION(S)], and provided 25 calories per serving. She said she was told by the nurse to use that as a substitute for the [MEDICATION(S)]. Review of the manufacturer's [MEDICATION(S)] information showed it was a food enhancer, and provided 333 calories for each 1.5 ounce, mixed with food. Review of resident #8's Nursing Admission Screening, dated 3/11/21, did not include an admit weight. Review of resident #8's Weights/ Vitals section of the electronic record showed the weight section was blank. Review of resident #8's Admission MDS, with the ARD of 3/24/21, showed a weight of 142 pounds. Review of resident #8's electronic record showed no documented daily weights, as documented in the Care Plan. A weight for resident #8 was requested by the surveyor on 4/14/21, and the weight was 135 pounds, a 5 percent decline and significant weight loss in less than one month. 2. During an observation and interview on 4/14/21 at 9:19 a.m., resident #12 had a bowl of cereal and juice on his bedside table. He was reclining in bed. He was not able to communicate. Staff member J stated the resident had not been eating, and had lost a lot of weight. He gestured he did not want breakfast this morning. Staff member J said, resident #12 would not drink a supplement, and she said he cannot speak. Sometimes he used sign language or a white board to communicate. Staff member J stated the resident would order fast food on [CONDITION(S)] days, but usually gave it away. Review of resident #12's Care Plan, dated 2/27/21, showed the facility should not weigh the resident. The restorative aide should document the dry weight from the [CONDITION(S)] center. Review of resident #12's Wt/Vital section of the electronic record showed the facility weighed the resident, and many of the weights were high weights, then a low weight. During an interview on 4/15/21 at 10:35 a.m. staff member A stated the facility had issues with the accuracy of the scale. She stated a new scale had been ordered, and the Hoyer lift scale weights were different from the wheelchair scale. She stated the Restorative Aide had assisted with obtaining resident weights, and would input them into the electronic record, the facility no longer had a Restorative Aide. Review of the [CONDITION(S)] Communication Record for resident #12, dated 4/10/21 and 4/13/21 did not include weights. Review of resident #12's Nursing Progress Note, dated 1/29/21 showed the resident ate 25 percent or less for 2 or more meals in the day. Review of resident #12's Nursing Progress Note, dated 3/7/21 showed the resident ate 25 percent or less for 2 or more meals in the day. Review of resident #12's Nursing Progress Note, dated 3/15/21 showed the resident ate 25 percent or less for 2 or more meals in the day. A supplement was offered and refused. Review of resident #12's Nursing Progress Note, dated 3/16/21 showed the resident ate 25 percent or less for 2 or more meals in the day. Review of resident #12's Nursing Progress Note, dated 3/17/21 showed the resident ate 25 percent or less for 2 or more meals in the day. Review of resident #12's Nursing Progress Note, dated 4/10/21, showed staff member A spoke with the [CONDITION(S)] nurse, who reports the resident had lost some significant weight, and the [CONDITION(S)] dietician would follow up with the nursing home and offer some recommendations. Review of resident #12's weight on 3/15/21 showed a weight of 140 pounds. The surveyor requested a current weight on 4/14/21, which was 126.2 pounds, a 10 percent severe weight loss in one month. Review of resident #12's progress note, dated 4/10/21, showed the physician was notified of the weight loss, and ordered Boost, protein powder drink, and double portions for meals, despite the fact the resident was reported to be not eating, and refusing supplements. The note stated the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of resident #12's Care Plan, dated 2/27/21, did not include interventions or potential causes for the weight loss. The facility did not identify or implement interventions until notification of the weight loss was received from the [CONDITION(S)] center on 4/10/21.

Based on observation, interview, and record review, facility staff failed to ensure hot liquids (coffee) were served at a temperature not to burn residents which affected 1 (#22) when the resident was burned by hot coffee; failed to ensure 4 (#s 1, 3, 17, and 23) residents were safe while smoking and staff followed the smoking policy; and failed to ensure staff safely transferred 2 (#s 10 and 25) of 14 sampled and supplemental residents. Findings include: Hot liquids: A review of a facility reported incident, dated 9/9/19 at 4:20 p.m., reported to the State Survey Agency on 9/27/19, showed resident #22 had sustained a burn to his left middle finger from a percolating coffee pot in the dining room. Facility staff immediately removed the percolator from the dining room. Temperatures of the percolated coffee pot were documented as 181 degrees. The facility reported incident showed the incident occurred in the dining room, witnessed by dietary staff, and it was reported to the former DON. The facility report showed they immediately removed the percolator from the dining room, cooled the coffee (pot) temperature for resident use, and had the coffee percolator fixed. Review of the investigation notes showed the resident and all staff involved were interviewed. Resident #22 sustained a 1 cm x 1 cm, serous fluid filled, intact, blister to the tip of middle finger on his left hand. The coffee brewer was fixed and (staff) utilized that immediately. No [MEDICAL CONDITION] been reported. During an observation and interview on 3/2/20 at 2:55 p.m., staff member S stated the coffee in the carafe had just been brewed. Staff member S obtained a temperature reading on the coffee. The temperature was 174 degrees. The coffee was to be placed out in the dining room for the residents. During an observation and interview on 3/3/20 at 8:40 a.m., the coffee in the carafe in the dining room was 173 degrees. The activities coffee carafe temperature was 172 degrees. Both carafes were in the dining room for resident use. Staff member U stated the coffee had been brewed at 8:30 a.m. During an observation on 3/4/20 at 7:15 a.m., the coffee in the carafe in the dining room was 142 degrees. During an interview on 3/2/20 at 1:55 p.m., staff member U stated the kitchen thermometers were just calibrated on 2/29/20. During an interview on 3/3/20 at 3:39 p.m., staff member A stated the kitchen staff had not been monitoring and tracking coffee temperature reading of the carafes available for resident use. During an interview on 3/3/20 at 4:15 p.m., staff member A stated he was able to get the coffee machine turned down to 170 degrees, and he was still trying to get the temperature to 145 degrees. He stated he had a call into the manufacturer for assistance. Staff member A stated after the incident in September 2019, when a resident got burned from the coffee, the facility staff moved the coffee maker to the kitchen and started using the carafes for the coffee. A facility policy and procedure titled, Safe Water/Coffee Temperatures, was reviewed. The policy showed . 1. Water/Coffee temperatures will be monitored and logged in all food and dining areas accessible to employees, residents as part of routine facility maintenance Smoking: 1. During an observation on 3/2/20 at 1:40 p.m., resident #1 and #23 were seated outside, in front of the entrance doors to the facility, smoking, unsupervised. At 1:43 p.m., an unknown staff member brought another male resident out to smoke. None of the residents wore a smoking apron. There was a no smoking sign posted on the entrance doors, NOTICE, No Smoking within 25 feet . During an observation on 3/3/20 at 9:33 a.m., the resident smoking area was observed. There was a coffee can on the ground with cigarette butts in it. There was a facility dining-room chair outside with a cigarette burn hole on the seat. There were numerous cigarette butts on the ground, inside a circular area, that had rocks and dried leaves in it and on the sidewalk. During an observation on 3/4/20 at 4:00 p.m., staff member A was shown two dining-room chairs that were outside where the residents are supposed to smoke. The two chairs had cigarette burn holes in the seats. Staff member A was shown a coffee can with cigarette butts in it and cigarette butts that were on the ground, inside a circular area, that had rocks and dried leaves in it and on the sidewalk. a. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. His most recent Annual MDS, with an ARD of 10/14/19, lacked a BIMS assessment. Review of an Annual MDS, with an ARD of 10/3/18, showed a BIMS of 5; severely impaired cognition. A review of resident #1's Care Plan, revised on 2/26/20, read, .Remind the resident that he must smoke under the canopy outside. The resident refuses to smoke in this designated area even after continuous reminders . The residents smoking supplies are stored by the facility staff at nurses station. A review of resident #1's Smoking Assessment, dated 1/3/20, showed the resident required minimal assistance to smoke. b. Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. His most recent Annual MDS, with an ARD of 2/7/20, showed a BIMS of 8; moderately impaired cognition. A review of resident #3's Care Plan, revised on 2/12/20, read, Monitor for any unsafe smoking practices. Observe clothing and skin for signs of [MEDICAL CONDITION]. The resident a supervised smoker. The residents smoking supplies are stored by the facility staff at nurses station. When taking resident outside to smoke, remind him that he must go to the designated smoking area under the canopy to smoke with whoever is taking him outside to smoke. A review of resident #3's Smoking Assessment, dated 1/3/20, showed the resident required minimal assistance to smoke. c. Resident #17 was admitted to the facility with [DIAGNOSES REDACTED]. His most recent Quarterly MDS, with an ARD of 12/26/19, showed a BIMS of 10; moderately impaired cognition. A review of resident #17's Care Plan, revised on 2/26/20, read, Monitor for increase in unsafe smoking practices . Remind resident of smoking risks and hazards, such as the need to wear a smoking apron . The resident requires supervised smoking or wear an apron. If the resident refuses to put apron on staff will remain with the resident and assist to properly extinguish the cigarette. A review of resident #17's Smoking Assessment, dated 1/3/20, had not been completed. d. Resident #23 was admitted to the facility with [DIAGNOSES REDACTED]. His Admissions MDS, with an ARD of 1/22/20, showed a BIMS of 9; moderately impaired cognition. A review of resident #23's Care Plan, initiated on 1/29/20, read, The resident was able to light own cigarette but must wear an apron or be supervised, smoking material kept by nursing staff . A review of resident #23's Smoking Assessment, dated 1/29/20, showed the resident required minimal assistance to smoke. During an interview on 3/3/20 at 3:11 p.m., staff member V stated resident #4 keeps his cigarettes and lighter in his coat pocket. Staff member V stated resident #23 kept his cigarettes and lighters in his coat. He stated the other residents had their cigarettes and lighter in the facility pantry. Staff member V stated sometimes resident #23 gave cigarettes to resident #1, as that is the culture. Staff member V stated resident #23 had a smoking apron, but did not like it, so resident #23 hid the apron, in December of 2019, and the staff were not able to find it. During an interview on 3/3/20 at 3:57 p.m., staff member B stated she was not sure if the smoking aprons were ordered or not. Staff member B stated she did not realize resident #4 and #23 had cigarettes and lighters in their room. During an interview on 3/4/20 at 5:00 p.m., staff member A stated he could not find documentation in resident #23's medical record that he refused or hid the smoking apron. During an interview on 3/4/20 at 6:00 p.m., staff member L stated all the residents have to wear a smoking apron, and they could go out every two to three hours. She stated resident #s 1, 3, 4, 14, and 23 all needed supervision while smoking. Staff member L stated there were usually two smoking aprons behind the laundry door. Staff member L showed the surveyor where the smoking aprons were usually kept. There were no smoking aprons observed. She stated the, Smoking aprons looked like a dishwashing cloth and must be in the laundry. During an interview on 3/4/20 at 6:10 p.m., staff member W stated resident #17 was the only resident who wore a smoking apron. Staff member W stated the smoking aprons were kept by the front door on the hooks. There were no smoking aprons observed by the front door on the hooks. During an interview on 3/4/20 at 6:25 p.m., staff member X stated resident #17 needed a smoking apron and staff supervision. She stated the staff had to fold the apron and put it up as resident #17 would try to hide the aprons. Staff member X said the extra smoking aprons were in the supply room. Staff member X showed the surveyor two un-opened smoking aprons, still in their packaging. The smoking aprons were in the supply room, on the bottom shelf, under some supplies. During an interview on 3/5/20 at 8:25 a.m., resident #23 stated he was upset the staff took his cigarettes and lighter away. He stated he had always kept them and always been able to go out and smoke whenever he wanted. He stated he kept his cigarettes and lighter in his pocket and there is no safer place for them. He stated he was not going to stay at the facility if he could not keep his smoking items. Staff member A was informed of the statements resident #23 made. Staff member A stated he would talk with resident #23 and would re-educate all the staff, residents, and family members on the smoking policy. A review of the facility's policy, Resident Non-Smoking, read, . 1. Prior to or upon admission, residents shall be informed that smoking is not permitted in this facility. Smoking is only allowed outside. 2. The outside smoking area will be accessible to all residents. Staff will assist residents when it has been determined by a 'Smoking Assessment' that the resident needs assistance when smoking . Transfers: 1. During an observation on 3/4/20 at 8:00 a.m., staff members G and N transferred resident #10 from a lift to her wheelchair. The brakes on the wheelchair were not locked. Staff members G and N stood on each side of resident #10's wheelchair as she was lowered into her chair. During an interview on 3/4/20 at 8:25 a.m., staff member N stated the wheelchair brakes should have been locked when resident #10 was transferred to the wheelchair. Review of resident #10's Care Plan, revised on 2/26/20, read, .Transfers: The resident is totally dependent on (2) staff for transferring and use of lift. 2. During an observation on 3/4/20 at 10:30 a.m., staff members N and Q transferred resident #25 from the bed to the wheelchair. Neither staff members locked the brakes on the wheelchair when lowering resident #25 to the wheel chair via the mechanical lift. During an interview on 3/4/20 at 11:15 a.m., staff member N stated the brakes should always be locked when transferring a resident to the wheelchair. Staff member Q stated they did not lock the brakes on resident #25's wheelchair, they just held it in place, in case they had to move the wheelchair when they lowered the resident into the wheel chair from the lift. Review of resident #25's Care Plan, revised on 4/4/19, did not address how staff were required to transfer the resident to and from his wheelchair. A review of a facility facsimile document submitted on 3/6/20 at 9:59 a.m., read, There is no P & P for Transferring residents to and from the wheelchair.

Based on observation, interview, and record review, facility staff failed to ensure 1 (#22) of 12 sampled residents had received prescribed anti-[MEDICAL CONDITION] medications, as ordered, and the resident had a [MEDICAL CONDITION]. Resident #22 was transported to the Emergency Department (ED) via Emergency Medical Services (EMS). This deficient practice had the potential to affect residents receiving anti-[MEDICAL CONDITION] medications from facility staff. Findings include: During an observation on 3/3/20 at 10:13 a.m., staff member E identified resident #22 seated in the dining room. Staff member E administered medications to resident #22, ordered for 8:00 a.m., two hours late. During an observation on 3/3/20 at 10:43 a.m., resident #22 had a [MEDICAL CONDITION] in the dining room. Staff member C brought equipment to obtain resident # 22's vital signs, and EMS was contacted. Review of resident #22's Care Plan, with a revision date of 4/12/19, showed interventions included, Anti-[MEDICAL CONDITION] medication as ordered for patient care of [MEDICAL CONDITION] diagnosis . Review of resident #22's Progress notes, dated 3/3/20 at 10:52 a.m., read, Resident presents with [MEDICAL CONDITION] in the dining room today at approximately 1045, (sic) witnessed by activities staff member, CNA notified this nurse, VSS T 98.3 F P 71 BP 102/82 POX 95%, [MEDICAL CONDITION] lasted for 4 minutes, resident is in a postictal state, no meds administered to break [MEDICAL CONDITION], squad arrived at 1053 to transfer resident to ER for further evaluation, resident has had no recent [MEDICAL CONDITION] in the past 2 months, transferred to ER via ambulance at 1100, report called to (name), unable to reach POA by phone, left message requesting call back, all other appropriate parties aware. Review of resident #22's ER Discharge Education, dated 3/3/20 at 2:48 p.m., read, Your ammonia level was 90 (high); your [MEDICATION NAME] level was 7.8 (low) . During an interview on 3/3/20 at 2:33 p.m., staff member B stated facility staff should administer medications according to the physician's orders [REDACTED]. Staff member B stated medications for resident #22 should have been a priority. Staff member B stated it was the expectation of staff to administer medications within one hour from the time ordered by the physician. During an interview on 3/4/20 at 11:36 a.m., staff member M stated resident #22's medications should have been administered at the time the medication was prescribed to be dispensed. Staff member M stated getting anti-[MEDICAL CONDITION] medications hours late was not a good thing. Staff member M stated he was new to the facility and thought resident #22 had been [MEDICAL CONDITION]-free for years. During an interview on 3/4/20 at 1:17 p.m., staff member E stated resident #22 should have received his medications in a timely manner. During an interview on 3/4/20 at 6:14 p.m., staff member F stated resident #22 should receive his medications within one hour of the time the medication were ordered. Staff member F stated he follows the medication administration standards, One hour before and one hour after, the prescribed time. Review of resident #22's March 2020, Medication Administration Record [REDACTED] - [MEDICATION NAME] 1 milligrams (mg) by mouth twice daily related to [MEDICAL CONDITION] - [MEDICATION NAME] 100 mg by mouth in the morning for [MEDICAL CONDITION] - [MEDICATION NAME] delayed release 500 mg by mouth twice daily for [MEDICAL CONDITION] - [MEDICATION NAME] 10 mg/ 15 milliliters (ml), 30 ml by mouth three times a day for ammonia level - Levetiracetam 500 mg, 2 tablets, twice daily for [MEDICAL CONDITION] - [MEDICATION NAME] 5 mg by mouth once a day for hypertension - [MEDICATION NAME] 10 mg by mouth once a day for itching - [MEDICATION NAME] 850 mg by mouth once a day for diabetes mellitus - Multiple Vitamin once a day for vitamin deficiency - [MEDICATION NAME] Acidophilus by mouth once daily for diarrhea - [MEDICATION NAME] delayed release 40 mg by mouth once daily for ulcer - Polyethylene [MEDICATION NAME] 3350, give 17 grams by mouth one time a day for bowel management with 8 ounces (oz) of fluids Review of resident #22's March 2020, Administration History Report, showed late administration times for prescribed anti-[MEDICAL CONDITION] medication administered on: - 3/2/20 all 8:00 a.m., doses of medications were administered at 9:10 a.m.; 1 hour and 10 minutes late - 3/2/20 all 8:00 p.m., doses of medications were administered at 11:59 p.m.; 3 hours and 59 minutes late. A review of Progress Notes, dated 7/12/19 through 3/4/20, lacked rational for medication being administered late. Staff documented on 9/1/19 at 10:00 a.m., resident #22, .Had a [MEDICAL CONDITION] in the dining room. patient was taken back to room and put in bed. he was not seizing when i got to dining room. patient had not urinated or defecated. will continue to monitor. Staff documented on 9/9/19 at 9:54 a.m., resident #22 had a [MEDICAL CONDITION], approx. 3 1/2 minutes. 2 ml [MEDICATION NAME] administered as ordered PRN for [MEDICAL CONDITION] Resident responded to [MEDICATION NAME] well recognizing name and responding with a slight smile . Review of resident #22's Medication Admin (sic) Audit Report, showed late administration times for prescribed anti-[MEDICAL CONDITION] medication administered on: - 9/2/19 all 8:00 a.m., doses of medications were administered at 11:40 a.m.; 3 hours and 40 minutes late - 9/2/19 all 8:00 p.m., doses of medications were administered on 9/3/19 at 1:52 a.m.; 4 hours and 52 minutes late - 9/4/19 all 8:00 p.m., doses of medications were administered at 10:33 p.m.; 2 hours and 33 minutes late - 9/5/19 all 8:00 p.m., doses of medications were administered at 10:46 p.m.; 2 hours and 46 minutes late - 9/6/19 all 8:00 p.m., doses of medications were administered on 9/7/19 at 12:06 a.m.; 4 hours and 6 minutes late - 9/7/19 all 8:00 p.m., doses of medications were administered on 9/8/19 at 1:11 a.m.; 5 hours and 11 minutes late - 9/8/19 all 8:00 p.m., doses of medications were administered on 9/9/19 at 3:07 a.m.; 6 hours and 7 minutes late Review of the facility's policy, Administering Medications, read, . 3. Medications must be administered in accordance with the orders, including any required time frame. 4. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) .

Based on observation, interview, and record review, the facility failed to reduce the risk of accident hazards by not appropriately assessing and implementing interventions for residents at risk for falls, for safety, and the residents' had injuries with the falls, for 3 (#s 5, 8 and 11); and the facility failed to sufficiently supervise and provide equipment for safety for a resident with a history of dementia, who as deemed unsafe to smoke independently for 1 (#12); and failed to accurately assess and implement interventions to ensure the safety of a resident who smoked, and the resident had a history of [REDACTED].#2) of 14 sampled and supplemental residents. Findings include: 1. During an observation on 2/2/19 at 4:30 p.m., resident #11 was at the nursing station. He was hanging onto the desk and appeared unsteady on his feet, and at risk for falling. During an interview on 2/3/19 at 1:54 p.m., staff member H stated resident #11 had previously fallen because he was wearing flip flops. Review of resident #11's nursing progress notes showed: - The resident had a fall on 12/30/18. Significant bruising was found around the resident's right eye, and the resident was unable to bear weight on both legs. Resident #11 was sent to the ER for further evaluation. - - A nursing progress note dated 1/1/19 showed resident #11 was witnessed sliding to the floor, and (Resident #11) denies any pain or discomfort Resident has ecchymosis (and) [MEDICAL CONDITION] to R eye, skin tear to R knee from earlier fall. - A nursing progress note, dated 1/3/19, showed Right knee is very bruised and resident is limping more than usual. Sending to the ER at this time for X-ray. - A nursing progress note, dated 1/24/19, showed a CNAs found resident #11 sitting on the floor, and he denied any injury (from fall). A review of resident #11's fall report, dated 12/30/18 showed the resident had an un-witnessed fall on 12/30/18. No evaluation and analysis of the risk factors, or direct causes were evident, such as new medications, confusion, or improper foot wear, and no new interventions were identified for the prevention of future falls. The form showed (Resident #11) was wearing flip-flops on his feet. The resident's medical record failed to show evidence of subsequent reports for the other falls (noted above) had been completed. Review of resident #11's current Care Plan, requested on 2/5/19, showed no focus area related to falls. There were no new goals identified for the resident's safety, and no new interventions to minimize the risk for the resident's falls, to include for those falls on 12/30/18, 1/1/19, and 1/24/19. 2. During an interview on 2/2/19 at 1:22 p.m., resident #8 stated he had a fall in the bathroom, when he transferred himself from his wheelchair onto the toilet. The resident stated he was a little sore for awhile after the fall. A review of resident #8's fall report, dated 12/21/18, showed the resident was found on the floor by a CNAs. Resident #8 was quoted saying The wheels on my wheelchair haven't been locking right and I fell . My hip, neck and shoulder hurt. Resident #8 was not moved from his position on the floor until the ambulance arrived to transport him to the ER. There was no evaluation or analysis of the direct root cause of the falls or risk factors contributing to the falls, and no new interventions were identified for future fall prevention to show the facility was proactive for the safety of the resident, related to falls. A review of resident #8's current Care Plan, requested on 2/4/19, showed the facility had not identified a problem focus area related to falls. There were no goals for fall safety, and no new interventions were identified to minimize the risk for falling, related to wheelchair transfers, although the resident has suffered pain in multiple areas of the body, related to the fall. 3. During an interview on 2/4/19 at 10:54 a.m., Staff member G stated resident #5 received therapy three days a week. Staff member G stated when resident #5 could not walk anymore, a restorative staff member met with the resident and evaluated him, and then an AFO was ordered (a brace). A review of resident #5's fall report, dated 1/13/19, showed the resident slid to the floor during an assisted wheelchair transfer. The report showed resident #5 was checked for injury. There were not an evaluation or analysis of the root cause or the contributing factors for the fall or prevention of the fall from the wheelchair during transfers. A review of resident #5's current Care Plan, requested on 2/3/19, showed the facility staff had not identified any problem focus areas, related to falls, and there were no new goals or interventions implemented for the resident's safety, related to prevention of future falls. During an interview on 2/4/19 at 10:18 a.m., staff member D stated the facility IDT discussed any new resident falls during the morning stand up meeting. He stated the team discussed if the facility needed to add anything to the resident's care plan, or if the fall was an isolated event. He stated We don't really do a root cause analysis, and we don't do a post fall huddle (staff gathering to discuss fall event). Staff member D stated resident #8 was trying to transfer, and he didn't lock his breaks, so we educated him on locking the brakes. During an observation and interview on 2/5/19 at 8:49 a.m., staff member E stated, the CNAs will usually find out which resident is a fall risk, when told by the nurse. If the resident falls, staff member E stated, We have to do neuro checks, we check on the resident frequently, bring them where they need to go, and help them in the bathroom. Staff member E stated I don't think resident #11 is a fall risk, he might be? (Resident #8) uses his wheelchair, rehab might help him. Staff member E stated the staff use gait belts for transfers, and the belts were kept in the resident's room. Staff member E entered the shared room of resident #8 and #11, and did not find a gait belt in the room. During an interview on 2/5/19 at 9:07 a.m., staff member F stated the nurses usually tell the CNAs who is a high risk for falls. Staff member F stated, I guess you could consider resident #5 high risk, he likes to flop back in his chair after you change him. Staff member F stated some residents have gait belts in their rooms, but most residents just need supervision, or we just hold their pants (so if the resident falls staff can help stop the fall). During an interview on 2/4/19 at 1:16 p.m., staff member I stated the team gets together when a resident falls and evaluates what can be done to avoid more falls. The process is to complete a head to toe assessment, and vital signs. The physician, family and Director of Nursing are to be notified of a fall. Staff member I stated when the fall is unwitnessed, the resident needs to be placed on monitoring for frequent vital signs and neurological checks, in case the resident hit their head. Staff member I stated he is ultimately responsible to update the Care Plan when there is a new issue identified related to a resident and falls. A review of the facility's Fall Protocol dated 5/31/17, showed The staff witnessing the fall will initiate incident/injury report and give it to the charge nurse .residents with a fall will stay on alert charting (fall monitoring) for 3 days . 4. During an observation on 2/2/19 at 1:00 p.m., resident #12 was observed outside the facility main entrance, in his wheelchair, smoking without supervision. The resident did not have a smoking apron. During an interview on 2/2/19 at 2:01 p.m., resident #12 stated I smoke. You have to go outside to smoke, it can be anywhere outside. I have my own cigarettes and keep them at the nurses station. During an observation on 2/3/19 at 11:42 a.m., resident #12 was observed coming in from outside the facility main entrance, wearing a smoking apron, and he had been without staff supervision when outside smoking. During an interview on 2/3/19 at 1:13 p.m., staff member D stated that resident #12's cigarettes and lighter were kept at the nursing station. He stated He should be supervised when outside smoking. During an interview on 2/5/19 at 8:40 a.m., staff member F stated We take them (the residents) outside, light the cigarette, place the apron. Staff member F said resident #12 is the only one that wears an apron. We stay out with resident #12 and #11. There are specific times for smoking, and they get one cigarette. Staff member F said all cigarettes and lighters are kept at the nursing station except for resident #18. Staff member F said He keeps his own cause he smokes all the time. Review of resident #12's Smoking - Safety Screen, dated 1/7/19, section E. SAFETY, #7. RESIDENT NEED FOR ADAPTIVE EQUIPMENT shows the need for a smoking apron and supervision. It further showed resident #12 had a history of [REDACTED]. The facility was not following the recommendations for supervision, as documented on the Smoking - Safety Screen, therefore, this increased the resident's risk of an accident when smoking unsupervised, and without an apron. Review of resident #12's Resident Smoking Assessment and Contract, dated 1/7/19, showed resident #12 required minimal staff assistance when smoking. Review of resident #12's Care Plan, with a revised date of 12/26/18, showed the resident was a supervised smoker. Resident will frequently ask for cigarettes and does not remember smoking after he had a cigarette. Resident does not remember or like wearing a smoking apron at times. Interventions with an initiated date of 8/9/19 showed: . Monitor for increase in unsafe smoking practices . Notify the supervisor if resident is suspected to have violated the smoking policy . Redirect resident to cement and fire sprinkler areas while smoking . Remind resident of smoking risks and hazards, such as the need to wear a smoking apron. . The resident requires supervised smoking and wears an apron. If the resident refused to put apron on staff will remain with the resident and assist to properly extinguish the cigarette. . Staff store resident's cigarettes and lighters Staff failed to follow the interventions listed on resident #12's Care Plan for supervision, increasing the risk of the resident's safety related to smoking. 5. During an observation on 2/2/19 at 1:00 p.m., resident #2 was outside smoking unsupervised. Review of resident #2's Wander/Elopement Risk Evaluation with a date of 8/23/18, showed: - High Risk with a score of 11. - Resident currently wanders or has a history of wandering? if YES, resident is a HIGH risk. marked YES . During an interview on 2/4/19 at 1:43 p.m., staff member D stated resident #2 likes to walk outside. Awhile back he went to the gas station (down the road) to try to buy cigarettes. Staff member D stated, It does seem contradictory to be high risk for wandering or elopement but be able to smoke unsupervised. Staff member D stated he would have to talk to his team about it. Review of resident #2's Progress Notes showed, on 10/12/18 at 11:52 p.m., Resident seen & picked up by passerby's at the casino parking lot. Passerby's came to front doors that were locked stating they found him at the casino & brought him back. Resident frequently exits facility out back door into employee parking lot. During an interview on 2/4/19 at 2:45 p.m., staff member D brought in an updated Wander/Elopement Risk Evaluation with a date of 2/4/19 at 2:25 p.m. Staff member D stated resident #2 was mistakenly identified as having [MEDICAL CONDITION] on the last Wander/Elopement Risk Evaluation dated 8/23/18 and that is why he was high risk for Wandering/Elopement. Staff member D stated resident #2 has to be reminded often to sign himself out of the facility when he leaves and he may have forgot when he went to the casino. Review of resident #2's Wander/Elopement Risk Evaluation dated 2/4/18 showed, Wandering, a previous attempt to elope or a history of elopement answer will result in an automatic HIGH risk score. Review of the facility's policy titled Elopements with a revision date of (MONTH) 2007 showed, Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. Resident #2 had eloped from the facility, and per the facility assessment, this would make him a high risk for elopement, and he was not being supervised outside while he smoked. The facility had not identified this concern prior to the survey.

Based on observation, interview, and record review, the facility failed to protect a resident (#1) from an employee who had a criminal conviction of abuse, and an allegation of sexual abuse from resident #1 reported against the employee, with the resident exhibiting ongoing fear and psychosocial harm, to include trembling and crying; and, the employee was allowed to continue to work at the facility with vulnerable residents, causing ongoing fear when services were provided, for 2 (#s 2 and 3) of 9 sampled residents. Findings include: 1. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A review of resident #1's Annual and Quarterly MDS', with ARDs of 8/9/17 and 2/6/18, reflected the resident had a BIMS of 15; cognitively intact. He required set-up assistance with ambulation, and was independent with transfers, dressing, and eating. Resident #1 used a wheelchair to self-propel himself throughout the facility. During an observation and interview on 2/28/18 at 2:40 p.m., resident #1 stated he had reported to nursing staff that staff member A had rubbed his penis when she was attempting to put a seatbelt on him on 7/14/17. The resident stated staff member A was always trying to touch his private areas, and he did not like being touched that way. The resident stated he was an acquaintance with staff member A from before her employment at the facility, and felt that staff member A had always wanted to be more than friends. Resident #1 stated he was not happy that staff member A had unsolicited touched his personal area, and she had left him in the transportation van several times with the windows up, and ignition off during the summer (YEAR). The resident stated staff member A had been the primary transportation driver for his appointments outside the facility, and that she also worked as a cook and housekeeper. The resident stated staff member A typically transported him to appointments on Mondays, Wednesdays, Fridays, and to other appointments as needed. Resident #1 stated he did not want staff member A transporting him anywhere, and on occasion, she continued to transport him to appointments after the (MONTH) (YEAR) event had occurred. The resident stated staff member A was still employed by the facility, and he thought she was up to something. Resident #1 stated he was depressed, and he had stopped taking his medications. He stated he had refused to attend appointments because staff member A was still employed at the facility, although other staff members or CHR (alternate van transport) transported him to his appointments. Resident #1 stated he was fearful of staff member A. Resident #1 stated staff member A had told him that she would not be fired because she was related to the administrator. Resident #1 was tearful and trembling during this interview. During an interview on 3/1/18 at 12:25 p.m., staff member C stated she knew staff member A had been convicted of assault, but it had been an isolated incident. Staff member C stated staff member A's allegations of inappropriate behavior had been brought to her attention, but staff member C stated resident #1 was known to have behaviors, such as refusing medications and attending appointments. Staff member C stated staff member A no longer provided transportation for resident #1, but staff member A was still providing transportation to other facility residents. During an interview on 2/28/18 at 5:13 p.m., NF3 stated resident #1 had called her into his room on, or about, 7/14/17. She stated resident #1 was trembling, crying, and upset because staff member A had sexually abused him. NF3 stated resident #1 had reported that staff member A had inappropriately touched his private areas, and the resident was very upset about it. NF3 stated she had reported the incident to two other staff members, including the administrator. NF3 stated the administrator had said, Don't tell anybody, I'll deal with it. NF3 stated resident #1 had been threatened with being kicked out of the facility if he said anything to anybody. NF3 stated resident #1 had stopped taking significant medications because of having increased depressive symptoms. A review of the facility's documentation, Social Service Referral Form, with a date of 6/12/17, read, Need for referral: Dramatic mood change (anxiety, fear, grief, depression) and Family problems/complaints. Plan was to have social services monitor resident #1 on a daily bases to see if resident had any further mood changes. No other social services notes were located prior to exiting the facility on 3/1/18. A review of resident #1's nursing notes, dated 5/15/17 through 2/27/18, showed multiple instances of the resident refusing to take prescribed medications, and he refused to attend medical appointments or treatments. During an interview on 2/28/18 at 6:25 p.m., staff member F stated NF3 had informed her that staff member A had inappropriate behavior with resident #1 during a transportation trip out of town. Staff member F stated the facility still had staff member A employed as a driver for other vulnerable residents, even after the administrator had been informed of the inappropriate behavior. Staff member F stated during the day in question, the administrator had been asked to return to the facility because of serious allegations voiced by resident #1. Staff member F stated other facility staff had approached her several months later with concerns regarding the allegations made by resident #1. Staff member F stated resident #1 was in scared, and that he had been threatened with expulsion from the facility if he continued to voice concerns about staff member A. Staff member F stated she provided psychosocial and mental support because resident #1 was fearful of staff member A. During an interview on 3/1/18 at 7:35 a.m., staff member A stated she had worked at the facility since (MONTH) (YEAR). Staff member A stated she started as a dietary aide, switched to being a driver, and occasionally working in the housekeeping department. Staff member A stated she was not sure why resident #1 had made the accusations of the inappropriate touching, since they were cousins. Staff member A stated she would not have made any sexual advances towards resident #1 because she knows now, about his aliments which she stated she heard from the streets and from other family members. Staff member A stated she had been convicted of assaulting a police officer in the past, and was currently on probation for conspiracy to distribute illegal substances, had served three years in prison, and she had been released from prison in (YEAR). Staff member A stated she is currently urine tested three times a week, at random times, and reported to her parole officer, as needed. Staff member A stated she had not received any real abuse training when she started working at the facility. She stated the administrator was her maternal niece, but she did not feel this relationship was the reason for her employment at the facility. During an interview on 3/1/18 at 9:35 a.m., staff member D stated staff member A had been hired to transport residents to and from outside facility appointments. Staff member D stated staff member A was not allowed to work directly with residents, and was only allowed to provide housekeeping duties, besides the transportation to appointments. Staff member D stated she was aware that staff member A had a conviction of assault, and that staff member A was currently on probation after spending time in prison. Staff member D stated she was not sure why staff member A would have been assisting resident #1 with a seatbelt since the resident was capable of applying his own seatbelt. Staff member D stated staff member A did not need to be putting a seatbelt on the resident. Staff member D stated staff member A was directly related to the administrator, and staff member D knew that was why staff member A had been hired at the facility. During an interview on 3/1/18 at 10:30 a.m., resident #9 stated staff member A provided transportation to and from appointments. Resident #9 had been identified in a facility investigation report after allegations of inappropriate behavior had been investigated by the facility for resident #1 and staff member A. Resident #9 stated she could not recall if anyone from the social service department had taken a statement from her regarding inappropriate behaviors by staff member. During an interview on 3/1/18 at 10:50 a.m., NF1 stated he started transporting resident #1 to and from appointments outside of the facility in (MONTH) (YEAR). He stated the facility had provided transportation on occasion, and they had three vehicles to use. NF1 stated resident #1 had, on occasion, refused to go to his appointments, but NF1 was not sure why. NF1 stated the facility staff did not like to drive in the winter, but NF1 had seen facility staff transporting other residents to and from appointments. During an interview on 3/1/18 at 2:20 p.m., staff member E stated she recalled the day when resident #1 reported that he had been inappropriately touched by staff member A. Staff member E stated she advised other staff to report the incident to the State Survey Agency, and was not sure if a report had been submitted. Staff member E stated all facility staff should have been reporting allegations of abuse to protect all of the residents. Staff member E stated she knew staff member A was on probation, had a history of [REDACTED]. Staff member E stated staff member A was related to the administrator. During an interview on 3/2/18 at 1:30 p.m., NF2 stated sometime in (MONTH) (YEAR), resident #1, had reported to her that he was fearful of staff member A. NF2 stated the resident was crying, was distraught, and was in fear of being kicked out of the facility for voicing his concerns. NF2 stated staff member A had still been transporting resident #1 to appointments, and providing housekeeping duties to resident #1, even though the resident had voiced concerns to the facility. NF2 stated staff member A was related to the administrator, and that is why staff member A continued to provoke resident #1. NF2 stated staff member A was currently transporting residents, including resident #1, to appointments outside of the facility. A review of the facility's Time Card Report showed staff member A started her employment on 4/21/17, and she had worked between 13 to 23 days each month, until (MONTH) (YEAR). A review of the facility's vehicle transportation sign out sheets, from (MONTH) (YEAR) through (MONTH) (YEAR), showed staff member A transported resident #1 to two appointments after the allegation of sexual abuse occurred, which were on: - On 8/29/17, resident #1 was transported to Hardin. - On 9/12/17, resident #1 was transported to Billings. A review of the personnel file for staff member A lacked a signed and dated job description, and training to prohibit and prevent abuse. The facility had not checked the diving record for staff member A upon hire. 2. During an interview on 2/27/18 at 4:30 p.m., resident #3 stated that she was scared of staff member A. She is from the facility. Her driving scares me. She talks all the time. Resident #3 explained one time staff member A was talking on her cell phone, and the phone dropped to the floor of the Van. Staff member A reached down to try to get the phone, and the Van started heading into the ditch. 3. Review of the Grievance/Complaint Investigation Report for resident #2, dated 12/13/17, showed resident #2 was afraid of staff member A. Resident #2 stated that staff member A Makes residents feel bad and makes fun of resident . This report also showed a statement under, Describe your findings, Resident is afraid of (staff member A). The incident was shown to have occurred on 12/12/17. During an interview on 3/1/18 at 1:15 p.m., staff member F stated there were more staff still employed at the facility who have criminal convictions or charges against them. Review of the facility's personnel handbook, for new employees, titled: Chief Sits In The Middle Of The Land Care Center, Personnel Handbook, Hourly Employees, showed new employees are to review, sign and date the handbook. Section C of the handbook showed the Resident Bill of Rights, which included information showing residents are to be free from abuse, verbal, sexual, physical or mental Review of staff member A's personal records showed the Resident Rights and Responsibilities signature sheet was signed and dated on 4/21/17, showing she understood and was informed of the resident rights policies of the facility.

Based on observation, interview, and record review, the facility failed to implement, operationalize, and uphold, policies and procedures for the prohibition and prevention of abuse and neglect, by allowing the employment of a staff member who had a known criminal conviction of abuse (assault), and 1 (#1) voiced a sexual allegation against the employee, and the resident had psychosocial harm from the event, but the employee was allowed to continue to work with vulnerable residents. Several employees of the facility had knowledge of the abuse event and criminal history of the employee, but the abuse policies and procedures were not upheld for resident protection, which created further risk for vulnerable residents who came into contact with the staff member, to include 1 (#3), of 9 sampled residents. Findings include: During an observation on 2/28/18 at 1:05 p.m., staff member A transported resident #3 to a medical appointment, which was to another town. The staff member and resident had not returned to the facility by 2/28/18 at 5:00 p.m. During an interview on 2/27/18 at 4:30 p.m., resident #3 stated that she was scared of staff member A. She is from the facility. Her driving scares me. She talks all the time. Resident #3 explained one time staff member A was talking on her cell phone, and the phone dropped to the floor of the Van. Staff member A reached down to try to get the phone, and the Van started heading into the ditch. During an observation and interview on 3/1/18 at 7:25 a.m., staff member A stated she had worked at the facility since (MONTH) (YEAR). Staff member A stated she had been previously convicted of assaulting a police officer (abuse) in the past, was currently on probation, and had been released from prison in (YEAR) after serving three years in prison. Staff member A states she currently has urine testing done three times each week, related to the latest conviction. She is also required to report to her parole officer. Staff member A stated she had not received any real abuse training when she began working at the facility. She stated the administrator was her maternal niece, but did not feel this relationship was the reason for her employment at the facility. During an interview on 2/28/18 at 6:25 p.m., staff member F stated the facility had staff member A employed as a driver for vulnerable residents, even after the administrator had been informed of the inappropriate behavior (sexual allegation) in the past. Staff member F stated staff member A was related to the administrator, and feared for his/her position, if the administrator knew the employee was speaking to the surveyors. During an interview on 3/1/18 at 12:25 p.m., staff member C stated she knew staff member A had been convicted of assault (abuse), but it had been an isolated incident. Staff member C stated staff member A's allegations of inappropriate behavior (sexual) had been brought to her attention, but staff member C stated staff member A no longer provided transportation for resident #1, but staff member A was still providing transportation for other facility residents. Staff member C stated resident #1 had a history of [REDACTED]. Staff member C had completed new hire paperwork for staff member A, showing the employee's current criminal history was clear, which was not the case. During an interview on 3/1/18 at 9:10 a.m., staff member K stated she was not aware that all potential staff needed to have a back ground check performed prior to hire. Staff member K stated she was responsible for ensuring all employee records were up to date. Review of the facility's personnel handbook for newly hired employees, titled: Chief Sits In The Middle Of The Land Care Center, Personnel Handbook, Hourly Employees, showed that new employees are to review, sign and date the handbook. Section C of the handbook showed the Resident Bill of Rights, which included information that residents are to be free from abuse, verbal, sexual, physical or mental Review of staff member A's Resident Rights and Responsibilities signature sheet, showed staff member A signed and dated the form on 4/21/17, showing she understood and acknowledged the resident rights policies. Review of the Resident Abuse, Mistreatment, Neglect, and Misappropriation of Personal Property (Pursuant to Subtitle C Nursing Home Reform, Section 4201 (g) (1) (C) of OBRA, 1987) policy, was not signed and available for review in staff member A's personnel file. Review of staff member A's personnel file, showed an Employee Warning Notice, dated 12/18/17, which related to staff member A being counseled by staff member D. The action taken showed staff member A would not be allowed in resident rooms to clean until an investigation was completed.

Based on interview and record review, the facility administrator and administrative staff failed to ensure residents were provided an environment free from abuse and harm, when a new staff member was hired, and the staff member had a criminal history of abuse (assault), and an allegation of sexual abuse was reported by 1 (#1) and the alleged employee caused ongoing psychosocial fear for 3 (#s 1, 2, and 3) of 9 sampled residents. Refer to F606 and F607 for details related to abuse. Findings include: During an interview on 3/1/18 at 12:25 p.m., staff member C stated she knew staff member A had been convicted of assault, but it had been an isolated incidence. Staff member C stated staff member A's allegations of inappropriate behavior had been brought to her attention, but staff member C stated resident #1 was known to have behaviors, such as refusing medications and attending appointments. Staff member C stated staff member A no longer provided transportation for resident #1, but staff member A was still providing transportation to other residents of the facility. During an interview on 3/1/18 at 2:20 p.m., staff member E stated she recalled the day when resident #1 reported that he had been inappropriately touched (in the genital area) by staff member A. Staff member E stated all facility staff should have been reporting allegations of abuse to protect the residents. Staff member E stated she knew staff member A was on probation, had a history of [REDACTED]. Staff member E had knowledge that staff member A was related to the administrator. During an interview on 2/28/18 at 6:25 p.m., staff member F stated NF3 had informed her staff member A had inappropriate behavior with resident #1 during a transportation trip out of town. Staff member F stated the facility still had staff member A employed as a driver for other vulnerable residents, even after the administrator had been informed of the sexually inappropriate behavior and allegation. Staff member F stated during the day in question, the administrator had been asked to return to the facility because of serious allegations voiced by resident #1. Staff member F stated other facility staff had approached her several months later with concerns, regarding the allegations made by resident #1, against staff member A. Staff member F stated resident #1 stated he had fear, and was scared because he had been threatened with expulsion from the facility if he continued to voice concerns about staff member A. Staff member F stated she provided psychosocial and mental support because resident #1 was so fearful of staff member A. During an interview on 3/1/18 at 9:10 a.m., staff member K stated she was not aware that all potential staff needed to have a back ground check performed prior to hire. Staff member K stated she was responsible for ensuring all employee records were up to date. During an interview on 3/1/18 at 12:20 p.m., staff member C stated she did not feel it mattered if an employee had a felony conviction as long as it was not for assault (abuse) or theft. Staff member C also wondered if it was okay to hire a person with a felony conviction in another department. A review of the new hire documentation for staff member A showed staff member C had signed and completed the background check information for the employee. The information documented on the background check was not up to date, reflecting the employee's current status with the criminal background.

Based on observation, interview, and record review, the facility failed to store and sanitize blood glucose testers in a manner to limit and prevent the transfer of pathogens to other residents; failed to utilize an effective sanitizing product; and, failed to follow manufacturer's directions for use for the required wet time on the blood glucose meters, for 6 (#s 7, 8, 9, 10, 11, and 12) out of 6 residents sampled. Staff failed to sanitize hands during care processes for 5 (#s 4, 5, 10, 15, and 16) out of 20 sampled and supplemental residents. The facility also failed to adequately operationalize and use the Infection Control policy and protocols for the program, for the identification, monitoring, prevention, and treatment of [REDACTED]. Findings include: On 5/2/17 at 1:40 p.m., the facility Administrator and Director of Nursing were notified that an Immediate Jeopardy existed in F441. Residents identified in the Immediate Jeopardy situation include: #s 7, 8, 9, 10, 11, and 12. See F000 for more detail on the plan to remove the immediacy for the deficient practice. 1. Blood Glucose Testing During an observation on 5/1/17 at 4:05 p.m., staff member D, without sanitizing her hands, gathered a glucometer from a basket on the top of the medication cart, along with a testing strip for the meter, a lancet, an alcohol prep pad, and cotton balls. Seven meters were observed stored together in the basket on the top of the medication cart. Although the meters were individually assigned to different residents, the meters were not stored in separate protective covers, and nothing prevented the possible transfer of blood between the meters, the lancets (which did not require a pen for use), and the loose cotton balls. The meter testing strips were being shared between all the residents requiring blood glucose testing, as well as the lancets and cotton balls. All the supply materials for blood glucose testing were stored in a basket on top of the medication cart, and nothing was in place to prevent the possible transfer of bloodborne and other pathogens between the supplies. The meters were assigned to resident #s 7, 8, 9, 10, 11, and 12. One additional meter was available, and ready for use by a new resident who might have needed the meter when they admitted to the facility. During the same observation on 5/1/17 at 4:05 p.m., staff member D approached resident #7's bedside with the materials for the blood glucose test. As staff member D reached the bed side she dropped one glove and the meter test strip. She picked the items up from the floor and continued administering the blood glucose test with the dirty glove and the dirty test strip. After the test was complete, all the testing supplies and the meter were gathered up and taken back to the nursing station where the nursing cart was stored. Staff member D placed the lancet in the sharps container, took off her gloves and wrapped them around the used supplies, and placed it all into the garbage can. Without cleaning the meter, and without cleaning her hands, staff member D picked up the meter and placed it back into the basket which held the other meters. During an interview on 5/1/17 at 4:20 p.m., staff member D said, We use the same strips for everybody, it's a house stock product. During an interview on 5/1/17 at 4:30 p.m., staff member D said, I just clean them (blood glucose meters) with bleach wipes, Clorox Disinfecting wipes, once or twice a shift. After being questioned about cleaning blood glucose meters, staff member D did not go back and clean the meter she had just used. When asked about sanitizing hands between resident medication passes and blood glucose testing, staff member D located a bottle of hand sanitizer on the medication cart. 2. Policy, Storage, and Cleaning of Blood Glucose Testers During an observation on 5/1/17 at 5:02 p.m., without sanitizing her hands, and after gathering all the needed materials, staff member D brought resident #10 to the nurses' station from the dining room to administer the blood glucose test. Staff member D put on gloves, but did not sanitize her hands. After conducting the blood glucose test, staff member D removed the strip from the meter, placed the meter back into the basket containing all the other meters, and removed her gloves. She did not clean the blood glucose meter, and she did not sanitize her hands. She then moved on to administer medications to resident #16. During an interview on 5/2/17 at 8:55 a.m., staff member D said she did not know where to find the policy and procedure manual (to look up facility policy), and said that she referred to staff member B when she needed to know policy and procedure. She said she signed off on an orientation skills check list when she was hired, but was not oriented to policy and procedure. During an interview on 5/1/17 at 10:35 p.m., staff member P said she used Clorox wipes to clean the blood glucose meters after each use. She did not know how long the Clorox needed to set wet on the meter to be effective, and guessed the meter should be wet for 15 seconds. A review of the Clorox Disinfecting Wipes (kill sheet) showed the wipes were not effective against hepatitis C, and the standing wet time for effectiveness against other agents was between one and four minutes. Prior to the end of the survey the facility had identified Sani-Wipes as an appropriate sanitizer, and planned training with each nurse prior to their next shift on the use of the product, including wet time. A request was made for a policy covering the storage of blood glucose meters and blood glucose test strips 5/1/17 at 4:45 p.m., and again 5/2/17 at 4:00 p.m No policy was received by the end of the survey. 3. Hand Sanitizing a. During an observation on 5/1/17 at 9:40 p.m., staff member P prepared medications for administration via a feeding tube to resident #4. She locked the cart by pushing on the lock with her fingers. She then knocked on the doorway of the resident's room and approached the resident and touched him on the shoulder, contacting his clothing. Staff member P proceeded to pull up the resident's garment to expose the feeding tube. She handled the tube to place it in a different position. Staff member P then put on gloves without washing or sanitizing her hands and administered medication to the resident. b. During an observation and interview on 5/2/17 at 4:10 p.m., staff member D administered a medication to resident #4 while wearing gloves. Upon completion of the administration, she reattached the tubing for the enteral feeding. Staff member D handled the feeding tube to reposition it. She rearranged the resident's clothing to cover the tube and pressed the buttons on the feeding pump to restart the flow of the feeding formula. Staff member D removed her gloves, rinsed out the graduate cylinder and syringe used for the procedure and placed them on a paper towel to dry. She left the room, pushed the nurse's cart down the hall a few feet, stopped in the hallway to use hand sanitizer and stated she should have washed her hands in the room. c. During an observation on 5/1/17 at 3:58 p.m., Refresh Tears where administered to resident #5. After administration of the eye gtts and other medications to resident #5, staff member D took off her gloves, but did not sanitize her hands prior to moving on to administer medications to the next resident. d. During an observation on 5/1/17 at 3:24 p.m., Ketolorac eye gtts, and [MEDICATION NAME] eye gtts, were administered to resident #15. After administration of the eye gtts and other medications to resident #15, staff member D changed her gloves, but did not wash or sanitize her hands prior to moving on to administer medication to another resident. 4. During an interview on 5/4/17 at 5:00 p.m., about the infection control program and handwashing, staff member B said: - I go on rounds with them (staff) and make sure they are washing their hands between procedures. I don't conduct and document audits. -There is no actual observed data. Staff member B said the facility was not documenting nosocomial infections, or that an infection meets the criteria for an active infection in the corresponding infection category. Staff member B did not offer any information when asked about antibiotic stewardship and drug/bug matching. Staff member B was not sure where the policy and procedure for the infection control program was located in the facility. A review of the Infection Control Log showed the facility was collecting data on resident use of antibiotics and for what purpose the antibiotics were being used. A facility map was utilized each month for documentation of areas in the facility where infections occurred. Staff member B offered no information of how this data was being used to plan performance improvement projects and education in the facility. Review of the in-service agenda and sign-in sheets showed the facility had educated staff in the following areas over the past year: -Infection Control, Hep B, C (attended by thirty three staff); -Blood Borne Pathogens and Infection Control (attended by twenty nine staff); -Blood Glucose Finger Stick, (attended by two staff); and, -Blood Born Pathogens (attended by thirty one staff). 5. Medication Cart - Drink During an observation of medication pass on 5/4/17 at 8:25 a.m., a bottle of Power Aid and a travel coffee cup were sitting on the top of the medication cart as the nurse was passing medications. During an interview on 5/4/17 at 8:25 a.m., staff member G said, We can't have them (the Power Aid and travel coffee cup) on the cart. I was going to put them on the table, but I didn't get that done before you came and saw it.

Based on observation, interview, and record review, the facility failed to adequately identify, assess, provide intervention, and document pain for a resident who exhibited pain; failed to provide adequate socialization opportunities for a resident who was unable to communicate effectively and relied on others to assist with socialization out of his room; and failed to provide services for the prevention of contracture's, to include restorative and therapy services timely, in an attempt to maintain the resident's highest practicable well being, and the multiple contracture's worsened and caused the resident pain; and failed to utilize equipment for the prevention of fractures (splints/braces), and address positioning needs in the wheelchair and bed, for 1 (#4); and failed to provide an intervention for a resident to prevent agitation for 1 (#2) of 20 sampled residents. Findings include: 1. Review of resident #4's Annual MDS, with the ARD of 2/7/17, showed he had no speech, could not make his needs known, and was dependent on staff for all activities of daily living. During an observation and interview on 5/2/17 at 11:25 a.m., resident #4 was in his chair, frowning with his eyes closed. Staff member H stated resident #4 usually looked more comfortable when he was in his bed. During an observation and interview on 5/2/17 at 3:30 p.m., resident #4 was in bed, grimacing and making a loud noise. When the resident was asked if he was in pain, he moved his right leg up and down. Staff member F discussed the resident's pain, and stated resident #4 was was in pain. She stated she would let the nurse know he needed medication for the pain. During an interview on 5/2/17 at 3:55 p.m., staff member D stated she would be giving resident #4 his medications at 4:30 p.m. This was 25 minutes after staff member F stated the resident was in pain. Staff member D stated she did not know the resident needed pain medication. Staff member F stated she had told staff member B to let the nurse know of the need for resident #4's pain medication, and the message did not get related to the nurse. Staff member D proceeded to the resident's room to provide the medication. During an observation and interview on 5/3/17 at 7:40 a.m., resident #4 was moaning and kicking his right leg. Staff members H and I stated the resident was communicating his pain, and they would let the nurse know. Staff member F stated resident #4 used his leg to communicated yes. The care plan showed the resident blinked his eye for yes and no responses. During an interview on 5/3/17 at 8:10 a.m., staff member G stated resident #4 was in pain, and she gave him pain medication. She stated, Poor guy, he is so contracted. During an interview on 5/3/17 at 10:50 a.m., staff member G stated resident #4's pain was not daily, and the resident would let the staff know he was in pain by thrashing or making noise. Review of resident #4's January 2017 MAR, showed no pain assessments were completed, and pain medications were not provided. Review of resident #4's February 2017 MAR, showed one PRN pain medication was provided on February 1st. Pain was assessed as being present on 2/6, 2/7, and 2/8. Pain medication was not provided, even though the resident was in pain. Review of resident #4's March 2017 MAR, showed the presence of pain on 3/14/17 and 3/28/17. Pain medication was provided on 3/3, 3/14, 3/21 and 3/28/17, showing inconsistencies in pain assessments and the provision of pain medication in the documentation. Therefore, it was unclear what the resident's status was relating to pain, the intensity of pain, how it was exhibited, and interventions for pain. During an interview on 5/3/17 at 9:30 a.m., NF1 stated resident #4's pain medication use came in spurts. She felt he could not tolerate anything routine or topical. He had difficulty tolerating the tube feeding formula, and his liver enzymes were elevated. During an interview on 5/3/17 at 11:10 a.m., staff member H stated the resident's level of pain depended on which nurse was on the floor, because some nurses did not attend to his pain needs. During an interview on 5/3/17 at 11:45 a.m., NF2 stated resident #4 was not in pain, and believed that pain medications were not good for him. The resident was observed to be uncomfortable (grimacing with eyes and face), but NF2 stated this was because his eyes were not clean. She stated he just needed his eyes cleaned. I tell the staff over and over to clean his eyes, and they don't listen. NF2 was not aware of the symptoms of pain exhibited by the resident. During an interview on 5/3/17 at 9:30 a.m., NF1 stated NF2 did not want resident #4 to use pain medication, because she believed they were not good for him. 2. During an observation on 5/2/17 at 9:50 a.m., resident #4 was lying on the top of his bedspread, with a small blanket on top of him. His right foot was on top of his left foot. He wore no braces on his ankles or wrists to assist with the prevention of contracture's. The resident had visible contracture's to both ankles, wrists, and hands. During an observation on 5/2/17 at 11:00 a.m., resident #4 was still laying on top of his bedspread with his feet crossed. His position had not changed, and no measures were in place for the prevention of contracture's. Review of resident #4's Physical Therapy Initial Evaluation, dated 2/21/17, showed, PT referral to reassess contracture's, contracture's have progressed. During an observation and interview on 5/2/17 at 11:30 a.m., staff members H and I placed the resident in his chair. A 2 cm blanchable red circle was noted on his ankle, where the feet were crossed over one another, and pressure had occurred to the skin, from the ankle's being crossed. The staff members stated they would let the nurse know about the red skin area. During an interview on 5/3/17 at 11:50 a.m., NF2 stated the staff always placed the resident on top of the bedspread, and staff did not reposition him. She told the staff she wanted him placed on the sheet, but this did not occur. 3. Review of resident #4's Monthly Summary, dated 10/5/16, showed (NF2) still requesting PT/OT. Review of resident #4's Physical Therapy Initial Evaluation, dated 2/21/17, which was four months after NF2's request for PT/OT, showed Patient is referred to PT for evaluation for restorative program . The PT recommended resident #4 have both heel suspension boots on at all times, and addressed the deterioration of contracture's. During observations on 5/3/17 and 5/4/17, resident #4 did not have suspension boots placed on his feet by staff. Review of resident #4's Medical Record showed a Brace Notice, the resident should wear a left and right ankle brace, right elbow brace, and a left and right wrist brace. A Delivery Ticket showed the purchase of the braces occurred on 11/17/14. During an interview on 5/1/17, at 1:10 p.m., during the initial tour, staff member K stated that she was the CNA who provided restorative nursing services. She said that the services were not really happening at that time because she was usually pulled from restorative services to work as an aide on the units. During the tour, staff member K stated that resident #4 had contractures and was on a restorative nursing program to maintain mobility. During an interview on 5/3/17 at 11:10 a.m., staff member H stated the last Director of Nursing told them to quit using the braces on the resident, but did not give a reason why. His ankles got a lot worse, she stated. She also stated he should have a rolled cloth in his hands (to assist with contracture prevention), but she did not provide one. During an observation on 5/3/17 at 11:15 a.m., resident #4's feet were internally rotated and parallel to the foot rest, due to contracture's. During an interview on 5/2/17 at 3:00 p.m., staff member K stated that resident #4's restorative program included moving his right leg as much as we can, and massaging his hands. That's about it. Review of resident #4's Restorative Flow Sheet showed the resident had been seen three times in March 2017, and had not been seen the entire month of April 2017. During an interview on 5/3/17 at 11:40 p.m., NF2 stated she told the social worker that resident #4 needed a new wheelchair, and he said he could not provide any assistance. During an interview on 5/4/17 at 10:45 a.m., staff member C stated the wheelchair was discussed in a care conference on 2/14/17. He stated he called (a hospital wheel chair clinic) and they agreed to see the resident. He stated he called NF2 twice, and she did not respond. No further action occurred on the new wheelchair, and the facility did not attempt alternate interventions for positioning. During an observation on 5/2/17 at 11:35 a.m., resident #4 was tilted back in his chair at a 45 degree angle to remove pressure on his legs pushing against the foot rests. 4. During an interview on 5/3/17 at 10:35 a.m., staff member Q stated she would read the bible to resident #4, and massage his hands. She stated NF2 preferred resident #4 to stay in his room (NF2 stated it was just for the times she would visit.) Staff member Q also stated the facility did not take resident #4 on trips out of the facility (although other residents went out), because there were concerns with the resident's tube feeding, and NF2 asked for trips at the last minute, which they could not accommodate. During an interview on 5/3/17 at 11:40 a.m., NF2 stated the facility did not take resident #4 out on trips because there was not enough CNAs to provide care. During observations on 5/2/17 and 5/3/17, resident #4 was not taken out of his room. 5. Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During an interview and observation on 5/1/17 at 1:50 p.m., staff member K stated resident #2 had dementia and behaviors, and he had Native American music to play that calmed him. The resident was in his room, and the music was not playing. During an observation on 5/2/17 at 4:05 p.m., resident #2 was sitting in his room, chanting and banging his hand on his overbed table. His music was not playing. During an interview on 5/3/17 at 7:38 a.m. staff members I and M stated the resident became combative at times and should have his peyote music on when he is in his room. During an observation on 5/3/17 at 4:20 p.m., resident #2 was sitting in his room, chanting and rocking his body forward and back. His music was not playing. Review of resident #2's care plan, dated 3/1/17, showed staff were to play soothing music from the resident's era, daily. The facility had identified an intervention to enhance the resident's quality of life, and maintain his well-being, but failed to utilize the intervention to assist with preventing agitation.

Based on observation and interview, the facility failed to properly use a lift to protect residents who received tub baths from harm for 4 (#s 3, 5, 6 and 10), failed to provide safe oral care which placed the resident at risk for a choking hazard, and failed to lock wheelchair brakes for 1 (# 3) out of 8 sampled residents, and failed to secure hazardous chemicals in a manner to prevent wandering residents, 3 (#s 1, 4, and 10) of 15 sampled and supplemental residents, from accessing them. IMMEDIATE JEOPARDY The facility failed to properly use a lift to protect residents who received tub baths from harm for 4 residents who take tub baths. The facility failed to provide safe oral care which placed a resident at risk for a choking hazard for 1 resident. On 1/13/16 at 6:05 p.m., the facility administrator was notified that an immediate jeopardy situation existed for 1 resident concerning a choking hazard. PLAN TO REMOVE THE IMMEDIACY OF THE SITUATION The facility submitted an acceptable plan to abate the immediate jeopardy on 1/13/16 at 11:00 p.m. A summary of the facility's abatement plan to remove the immediate jeopardy was as follows: 1) All personal care staff will be in-serviced and trained to use the bite block when performing oral care/cleaning 2)The charge nurse will demonstrate to all personal care staff at the beginning of each shift, until everyone has signed and dated that they have received the in-service 3) The charge nurse will also inform the staff of the dangers and the importance of using the bite block during oral care for residents that require its use 4) All staff will have received the in-service before they proceed to the floor after clocking in for their shift 5) A step-by-step hand-out will be given to everyone 6) A reminder will be put on the inside of the closet where oral care tools (toothbrush, bite block and toothpaste) are kept 7) The charge nurse will observe staff performing oral care for residents that require a bite block at least once daily for the first 30 days and document the staff member observed, the charge nurse that observed and ensured the correctness of using the bite block. Any new care staff will be demonstrated to and will be observed performing oral care with the bite block 8) The use of the bite block will be included in the care plan for the resident and reviewed quarterly and annually with the family and resident's physician 9) The resident's family will be counseled on the importance of using the bite block and only items that cannot be bitten and broken off while performing oral care along with the reasoning for no longer using the toothettes 10) The QA team will be informed of the issue and the remedy. During the quarterly meeting the team will be presented with documentation that the bite block training was given and received by any new nursing staff. On 1/14/16 at 9:55 a.m., the facility administrator was notified of an immediate jeopardy situation concerning improper lift use by staff for four residents who received tub baths. PLAN TO REMOVE THE IMMEDIACY OF THE SITUATION The facility submitted an acceptable plant to abate the immediate jeopardy on 1/14/16 at 5:52 p.m. A summary of the facility's abatement plan to remove the immediate jeopardy was as follows: 1) Beginning immediately the bath tub will not be available for resident baths 2) The one resident that prefers a bath will be directed to use the shower or can be given a bed bath. 3) The other residents will receive bed baths until a new lift is purchased 4) The resident, family and physician will be notified that the bath tub is out of service. 5) For those residents unable to safely sit on the shower chair, a bed bath will be more efficient 6) A mobile shower chair and bed have been ordered, which are both compatible for the bath tub. 7) The resident will be on the schedule as a bed bath, they will be asked their preference of time. Findings include: 1. Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. The resident was diagnosed with [REDACTED]. A review of physician progress notes [REDACTED]. A review of the resident's care plan, initiated 5/7/14 and updated on 8/13/15, read, Oral care is to be done three times daily using a bite guard and toothbrush. During an observation on 1/13/16 at 10:30 a.m., staff members E and G provided perineal and oral care to the resident. Staff member E used a white wash cloth to clean the resident's face and lips. The staff member used two pink toothettes to clean the resident's gums and teeth. The resident continually bit at the staff member and toothette during the oral care. The staff member had to quickly pull the toothette away from the resident, four times, to avoid being bit and to avoid the resident biting on the swab. During an interview on 1/13/16 at 10:46 a.m., staff member E stated, We need to watch when we use the oral sponge with (name) because he will bite the (pink) sponge off. He has done it twice within the last year. Each time he's bitten (it) off, the nurse had to come and pry (name) mouth open and dig out the sponge with a toothbrush. It's very scary. During an interview on 1/13/16 at 5:00 p.m., the resident's physician stated she was not aware of resident #3 chewing on the oral toothette swabs. The physician stated, chewing on the swabs was a choking hazard. During an observation on 1/13/16 at 6:40 p.m., staff member D provided oral care to resident #3 using six pink toothette swabs and a green bite stick. The staff member instructed staff members H and I to use the green bite stick and toothettes to provide lip, gum and tooth care to the resident. During an interview on 1/13/16 at 7:17 p.m., staff member H stated oral care was provided to resident #3 nightly before bed and as needed. The staff member stated the resident was known to bite the toothette swab and pull off the sponge. The staff member stated, it had been a while since she had been provided oral care training or instructions. During an interview on 1/13/15 at 9:06 p.m., staff member I stated the resident was known to bite off the pink sponge of the toothette sticks. The staff member stated that once the resident has bitten down on the sponge, it will take (resident's name) a while to release the toothette. During an observation on 1/13/16 at 9:09 p.m., staff member H and I transferred resident #3 from a tilt wheelchair to the tub. The resident was seated in a white sling attached to the Hoyer lift and the lift was in its highest position. The resident was physically lifted over the rim of the tub by the staff members. The water level was 6 below the rim of the tub. The resident's lower back scraped the rim of the tub while being physically lifted over the rim and into the tub. During an observation on 1/13/16 9:36 p.m., staff members H and I transferred resident #3 from the tub to the tilt wheelchair. The wheelchair brakes were not locked. The resident was physically lifted over the rim of the tub by the staff members. The resident was seated in the white sling attached to the Hoyer lift and the lift was in its highest position. The resident's lower back scraped the rim of the tub while being physically lifted out of the tub. During an observation and interview on 1/14/16 at 10:30 a.m., staff member C wiped the resident's lower back with a white wash cloth and soap. The staff member stated the skin appeared to have old lotion residue. During an observation and interview on 1/14/16/16 at 10:33 a.m., staff member T wiped the resident's lower back with the same white wash cloth and soap. The staff member stated the skin appeared to have dirty, dry skin. During an interview on 1/13/16 at 10:01 p.m., staff member H stated wheelchair brakes are suppose to be locked during all resident transfers. The staff member stated she forgot to lock the wheelchair brakes for resident #3. During an interview on 1/13/16 at 10:06 p.m., staff member I stated wheelchair brakes needed to be locked during resident transfers. During an observation on 1/13/16 at 9:45 p.m., staff member D instructed staff members H and I on how to provide oral care to resident #3. Staff member D used a green bite stick, instead of the bite block, and toothbrush to demonstrate oral care. Staff member D inserted the green bite stick into the right side of the resident's mouth and the resident bit down on the stick. The staff member used a yellow toothbrush with a small amount of toothpaste and brushed the resident's teeth. During an interview on 1/13/16 at 9:50 p.m., staff member D stated he had observed the resident bite through the pink swab toothette, and bite the sponge off. The staff member stated when the resident bites down on anything, (resident's name) tends to hold on and not open his mouth. The staff member stated this made it difficult to remove the object the resident had bitten. During an observation on 1/14/16 at 9:50 a.m., staff member C instructed staff members F and T to use a bite block, not a bite stick, with a pea size amount to toothpaste. The resident's hard palate sloughed off and the resident was moaning and attempting to bite on the bite block. Staff member C used the tooth brush to remove several large chunks of white, hard, thick mucus. The resident's gums were bleeding and he was audibly moaning. During an observation on 1/14/16 at 1:36 p.m., staff member C instructed staff members R and S on providing oral care to resident #3. The staff member used a bite block and a yellow toothbrush. The staff were instructed on using a bite block, toothbrush and small amounts of toothpaste. The resident's gums were bleeding and he was moaning audibly. 2. Resident #6 was admitted with [DIAGNOSES REDACTED]. During an observation on 1/13/16 at 3:15 p.m., staff member E and G transferred resident #10 from a wheelchair to the tub. The resident was seated in a white sling attached to the Hoyer lift and the lift was in its highest postions. The resident was physically lifted over the rim of the tub by the staff members. The resident was lowered into the tub by staff member G. During an interview on 1/13/16 at 3:25 p.m., staff member E stated the rim of the tub was too high to accommodate the Hoyer lift at its highest position. The staff member stated a larger sling was used with the Hoyer for resident #10 to provide head and neck support. The staff member stated the resident needed to be physically lifted over the rim of tub which, was not good. The staff member stated she did not know how to wash the resident's back and buttocks due to the sling. 3. Resident #10 was admitted with [DIAGNOSES REDACTED]. Review of resident #10's quarterly MDS, with an ARD of 9/16/15, reflected the resident required total two person assistance with transfers, bed mobility, dressing and toileting. The MDS reflected the resident required total assistance of one person for personal hygiene and bathing. During an interview on 1/14/16 at 7:25 p.m., staff member J identified resident #10 as one of the residents receiving tub baths using the Hoyer lift. 4. During an observation and interview on 1/12/16 at 2:25 p.m., resident #5 showed the surveyor a lift in the facility tub room. Resident #5 stated the lift for the tub had been broken for approximately one year. During an interview on 1/12/16 at 3:15 p.m., staff member F stated the tub lift was broken. Staff member F stated, We always used it (tub lift). You can adjust the depth and head up/down. Now we have to use a Hoyer lift to give baths in the tub. Staff member F stated the lift had been broken for approximately 6 months or so. During an interview on 1/13/16 at 9:00 a.m., staff member A stated she was not sure how long the lift had been broken, but possibly since September. Staff member A stated she was not aware that staff was using the Hoyer lift to provide baths in the tub. Staff member A stated she was not for sure when the staff was last trained on the use of the Hoyer lift. Staff member A submitted an email dated 11/5/15 that reflected information about two tub options, but did not show an order had been placed for a new tub lift for the current tub or documentation that addressed a concern for the broken tub lift. On 1/13/16 at 5:15 p.m., a written request for a copy of the sign-off sheet that reflected the last Hoyer lift training for staff members E, F and G was submitted to staff member B. The facility did not provide the requested information prior to exit. During an interview on 1/13/16 at 9:15 p.m., staff member H stated the tub lift used to provide baths to the residents had been broken for a while. The staff member stated, Using the Hoyer lift can be unsafe, especially when staff forget to change the battery and the lift stops working. On 1/14/16 at 9:00 a.m., a written request for a copy of the tub manual and tub lift manual were requested. On 1/14/16 at 9:15 a.m. staff member B stated maintenance did not have the manuals. Review of the Vander-Lift 450 (Hoyer lift) manual reflected, Before using the Vander-Lift to transfer patients, all staff must be trained and authorized to use the Vander-Lift. Warning- watching the video without hands on training DOES NOT QUALIFY AS TRAINING. On 1/13/16 at 4:08 p.m., staff member B submitted a note that reflected new staff are trained on how to use the Vander-Lift (Hoyer lift) during orientation by watching a video. Under the heading, Leaving Slings Positioned Under Patients in Wheelchairs etc., was the following warning; The patient's posture must be evaluated by a nurse or professional rehabilitation department staff member to see if leaving the sling under the patient might contribute to the patient sliding out of or falling off of a wheelchair or chair. The patient's clothing, the sling fabric, and the surface of the chair or wheelchair must be assessed for slipperiness. Warning. If leaving the sling under the patient places the patient at risk of sliding out of or falling off of the chair or wheelchair, the sling may not be left under the patient. 5. During an observation on 1/11/16 at 1:25 p.m., the tub room had a pink double door cabinet hanging on the wall. A hasp was attached to the doors and a sign was taped to the front of the cabinet stating, Keep locked at all times. A small combination lock was hanging from the hasp and was open. Inside the cabinet was several 32 ounce bottles of (name brand) shampoo, two bottles of body wash, an 8 ounce spray bottle of wound cleanser, and two 24 ounce spray bottles of an unidentified pink substance. Sitting on the front on the tub above the water spout was a bottle of body wash, one bottle of body wash on top of the hydro sound power box and one 32 ounce bottle of (brand name) shampoo was sitting in a pink basin on the tub chair next to the tub. 6. During an observation on 1/11/16 at 1:30 p.m., the shower room contained two 32 ounce bottles of (brand name) shampoo, two 16 ounce bottles of a dandruff shampoo, and two 24 ounce spray bottles of an unidentified pink substance. 7. During an observation on 1/11/16 at 1:35 p.m., a housekeeping cart was in the 100 wing unattended. The cart contained a 16 ounce spray can of (brand name) ant killer, and a 16 ounce spray can of (brand name) stainless cleaner. The label of the (brand name) stainless cleaner contained a warning which read, Harmful or fatal if swallowed. The cart also contained a 16 ounce can of (brand name) dust mop treatment, a 16 ounce bottle of (brand name) no rinse scum away sanitizer, and an 8 ounce spray can of (brand name) odor neutralizer. The housekeeper returned to the housekeeping cart at 1:45 p.m. 8. During an observation on 1/11/16 at 1:40 p.m., resident #10 was seated in his wheelchair in the doorway of the tub room. The resident was inside the tub room and pulling on black shower boots that were on the floor of the room. During an interview on 1/11/16 at 1:41 p.m., staff member O stated the resident had a habit of getting into unlocked and unattended rooms, drawers and cabinets. During an interview on 1/11/16 at 1:45 p.m., staff member O said she was filling in for the regular housekeeper. Staff member O said it was not typical to leave the cleaning cart sitting in the hallway. She said the cleaning cart should have been put in the closet. During an interview on 1/13/16 at 9:15 a.m., staff member F said the pink cabinet in the tub room should only be locked if there were antimicrobial sprays in it. During an interview on 1/13/16 at 10:10 a.m., staff member P said the pink substance in the spray bottles was an antimicrobial spray to clean sinks, counter tops, the bath tub, and the shower chairs. During multiple observations from 1/11/16 to 1/14/16, the pink cabinet in the tub room was not secured by the combination lock. During these observations, the cabinet contained at least one 24 ounce bottle of the pink substance identified by housekeeping staff as antimicrobial cleaner. Material Safety Data Sheets for (brand name) ant killer, (brand name) stainless steel cleaner, (brand name) dust mop treatment, (brand name) no rinse scum away sanitizer, and (brand name) odor neutralizer were requested from the facility. The information was not provided.

Based on observation, interview and record review, the facility failed to promote the highest practicable well-being for 1 (#3) of 8 sampled residents. Specifically, the facility failed to medicate the resident for pain. Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. The resident used agastrostomy-jejunostomy tube for medications and feedings. Review of the resident's quarterly MDS, with ARD of 8/13/15, showed the resident was totally dependent on staff assistance for transfers, dressing, oral hygiene and bathing. The resident was incontinent of bowel and bladder and was in a turn and reposition program every 2°. During an observation on 1/14/16 at 9:50 a.m., staff member C instructed staff members F and T to use a bite block, not bite stick, with a pea size amount to toothpaste. The resident's hard palate sloughed off and the resident was moaning and attempting to bite on the bite block. Staff member C used the tooth brush to remove several large chunks of white, hard, thick mucus. The resident's gums were bleeding and he was moaning audibly and drooling onto his shirt. During an observation on 1/14/16 at 1:36 p.m., staff member C instructed staff members R and S on providing oral care to resident #3. The staff member used a bite block and a yellow toothbrush. The staff was instructed on using a bite block, toothbrush and small amounts of toothpaste. The resident's gums were bleeding and he was moaning audibly and drooling onto his shirt. During an observation on 1/14/16 at 3:11 p.m., resident #3's was lying in bed moaning and drooling and his right cheek and face were red and swollen. During an observation on 1/14/16 at 3:15 p.m., staff member B informed staff member C that resident #3 was moaning, drooling and appeared to be in pain. Staff member B instructed staff member C to review the resident's MAR and medicate the resident for pain. Staff member B instructed staff member C to medicate the resident with liquid [MEDICATION NAME] instead of crushed Tylenol due to the resident's mouth inflammation and swelling. During an observation on 1/14/16 at 4:30 p.m., the resident was lying in bed watching T.V. without moaning or drooling. During an interview on 1/14/16 at 3:20 p.m., staff member B stated the hands-on training for the use of the bite block and toothbrush would be postponed until the resident's cheek and hard palate weren't as red or swollen.

Based on observation, interview and record review, the facility failed to provide adequate services for the prevention of pressure ulcers for 1 (#3) of 8 sampled residents. Specifically, the facility failed to turn and reposition a resident known to be at risk for developing a pressure ulcer every 2 hours. Findings include: Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. The resident used a gastrostomy-jejunostomy tube for medications and feedings. A review of the resident's quarterly MDS, with ARDs of 8/13/15 and 2/15/15, showed a formal skin and clinical assessment determined the resident was at risk of developing a pressure ulcer. The resident did not have any open areas and did not have any unhealed pressure ulcers. The resident's skin and ulcer treatments included a pressure reducing device on the bed and chair and the resident was on the turning/reposition program. A review of the resident's annual MDS, with ARD of 2/7/14, showed a formal skin and clinical assessment determined the resident was at risk of developing a pressure ulcer. The resident did not have any open areas, and did not have any unhealed pressure ulcers. The resident's skin and ulcer treatments included a pressure reducing device on the bed and chair and the resident was on the turning/reposition program for the facility. A review of the resident's care plan, initiated on 5/9/14 and revised on 8/13/15, showed the resident was to be turned and repositioned every 2 hours. During the initial tour on 1/11/16 at 1:45 p.m., staff member C stated the resident was totally dependent on staff to provide care. The staff member stated the resident was incontinent of bowel and bladder control and had a history of [REDACTED]. The staff member stated the resident did not have any open pressure sores at the time of the tour. During an observation on 1/12/16 at 7:17 a.m., the resident was lying on his back with a pillow under each arm and the head of his bed elevated 45 degrees. During an observation on 1/12/16 at 9:50 a.m., the resident was lying on his back with a pillow under each arm and the head of his bed elevated 45 degrees. The resident had not been repositioned. During an observation on 1/12/16 at 10:40 a.m., staff members F and G, provided perineal care to the resident. The resident was rolled onto his left side by staff member F. The resident had a circular 3 x 4 cm, white granulated scar from a healed pressure sore on the right medial buttock. The resident had two semi-circular reddened areas to his lower back. One area was approximately 7 cms on the left and one was approximately 10 cm on his right lower back. The resident was dressed and transferred from his bed to his tilt wheelchair. The resident was seated with the head of his chair up 50 degrees and his feet rest was up 45 degrees. During an interview on 1/12/16 at 10:45 a.m., staff member C stated the reddened areas on the resident's lower back were related to the resident's immobility. The staff member instructed staff members F and G to, Keep (resident name) up in the chair for 3 hours. Staff member C stated the resident was on a turn and reposition schedule every one to two hours. During an observation on 1/12/16 at 1:15 p.m., resident #3 was seated in his tilt wheelchair. The resident was moaning and seated in the same wheelchair and in the same position. During an interview on 1/12/16 at 1:17 p.m., staff member F stated the resident had not been repositioned. During an interview on 1/12/16 at 1:33 p.m., staff member G stated the resident had not been repositioned. During an observation on 1/12/16 at 1:40 p.m., resident #3 was seated in his tilt wheelchair. The resident was moaning and in the same position as before. During an observation on 1/12/16 at 2:20 p.m., resident #3 was seated in his tilt wheelchair. The resident was moaning with the head of his chair up 50 degrees and his feet rest was up 45 degrees. During an observation on 1/12/16 at 3:10 p.m., staff member F walked pasted resident #3's room, looked inside, and kept walking in the corridor. The resident was moaning and seated with the head of his chair up 50 degrees and his feet rest was up 45 degrees. During an observation on 1/12/16 at 3:55 p.m., staff members E and G transferred the resident from the wheelchair to his bed. The resident was provided perineal care. The resident's lower back remained reddened and the 3 x 4 cm circular scar on his right buttock was pink. During an interview on 1/12/16 at 4:20 p.m., staff member E stated the resident should have been repositioned every 2 hours. During an interview on 1/12/16 at 4:35 p.m., staff member G stated the resident should be repositioned every 2 hours when (resident's name) is in bed. The staff member stated on occasion the nursing schedule and assignment interferes with the resident getting repositioned every 2 hours. During an observation on 1/13/16 at 7:17 a.m., resident #3 was lying in bed, mainly on his left side, with the head of his bed elevated. There was a white pillow under the resident's right and left arm. During an observation on 1/13/16 at 10:00 a.m., resident #3's position remained unchanged from the observation at 7:17 a.m. During an observation on 1/13/16 at 9:30 p.m., staff members H and I transferred resident #3 from the tub room back to the resident's room after a tub bath. The resident had a friction abrasion to his entire lower back region with a 2 x 0.5 cm shearing to the right lower back. The circular scar tissue was bright pink and the edges were bright red and shiny. During an interview on 1/14/16 at 10:45 a.m., staff member F stated the resident was suppose to be turned and repositioned every 2°. During an interview on 1/14/16 at 1:55 p.m., staff member B stated any skin changes should be documented on the resident's skin assessment sheet. The staff member stated the facility staff should have been turning and repositioning the resident every two hours. A review of nurses' notes for resident #3 dated 1/14/16 at 5:45 a.m., read, Resident appears to have slight scratching or abrasion (sic) to buttock on right cheek. [MEDICATION NAME] applied. A review of nurse's noted for resident #3 dated 1/14/16 at 2:50 p.m., read, T&R q 1°-2°, eschar on buttock reddened and lower back has two areas of redness with [MEDICATION NAME] applied to affected areas per standing orders. During an interview on 1/14/16 at 7:05 p.m., staff member C stated a weekly pressure ulcer record was started on the resident. A review of the facility's Weekly Pressure Ulcer Record, begun on 1/14/16, showed a 3 x 4 cm, stage 2, pressure sore to the resident's posterior right buttock.

Based on record review and staff and resident interviews, the facility failed to provide the necessary care to maintain the highest practical physical well being for 4 (#s 2, 8, 9, and 10) of 7 diabetic residents in the facility and 1 (#1) of 8 sampled residents. Specifically: -resident #2 did not receive scheduled insulin and sliding scale insulin as ordered -resident #8 did not receive scheduled insulin, and sliding scale insulin as ordered, and blood sugars were not consistently measured and recorded -resident #9 did not receive scheduled insulin, sliding scale insulin as ordered, and blood sugars were not consistently measured and recorded -resident #10 did not receive sliding scale insulin due to missed blood sugar monitoring On [DATE] at approximately 10:50 a.m., the facility administration was notified that an immediate jeopardy situation existed for resident' #2, 8, 9, and 10. These residents had a current and past history of receiving incorrect doses of sliding scale insulin, not receiving scheduled insulin, and not having blood sugars monitored as ordered. The facility administrator was notified of the requirement to provide an abatment plan for how the immediate jeopardy situation would be resolved. The facility's abatement plan to remove the immediate jeopardy was as follows: -Write a policy for correct administration of insulin - including regular and sliding scales and for high or low blood sugars - The two current forms: Physician protocols and Regular Insulin Sliding Scale grid. Physician protocols (Standing Orders for Insulin Sliding Scales) from the Medical Director and Regular Insulin Sliding Scale orders will be discontinued with the Medical Director's immediate verbal approval. Upon his return to the state, he will sign a new Standing Order Sheet with the Insulin Sliding Scale deleted. A note will be added to the Standing Orders stating each resident needing insulin will have an individualized insulin order describing what sliding scale insulin is required if needed and what action to take if the blood sugar levels fall below 75 or go above 400. Residents will receive insulin as ordered by their respective physicians on an individualized format. Each resident needing a sliding scale will have that scale listed individually on the resident's respective MAR indicated [REDACTED]. A policy is written for the directives of what actions the nurses take if the blood glucose levels fall below 50 and/or between ,[DATE]. Rechecks of low sugar levels below 75 will be done every 15 minutes, and the resident will not be left alone until blood sugar levels come above 75. All nurses will be trained and educated regarding this policy by signing this document before working the next scheduled shift. -An education tool has been created that identifies and lists the signs and symptoms of both hypo or hyper glycemic conditions. All staff will be trained to understand these signs and symptoms and the action to take any are recognized. This in-service will be held [DATE] at 1:00 p.m. and 3:00 p.m. All staff and [MEDICATION NAME]/pool nurses will be trained starting with the shift change today [DATE] and following until all are trained. They will sign off on this document. -The facility will require each oncoming nurse will review with the outgoing nurse the insulin administration for each resident. This will be done every shift change. Daily audits by the administrator will ensure the insulin was given properly as ordered. (See number 5 below) -The nurses will follow the insulin administration schedule to ensure residents receive their insulin as ordered. The administrator will perform daily audits for two weeks including weekends starting [DATE]. Thereafter, the audits will be performed at least weekly for two months to ensure continued compliance. -The facility will have a mandatory in-service for all nurses to instruct them on the necessity of following all doctor/provider orders and informing those providers if their orders cannot be followed or if a resident refuses the insulin or ordered medication. Any refusal of medication or insulin will be documented in the nurses' notes each time and the physician/provider will be notified. -The administrator will conduct daily audits for two weeks. The administrator will ensure all staff members will receive training on the signs and symptoms of hypo or hyper glycemic conditions before their next scheduled shift. The audits will consist of the following: A. Were the blood sugars taken? B. Were the physician/provider orders followed? C. Was the physician/provider notified of blood sugar levels out of the normal ranges or if the insulin given was not effective? D. Did the nurse properly document the insulin given as ordered? E. If the resident refuses either all or part of the insulin order, was the physician/provider notified? F. Have all staff received the required training listed on the document? The audits will track this process each shift for at least two weeks starting [DATE]. Thereafter, audits will be performed at least weekly for two months to ensure continued compliance. -These audits will track accurate assessment of blood sugars before insulin administration; the accurate administration of the correct dose; charting evidence of physician/provider notification when required by standing orders and facility policy; signatures on the MARs of insulin and dosage given; assessment of signs and symptoms that are indicative of a blood sugar issue; and rechecks of blood sugars out of the normal limits for that resident according to the policy. -All nurses will receive education by the administrator on the 5 rights of medication administration before their next scheduled shift. The nurse and trainer will both confirm the training document. -Any errors found will be discussed with the nurse involved and education provided at the time the error is found or before working the next scheduled shift. -Results of audits will be reported to the QA team meeting and to the physician/provider. -This plan was shared with the Medical Director for approval by phone on [DATE] at 8:00 a.m., since Medical Director is out of state. Results will be presented to the QA team at each monthly meeting starting [DATE]. The extended survey was conducted by the surveyors. The immediate jeopardy was abated on [DATE] at 10:35 a.m. The exit conference was held on [DATE] at 11:00 a.m. with administration. The administration stated that staff member G, travel LPN, and staff member B, DON, would be in the facility throughout the weekend. After the immediate jeopardy was abated for residents #2, 8, 9, and 10, the deficient practice remained at a scope and severity level of an E (potential for more than minimal harm that was a pattern). On [DATE] at 3:30 p.m., the surveyor interviewed staff member B, the DON. She stated that residents (#s 2 and 9) decide what dose of insulin they want to take each day. She stated they "make up their own mind."? She also stated the "(nurses) need to call the doctor if resident #9 is not taking the amount needed." On [DATE] at 3:40 p.m., the surveyor interviewed staff member C, LPN, about the insulin dose changes in the charts. She stated it was a med error on her part and she (nurse) didn't give it because she (resident #9) drops quickly. I used my nursing judgment. She stated "she (resident #9) will either refuse the whole insulin dose or take all, she never dictates how much of the dose she wants." On [DATE] at 3:45 p.m., the surveyor interviewed resident #9 concerning insulin doses. The resident stated she agrees on what insulin dose the nurse gives her. On [DATE] at 7:30 a.m., the surveyor asked resident #2 if he ever asks to change his prescribed insulin dose. He stated "they (nurses) tell me how much medicine and how high my blood sugar is, I never miss any." Resident #2 further explains the symptoms he gets from diabetes "I feel wobbly when high and weak when low." On [DATE] at 10:15 a.m., the surveyor spoke to staff member I, the medical director/physician, of the facility. He was unaware of the sliding scale insulin ([MEDICATION NAME]/Humalog) dose changes occurring with the diabetic residents at the facility. He was also unaware of the omission of several [MEDICATION NAME] (long-acting) insulin doses to multiple residents. He stated "I expect my nurses to follow my orders as written. I would also expect them to call me with any changes."? The medical director stated he would call the other physicians in the facility to make them aware of the issue. Findings include: 1. Resident #2 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The staff of the facility had identified "unstable blood sugars" on the current resident care plan with the following interventions: -monitor for signs and symptoms of [DIAGNOSES REDACTED] and [MEDICAL CONDITION] -report to nurse dizziness, lethargy, fruity breath, rapid or slow respirations, agitation, change in level of consciousness -assess resident's level of understanding about the [DIAGNOSES REDACTED]. -assess skin carefully with daily care -fingernails to be trimmed by nurse -toenails to be trimmed by podiatrist -monitor lab values -administer medications as ordered The care plan was not followed by the staff administering medications as ordered by the provider. The physician diabetic orders for this resident were as follows: -Blood Glucose check AC & HS postprandial -[MEDICATION NAME] 100 units/mL - 10 units SQ every a.m. -Humalog 100 units/mL - sliding scale with meals and before bedtime dosing according to blood sugar level as follows: ,[DATE] = 0 units ,[DATE] = 1 units ,[DATE] = 2 units ,[DATE] = 3 units ,[DATE] = 4 units ,[DATE] = 5 units ,[DATE] = 8 units There were no parameters on the MAR for when to notify the physician or what staff should do if BS is out of normal range. The following instances were in the resident's record from [DATE]-[DATE]. Inaccurate sliding scale insulin (Humulog) doses were administered, physician orders [REDACTED]. December: - [DATE], BS 223 at 11:30 a.m. According to the physician's orders [REDACTED]. - [DATE], BS 134 at 7:30 a.m. According to the physician's orders [REDACTED]. - [DATE], BS 122 at 7:30 a.m. According to the physician's orders [REDACTED]. - [DATE], BS 260 at 11:30 a.m. According to the physician's orders [REDACTED]. - [DATE], BS 148 at 4:30 p.m. According to the physician's orders [REDACTED]. Also the scheduled dose of [MEDICATION NAME] 10 units in the a.m. was not given. -[DATE], BS 160 at 7:30 a.m., According to the physician's orders [REDACTED]. -[DATE], BS 152 at 7:30 a.m. According to the physician's orders [REDACTED]. -[DATE], the scheduled dose of [MEDICATION NAME] 10 units in the a.m. was not given. -[DATE], the scheduled dose of [MEDICATION NAME] 10 units in the a.m. was not given. January: - [DATE], BS 281 at 11:30 a.m. According to the physician's orders [REDACTED]. - [DATE], BS 222 at 11:30 a.m. According to the physician's orders [REDACTED]. - [DATE], BS 122 at 11:30 a.m. According to the physician's orders [REDACTED]. - [DATE], the scheduled dose of [MEDICATION NAME] 10 units in the a.m. was not given. 2. Resident #8 was re-admitted to the facility on [DATE] and expired on [DATE]. The resident's [DIAGNOSES REDACTED]. The staff of the facility had identified "unstable blood sugars" on the current resident care plan with the following interventions: -monitor for signs and symptoms of [DIAGNOSES REDACTED] and [MEDICAL CONDITION] -report to nurse dizziness, lethargy, fruity breath, rapid or slow respirations, agitation, change in level of consciousness -assess resident's level of understanding about the [DIAGNOSES REDACTED]. -assess skin carefully with daily care -administer medications as ordered -assess feet with daily care -toenails to be trimmed by podiatrist -monitor lab values -monitor for infections The care plan was not followed by the staff administering medications as ordered by the provider. The physician diabetic orders for this resident were as follows: -Blood Glucose check AC & HS -[MEDICATION NAME] gel if BS less than 61 -[MEDICATION NAME] 100 units/mL - 40 units SQ every a.m. -[MEDICATION NAME] 100 units/mL - sliding scale with meals and HS dosing according to blood sugar level as follows: ,[DATE] = 0 units ,[DATE] = 3 units ,[DATE] = 5 units ,[DATE] = 10 units ,[DATE] = 15 units ,[DATE] = 20 units ,[DATE] = 25 units There were no parameters identified on the MAR for notification of the physician of blood glucose readings outside of the identified sliding scale. The following instances were in the resident's record from [DATE]-[DATE]. Inaccurate sliding scale insulin ([MEDICATION NAME]) doses were administered, physician orders [REDACTED]. December: - [DATE], BS 122 at 11:30 a.m. According to the physician's orders [REDACTED]. The scheduled dose of [MEDICATION NAME] 40 units in the a.m. was not given. - [DATE], No BS taken at 11:00 a.m., No BS taken at 4:00 p.m. - [DATE], No BS taken at 4:00 p.m. - [DATE], No BS taken at 7:30 a.m., No BS taken at 11:00 a.m., No BS taken at 4:00 p.m. - [DATE], BS 136 at 7:30 a.m. According to the physician's orders [REDACTED]. - [DATE], BS 347 at 7:30 a.m. According to the physician's orders [REDACTED]. - [DATE], BS 310 at 4:00 p.m. According to the physician's orders [REDACTED]. - [DATE], BS 160 at 7:30 a.m. According to the physician's orders [REDACTED]. BS 369 at 4:30 p.m. According to physician's orders [REDACTED]. - [DATE], BS 362 at 4:30 p.m. According to the physician's orders [REDACTED]. BS 249 at 9:00 p.m. According to the physician's orders [REDACTED]. - [DATE], BS 208 at 11:30 a.m. According to the physician's orders [REDACTED]. January: - [DATE], BS 135 at 7:30 a.m. According to the physician's orders [REDACTED]. The scheduled [MEDICATION NAME] 40 units in the a.m. was not given. No BS was taken at 4:30 p.m. BS was "Hi" at 9:00 p.m. 25 units of [MEDICATION NAME] was given but no physician notification or re-check of BS was done. 3. Resident #9 was re-admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The staff of the facility had identified "unstable blood sugars" on the current resident care plan with the following interventions: -monitor for signs and symptoms of [DIAGNOSES REDACTED] and [MEDICAL CONDITION] -administer medications as ordered -toenails to be trimmed by podiatrist -call physician regarding continued elevated blood glucose levels The care plan was not followed by the staff administering medications as ordered by the provider. The physician diabetic orders for this resident were as follows: -Blood Glucose check AC & HS -[MEDICATION NAME] 100 units/mL - 30 units SQ at HS -[MEDICATION NAME] 100 units/mL - sliding scale with meals and HS dosing according to blood sugar level as follows: ,[DATE] = 2 units ,[DATE] = 4 units ,[DATE] = 6 units ,[DATE] = 8 units ,[DATE] = 12 units ,[DATE] = 16 units >400 = 20 units and call MD There are no parameters on the MAR for when to re-check the BS if out of normal range. The following instances were in the resident's record in [DATE]. Inaccurate sliding scale insulin ([MEDICATION NAME]) doses were administered, physician orders [REDACTED]. December: - [DATE], The scheduled [MEDICATION NAME] 30 units at HS was not given. - [DATE], BS 121 at 11:30 a.m. According to the physician's orders [REDACTED]. BS 209 at 4:30 p.m. According to the physician's orders [REDACTED]. No BS was taken at HS. The scheduled [MEDICATION NAME] 30 units at HS was not given. - [DATE], BS 248 at 7:30 a.m. According to the physician's orders [REDACTED]. No BS taken at 11:30 a.m. No BS taken at 4:30 p.m. - [DATE], The scheduled [MEDICATION NAME] 30 units at HS was not given. No BS taken at 7:30 a.m. No BS taken at 11:30 a.m. No BS taken at 4:30 p.m. - [DATE], The scheduled [MEDICATION NAME] 30 units at HS was not given. - [DATE], The scheduled [MEDICATION NAME] 30 units at HS was not given. - [DATE], BS 489 at 7:30 a.m. According to the physician's orders [REDACTED]. The physician was not notified. **New physician diabetic orders for this resident were received on [DATE] for the following: -Blood Glucose check AC & HS -[MEDICATION NAME] 100 units/mL - 20 units SQ every a.m. -[MEDICATION NAME] 100 units/mL - 10 units SQ with dinner -[MEDICATION NAME] 100 units/mL - sliding scale with meals and HS dosing according to blood sugar level as follows: ,[DATE] = 2 units ,[DATE] = 4 units ,[DATE] = 6 units ,[DATE] = 8 units ,[DATE] = 12 units ,[DATE] = 16 units >400 = 20 units and call MD There were no parameters identified on the MAR for notification of the physician of blood glucose readings outside of the identified sliding scale. The following instances were in the resident's record from [DATE] - February 2014. Inaccurate sliding scale insulin ([MEDICATION NAME]) doses were administered, physician orders [REDACTED]. January: - [DATE], BS 296 at 7:30 a.m. According to the physician's orders [REDACTED]. - [DATE], BS 431 at 9:00 p.m. According to the physician's orders [REDACTED]. The physician was not notified. - [DATE], BS 130 at 7:30 a.m. According to the physician's orders [REDACTED]. February: - [DATE], BS 177 at 9:00 p.m. According to the physician's orders [REDACTED]. - [DATE], BS 203 at 9:00 p.m. According to the physician's orders [REDACTED]. - [DATE], BS 301 at 9:00 p.m. According to the physician's orders [REDACTED]. - [DATE], BS 283 at 9:00 p.m. According to the physician's orders [REDACTED]. - [DATE], BS 148 at 9:00 p.m. According to the physician's orders [REDACTED]. - [DATE], BS 131 at 7:30 a.m. According to the physician's orders [REDACTED]. - [DATE], BS 133 at 9:00 p.m. According to the physician's orders [REDACTED]. - [DATE], BS 136 at 7:30 a.m. According to the physician's orders [REDACTED]. - [DATE], BS 121 at 7:30 a.m. According to the physician's orders [REDACTED]. BS 220 at 4:30 p.m. According to the physician's orders [REDACTED]. - [DATE], BS 120 at 7:30 a.m. According to the physician's orders [REDACTED]. - [DATE], BS 176 at 9:00 p.m. According to the physician's orders [REDACTED]. - [DATE], BS 121 at 7:30 a.m. According to the physician's orders [REDACTED]. - [DATE], BS 178 at 11:30 a.m. According to the physician's orders [REDACTED]. - [DATE], BS 151 at 7:30 a.m. According to the physician's orders [REDACTED]. BS 205 at 11:30 a.m. According to the physician's orders [REDACTED]. BS 186 at 4:30 p.m. According to the physician's orders [REDACTED]. - [DATE], BS 179 at 7:30 a.m. According to the physician's orders [REDACTED]. BS 218 at 11:30 a.m. According to the physician's orders [REDACTED]. BS 203 at 4:30 p.m. According to the physician's orders [REDACTED]. - [DATE], BS 156 at 7:30 a.m. According to the physician's orders [REDACTED]. - [DATE], No BS taken at 9:00 p.m. - [DATE], BS 176 at 7:30 a.m. According to the physician's orders [REDACTED]. BS 246 at 11:30 a.m. According to the physician's orders [REDACTED]. BS 126 at 4:30 p.m. According to the physician's orders [REDACTED]. - [DATE], BS 159 at 7:30 a.m. According to the physician's orders [REDACTED]. BS 143 at 11:30 a.m. According to the physician's orders [REDACTED]. BS 449 at 4:30 p.m. According to the physician's orders [REDACTED]. The physician was not notified. - [DATE], BS 227 at 7:30 a.m. According to the physician's orders [REDACTED]. BS 244 at 11:30 a.m. According to the physician's orders [REDACTED]. BS 230 at 4:30 p.m. According to the physician's orders [REDACTED]. - [DATE], BS 205 at 11:30 a.m. According to the physician's orders [REDACTED]. 4. Resident #10 was re-admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The staff of the facility had identified "unstable blood sugars" on the current resident care plan with the following interventions: -monitor for signs and symptoms of [DIAGNOSES REDACTED] and [MEDICAL CONDITION] -administer medications as ordered -toenails to be trimmed by podiatrist -call physician regarding continued elevated blood glucose levels The care plan was not followed for monitoring blood sugar as the blood sugar was not taken on several occasions. The physician diabetic orders for this resident were as follows: -Blood Glucose check AC -[MEDICATION NAME] 100 units/mL - 25 units SQ every a.m. -[MEDICATION NAME] 100 units/mL - sliding scale with meals dosing according to blood sugar level as follows: ,[DATE] = 0 units ,[DATE] = 0 units ,[DATE] = 3 units ,[DATE] = 7 units ,[DATE] = 10 units ,[DATE] = 14 units ,[DATE] = 17 units >400 = give [MEDICATION NAME]based on ,[DATE]. Re-check BS Q 30 minutes X 2 There are no parameters on the MAR for when to notify the provider. The following instances were in the resident's record for February 2014. The physician orders [REDACTED]. February: - [DATE], No BS was taken at 4:30 p.m. - [DATE], No BS was taken at 4:30 p.m. - [DATE], No BS was taken at 4:30 p.m. 5. Resident #1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #1's admission note written [DATE] by staff member B, the DON, indicated that the resident was being admitted to have a knee replacement, and then recover at the facility. According to the admission note from the facility physician dated [DATE] the resident was well known to her, and the resident had been getting [MEDICATION NAME] from multiple providers, even after presenting with [MEDICAL CONDITION] suspected to be caused by high [MEDICATION NAME] use. The physician diagnosed the resident with chronic pain and "presumed [MEDICAL CONDITION]." The resident was receiving [MEDICATION NAME] for pain from [MEDICAL CONDITION] arthritis, per the physician orders [REDACTED]. On [DATE], resident #1 had a witnessed [MEDICAL CONDITION], per nursing progress note dated [DATE]. The ER note dated [DATE] reported that the resident had a similar event about a year ago, and had not been on anti-[MEDICAL CONDITION] drugs. The note also stated that [MEDICAL CONDITION] was diagnosed on [DATE]. The final [DIAGNOSES REDACTED]. The physician progress notes [REDACTED]." On [DATE], resident #1 was sent to the ER with declining oxygen saturation levels. According to the record, the resident was diagnosed with [REDACTED]. During a physician visit on [DATE], the resident reported to the physician that she had a [MEDICAL CONDITION] in the ambulance. The facility physician again diagnosed "uninvestigated [MEDICAL CONDITION] disorder, and ordered a cardiology, neurology, and rheumatolgy consults. "I consider these urgent as it has been delayed several month inspite of multiple hospitalization s for consequences of these disorders." The facility stated the neurology appointment scheduled for [DATE] was canceled per patient request, and that a local neurology appointment for November was canceled due to insurance problems. No documentation was provided by the facility to indicate that another neurology appointment was pursued until January, 2014 despite the physicians orders from the ,[DATE]//13 visit. On [DATE], resident #1 had a 26 minute [MEDICAL CONDITION] at 4 a.m. per the nursing progress note. "Lost bowels and urine and bit tongue during [MEDICAL CONDITION]." Resident #1 was sent to the ER, and then she was admitted to the hospital. On [DATE], the resident was readmitted to the facility and had a physicians order to begin [MEDICATION NAME], an anti-[MEDICAL CONDITION] medication, 6 months after her first [MEDICAL CONDITION]. During an interview with the facility physician by phone on [DATE] at 12:25 p.m., the physician stated she felt slightly responsible, because she had thought the resident had been to her neurology appointment. REFERENCES: ?***"Document each medication given. - Record the medication given, dosage, time, any complaints or assessments of the client and your signature. - If medication was refused or omitted, record this fact on the appropriate record; document the reason, when possible, and the nurse's actions according to agency policy." Kozier, B., Erb, G., Berman, A., & Snyder, S. (2004). Techniques in Clinical Nursing: Basic to Intermediate Skills (5th ed.). Upper Saddle River New Jersey: Pearson Education, Inc. ?***Nurses are obligated to follow the orders of a licensed physician or other designated health care provider unless the orders would result in client harm. DeLaune, S. & Ladner, P. (1998). Fundamentals of Nursing, Standards and Practice (p.237). Albany, N.Y

Based on record review and staff and resident interviews, the facility failed to follow physician orders [REDACTED].#'s 2, 8, 9, and 10) of 7 diabetic residents in the facility. Specifically: -resident #2 did not receive scheduled insulin and ordered sliding scale insulin dosing; -resident #8 did not receive scheduled insulin, ordered sliding scale insulin dosing, and missed blood sugars; -resident #9 did not receive scheduled insulin, ordered sliding scale insulin dosing, and missed blood sugars; -resident #10 did not receive sliding scale insulin due to missed blood sugars. Findings include: 1. Resident #2 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The staff of the facility had identified "unstable blood sugars" on the current resident care plan with the following interventions: -respirations, agitation, change in level of consciousness -assess resident's level of understanding about the [DIAGNOSES REDACTED]. -assess skin carefully with daily care -fingernails to be trimmed by nurse -toenails to be trimmed by podiatrist -monitor lab values -administer medications as ordered The care plan was not followed by the staff administering medications as ordered by the provider. The physician diabetic orders for this resident were as follows: -Blood Glucose check AC & HS postprandial -[MEDICATION NAME] 100 units/mL - 10 units SQ every a.m. -Humalog 100 units/mL - sliding scale with meals and before bedtime dosing according to blood sugar level as follows: ,[DATE] = 0 units ,[DATE] = 1 units ,[DATE] = 2 units ,[DATE] = 3 units ,[DATE] = 4 units ,[DATE] = 5 units ,[DATE] = 8 units There were no parameters identified on the MAR for notification of the physician of blood glucose readings outside of the identified sliding scale. The following instances were in the resident's record from [DATE]-[DATE]. Inaccurate sliding scale insulin (Humulog) doses were administered, physician orders [REDACTED]. December: - [DATE], BS 223 at 11:30 a.m. According to the physician's orders [REDACTED]. - [DATE], BS 134 at 7:30 a.m. According to the physician's orders [REDACTED]. - [DATE], BS 122 at 7:30 a.m. According to the physician's orders [REDACTED]. - [DATE], BS 260 at 11:30 a.m. According to the physician's orders [REDACTED]. - [DATE], BS 148 at 4:30 p.m. According to the physician's orders [REDACTED]. Also the scheduled dose of [MEDICATION NAME] 10 units in the a.m. was not given. -[DATE], BS 160 at 7:30 a.m., According to the physician's orders [REDACTED]. -[DATE], BS 152 at 7:30 a.m. According to the physician's orders [REDACTED]. -[DATE], the scheduled dose of [MEDICATION NAME] 10 units in the a.m. was not given. -[DATE], the scheduled dose of [MEDICATION NAME] 10 units in the a.m. was not given. January: - [DATE], BS 281 at 11:30 a.m. According to the physician's orders [REDACTED]. - [DATE], BS 222 at 11:30 a.m. According to the physician's orders [REDACTED]. - [DATE], BS 122 at 11:30 a.m. According to the physician's orders [REDACTED]. - [DATE], the scheduled dose of [MEDICATION NAME] 10 units in the a.m. was not given. 2. Resident #8 was re-admitted to the facility on [DATE] and expired on [DATE]. The resident's [DIAGNOSES REDACTED]. The staff of the facility had identified "unstable blood sugars" on the current resident care plan with the following interventions: -monitor for signs and symptoms of [DIAGNOSES REDACTED] and [MEDICAL CONDITION] -report to nurse dizziness, lethargy, fruity breath, rapid or slow respirations, agitation, change in level of consciousness -assess resident's level of understanding about the [DIAGNOSES REDACTED]. -assess skin carefully with daily care -administer medications as ordered -assess feet with daily care -toenails to be trimmed by podiatrist -monitor lab values -monitor for infections The care plan was not followed by the staff administering medications as ordered by the provider. The physician diabetic orders for this resident were as follows: -Blood Glucose check AC & HS -[MEDICATION NAME] gel if BGS less than 61 -[MEDICATION NAME] 100 units/mL - 40 units SQ every a.m. -[MEDICATION NAME] 100 units/mL - sliding scale with meals and HS dosing according to blood sugar level as follows: ,[DATE] = 0 units ,[DATE] = 3 units ,[DATE] = 5 units ,[DATE] = 10 units ,[DATE] = 15 units ,[DATE] = 20 units ,[DATE] = 25 units There were no parameters identified on the MAR for notification of the physician of blood glucose readings outside of the identified sliding scale. The following instances were in the resident's record from [DATE]-[DATE]. Inaccurate sliding scale insulin ([MEDICATION NAME]) doses were administered, physician orders [REDACTED]. December: - [DATE], BS 122 at 11:30 a.m. According to the physician's orders [REDACTED]. The scheduled dose of [MEDICATION NAME] 40 units in the a.m. was not given. - [DATE], No BS taken at 11:00 a.m., No BS taken at 4:00 p.m. - [DATE], No BS taken at 4:00 p.m. - [DATE], No BS taken at 7:30 a.m., No BS taken at 11:00 a.m., No BS taken at 4:00 p.m. - [DATE], BS 136 at 7:30 a.m. According to the physician's orders [REDACTED]. - [DATE], BS 347 at 7:30 a.m. According to the physician's orders [REDACTED]. - [DATE], BS 310 at 4:00 p.m. According to the physician's orders [REDACTED]. - [DATE], BS 160 at 7:30 a.m. According to the physician's orders [REDACTED]. BS 369 at 4:30 p.m. According to physician's orders [REDACTED]. - [DATE], BS 362 at 4:30 p.m. According to the physician's orders [REDACTED]. BS 249 at 9:00 p.m. According to the physician's orders [REDACTED]. - [DATE], BS 208 at 11:30 a.m. According to the physician's orders [REDACTED]. January: - [DATE], BS 135 at 7:30 a.m. According to the physician's orders [REDACTED]. The scheduled [MEDICATION NAME] 40 units in the a.m. was not given. No BS was taken at 4:30 p.m. BS was "Hi" at 9:00 p.m. 25 units of [MEDICATION NAME] was given but no physician notification or re-check of BS was done. 3. Resident #9 was re-admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The staff of the facility had identified "unstable blood sugars" on the current resident care plan with the following interventions: -monitor for signs and symptoms of [DIAGNOSES REDACTED] and [MEDICAL CONDITION] -administer medications as ordered -toenails to be trimmed by podiatrist -call physician regarding continued elevated blood glucose levels The care plan was not followed by the staff administering medications as ordered by the provider. The physician diabetic orders for this resident were as follows: -Blood Glucose check AC & HS -[MEDICATION NAME] 100 units/mL - 30 units SQ at HS -[MEDICATION NAME] 100 units/mL - sliding scale with meals and HS dosing according to blood sugar level as follows: ,[DATE] = 2 units ,[DATE] = 4 units ,[DATE] = 6 units ,[DATE] = 8 units ,[DATE] = 12 units ,[DATE] = 16 units >400 = 20 units and call MD There are no parameters on the MAR for when to re-check the BS if out of normal range. The following instances were in the resident's record in [DATE]. Inaccurate sliding scale insulin ([MEDICATION NAME]) doses were administered, physician orders [REDACTED]. December: - [DATE], The scheduled [MEDICATION NAME] 30 units at HS was not given. - [DATE], BS 121 at 11:30 a.m. According to the physician's orders [REDACTED]. BS 209 at 4:30 p.m. According to the physician's orders [REDACTED]. No BS was taken at HS. The scheduled [MEDICATION NAME] 30 units at HS was not given. - [DATE], BS 248 at 7:30 a.m. According to the physician's orders [REDACTED]. No BS taken at 11:30 a.m. No BS taken at 4:30 p.m. - [DATE], The scheduled [MEDICATION NAME] 30 units at HS was not given. No BS taken at 7:30 a.m. No BS taken at 11:30 a.m. No BS taken at 4:30 p.m. - [DATE], The scheduled [MEDICATION NAME] 30 units at HS was not given. - [DATE], The scheduled [MEDICATION NAME] 30 units at HS was not given. - [DATE], BS 489 at 7:30 a.m. According to the physician's orders [REDACTED]. The physician was not notified. **New physician diabetic orders for this resident were received on [DATE] for the following: -Blood Glucose check AC & HS -[MEDICATION NAME] 100 units/mL - 20 units SQ every a.m. -[MEDICATION NAME] 100 units/mL - 10 units SQ with dinner -[MEDICATION NAME] 100 units/mL - sliding scale with meals and HS dosing according to blood sugar level as follows: ,[DATE] = 2 units ,[DATE] = 4 units ,[DATE] = 6 units ,[DATE] = 8 units ,[DATE] = 12 units ,[DATE] = 16 units >400 = 20 units and call MD There are no parameters on the MAR for when to re-check the BS if out of normal range. The following instances were in the resident's record from [DATE] - February 2014. Inaccurate sliding scale insulin ([MEDICATION NAME]) doses were administered, physician orders [REDACTED]. January: - [DATE], BS 296 at 7:30 a.m. According to the physician's orders [REDACTED]. - [DATE], BS 431 at 9:00 p.m. According to the physician's orders [REDACTED]. The physician was not notified. - [DATE], BS 130 at 7:30 a.m. According to the physician's orders [REDACTED]. February: - [DATE], BS 177 at 9:00 p.m. According to the physician's orders [REDACTED]. - [DATE], BS 203 at 9:00 p.m. According to the physician's orders [REDACTED]. - [DATE], BS 301 at 9:00 p.m. According to the physician's orders [REDACTED]. - [DATE], BS 283 at 9:00 p.m. According to the physician's orders [REDACTED]. - [DATE], BS 148 at 9:00 p.m. According to the physician's orders [REDACTED]. - [DATE], BS 131 at 7:30 a.m. According to the physician's orders [REDACTED]. - [DATE], BS 133 at 9:00 p.m. According to the physician's orders [REDACTED]. - [DATE], BS 136 at 7:30 a.m. According to the physician's orders [REDACTED]. - [DATE], BS 121 at 7:30 a.m. According to the physician's orders [REDACTED]. BS 220 at 4:30 p.m. According to the physician's orders [REDACTED]. - [DATE], BS 120 at 7:30 a.m. According to the physician's orders [REDACTED]. - [DATE], BS 176 at 9:00 p.m. According to the physician's orders [REDACTED]. - [DATE], BS 121 at 7:30 a.m. According to the physician's orders [REDACTED]. - [DATE], BS 178 at 11:30 a.m. According to the physician's orders [REDACTED]. - [DATE], BS 151 at 7:30 a.m. According to the physician's orders [REDACTED]. BS 205 at 11:30 a.m. According to the physician's orders [REDACTED]. BS 186 at 4:30 p.m. According to the physician's orders [REDACTED]. - [DATE], BS 179 at 7:30 a.m. According to the physician's orders [REDACTED]. BS 218 at 11:30 a.m. According to the physician's orders [REDACTED]. BS 203 at 4:30 p.m. According to the physician's orders [REDACTED]. - [DATE], BS 156 at 7:30 a.m. According to the physician's orders [REDACTED]. - [DATE], No BS taken at 9:00 p.m. - [DATE], BS 176 at 7:30 a.m. According to the physician's orders [REDACTED]. BS 246 at 11:30 a.m. According to the physician's orders [REDACTED]. BS 126 at 4:30 p.m. According to the physician's orders [REDACTED]. - [DATE], BS 159 at 7:30 a.m. According to the physician's orders [REDACTED]. BS 143 at 11:30 a.m. According to the physician's orders [REDACTED]. BS 449 at 4:30 p.m. According to the physician's orders [REDACTED]. The physician was not notified. - [DATE], BS 227 at 7:30 a.m. According to the physician's orders [REDACTED]. BS 244 at 11:30 a.m. According to the physician's orders [REDACTED]. BS 230 at 4:30 p.m. According to the physician's orders [REDACTED]. - [DATE], BS 205 at 11:30 a.m. According to the physician's orders [REDACTED]. 4. Resident #10 was re-admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The staff of the facility had identified "unstable blood sugars" on the current resident care plan with the following interventions: -monitor for signs and symptoms of [DIAGNOSES REDACTED] and [MEDICAL CONDITION] -administer medications as ordered -toenails to be trimmed by podiatrist -call physician regarding continued elevated blood glucose levels The care plan was not followed for monitoring blood sugar as the blood sugar was not taken on several occasions. The physician diabetic orders for this resident were as follows: -Blood Glucose check AC -[MEDICATION NAME] 100 units/mL - 25 units SQ every a.m. -[MEDICATION NAME] 100 units/mL - sliding scale with meals dosing according to blood sugar level as follows: ,[DATE] = 0 units ,[DATE] = 0 units ,[DATE] = 3 units ,[DATE] = 7 units ,[DATE] = 10 units ,[DATE] = 14 units ,[DATE] = 17 units >400 = give [MEDICATION NAME]based on ,[DATE]. Re-check BS Q 30 minutes X 2 There were no parameters identified on the MAR for notification of the physician of blood glucose readings outside of the identified sliding scale. The following instances were in the resident's record for February 2014. The physician orders [REDACTED]. February: - [DATE], No BS was taken at 4:30 p.m. - [DATE], No BS was taken at 4:30 p.m. - [DATE], No BS was taken at 4:30 p.m. On [DATE] at 3:30 p.m., the surveyor interviewed staff member B, the DON. She stated that residents (#'s 2 and 9) decide what dose of insulin they want to take each day. She stated they "make up their own mind." She also stated the "girls (nurses) need to call the doctor if resident #9 is not taking the amount needed." The DON stated "It's wrong, I don't know how to answer, just wrong, need to talk." On [DATE] at 3:40 p.m., the surveyor interviewed staff member C, a LPN, about the insulin dose changes in the charts. She stated it was a med error on her part and she (nurse) didn't give it because she (resident #9) drops quickly. I used my nursing judgment. She stated "she (resident #9) will either refuse the whole insulin dose or take all, she never dictates how much of the dose she wants." On [DATE] at 3:45 p.m., the surveyor interviewed resident #9 concerning insulin doses. The resident stated she agrees on what insulin dose the nurse gives her. On [DATE] at 7:30 a.m., the surveyor asked resident #2 if he ever asked to change his insulin dose that was ordered. He stated "they (nurses) tell me how much medicine and how high my blood sugar is, I never miss any." Resident #2 further explained the symptoms he got from diabetes "I feel wobbly when high and weak when low." On [DATE] at 10:15 a.m., the surveyor spoke to staff member I, the medical director/physician, of the facility. He was unaware of the sliding scale insulin ([MEDICATION NAME]/Humalog) dose changes occurring with the diabetic residents at the facility. He was also unaware of the omission of several [MEDICATION NAME] (long-acting) insulin doses to multiple residents. He stated "I expect my nurses to follow my orders as written. I would also expect them to call me with any changes." The medical director stated he would call the other physicians in the facility to make them aware of the issue.

Based on record review and staff interview, the facility failed to ensure that one 1 (#4) of 15 sampled and supplemental residents, who entered the facility without a pressure ulcer, did not develop one during the course of his stay. The facility failed to: -Complete regular skin assessments; -Notify the physician in a timely manner; -Implement prescribed treatment and safety precautions to protect the pressure ulcer and promote healing; -Develop a revised care plan to address the stage II pressure ulcer on the residents right heel and; -Assess and implement nutritional interventions to promote wound healing in a timely manner. Findings include: 1. Resident #4 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's significant change MDS with an ARD of 3/22/13 indicated that the resident had a stage II pressure ulcer. Skin Integrity Evaluations were completed quarterly until 12/16/13. The active care plan, with a revision date of 3/22/13, had interventions that included skin assessments weekly and as needed. The care plan had not been updated to include the resident's right heel pressure ulcer. The last update, on 12/19/13, stated that the resident's skin was intact. Nursing notes dated 12/30/13 revealed the resident had a stage II on his right heel "about a quarter in size in ocular shape Has a Red center in the center outer edges is harden skin... Bacatraicin (sic) applied to area and wrapped with curlex (sic)....egg crate boot..." On 12/23/13, the registered dietician added a nutritional progress entry which noted the resident's skin was intact. There was no documentation in the record that the dietitian was notified of the development of a stage II pressure ulcer found on resident #4's right heel on 12/30/13. The facility staff did not address the right heel pressure ulcer, and there were no added dietary interventions after the onset of the ulcer. There was no documentation in the record that the dietitian had reviewed the resident until 2/18/14. At that time, the dietician noted the resident's skin was healing. Review of the bath sheets, completed on each resident during a bath/shower, showed a CNA documented an open sore on resident #4's right foot on 1/8/14. On 1/16/14, the resident's physician ordered duoderm on the right heel, change to be every 72 hours. The physician's orders [REDACTED]. The facility Standing Orders, signed by the physician on 3/10/09, identified the use of [MEDICATION NAME] for areas of superficial breakdown until resolved as needed. "Contact the physician if ulceration occurs...update physician regarding wound status." According to nurse's notes on 1/25/14 at 2:00 a.m. the resident received duoderm to his right heel and the "skin was closed, very pink in color... Placed the foam boot on his right foot and repositioned the foot to the point of no pressure to the area..." On 2/26/14 at 3:11 p.m., staff member B, the DON, stated resident #4 did not have skin breakdown at the time of the survey. She stated there were no skin issues at the time in the facility. She was asked about more information on resident #4's skin monitoring but no further information was provided throughout the survey. The facility staff was aware of the resident's history of pressure ulcers. When the facility identified the stage II on the resident's right heel, the facility staff did not follow the facility's standing orders. The facility did not notify the resident's physician in a timely manner. The dietician was not aware of the resident's skin condition. The facility's standing orders had not been updated after the resident's discharge to the hospital, care plans were not revised with the change in skin conditions and the nursing staff were not monitoring the pressure ulcer routinely.