Every finding on record at Bartow Center

Based in interview and record review, the facility failed to ensure the accuracy of the Level I Pre-Admission Screening and Resident Review (PASRR) for twenty-three (#2, #3, #21, #16, #66, #87, #96, #53, #7, #31, #48, #32, #74, #62, #89, #10, #11, #27, #102, #51, #4, #33, and #20) of twenty-three residents reviewed. Findings included: 1. Record review revealed Resident #89 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, bipolar type and major depressive disorder according to the Admission Record. Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed: -Section I: Active Diagnosis - Depression and Schizophrenia -Section N: Medications administered - Antidepressant. Review of the Medication Administration Record (MAR) for July 2024 showed: -Duloxetine 30 milligrams (mg) - 1 capsules via G-Tube daily for depression -Trazodone 50mg via G-Tube daily for depression. Review of the PASRR Level I, dated 06/07/2023, revealed: -Section IA, Bipolar and Schizophrenia checked, depressive disorder was not checked -Section II 5 primary diagnosis of Dementia checked no. -Section II 6 secondary diagnoses of Dementia checked no. 2. Record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses that included vascular dementia, major depressive disorder, and other recurrent depressive disorders. Review of the significant change MDS, dated [DATE], revealed: -Section I: Active Diagnosis - depression -Section N: Medications administered - none checked. Review of the PASRR Level I, dated 07/28/2024, revealed: -Section IA, no Mental Illness, or suspected Mental Illness checked. -Section II 5 primary diagnosis of Dementia checked yes. -Section II 6 secondary diagnoses of Dementia checked no. 3. Record review revealed Resident #33 was admitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia, unspecified schizophrenia, psychosis and anxiety. Review of the quarterly MDS, dated [DATE], revealed: -Section I: Active Diagnosis - Anxiety, Psychotic Disorder and Schizophrenia -Section N: Medications administered - Antipsychotic. Review of the MAR for July 2024 showed: -Quetiapine 25mg - 1 tablet orally daily for Schizophrenia -Quetiapine 50mg - 1 tablet orally at bedtime for Schizophrenia. Review of the PASRR Level I, dated 03/08/2023 revealed: -Section IA, Anxiety checked, Schizophrenia not checked. -Section II 5 primary diagnosis of Dementia checked no. -Section II 6 secondary diagnoses of Dementia checked no. 4. Record review revealed Resident #27 was admitted to the facility on [DATE] with diagnoses that included vascular dementia, schizoaffective disorder, and major depressive disorder. Review of the quarterly MDS, dated [DATE], revealed: -Section I: Active Diagnosis -Depression and Schizophrenia -Section N: Medications administered - none. Review of the MAR for July 2024 showed: -Adlarity Patch weekly 10mg/day every Tuesday for dementia. Review of the PASRR Level I, dated 01/10/2019 revealed: -Section IA, no Mental Illness, or suspected Mental Illness checked. -Section II 5 primary diagnosis of Dementia checked yes. -Section II 6 secondary diagnoses of Dementia checked no. 5. Record review revealed Resident #21 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder and anxiety. Review of the admission MDS, dated [DATE], revealed: -Section I: Active Diagnosis -Anxiety and Depression. -Section N: Medications administered - Antipsychotic, Antianxiety, and Antidepressant. Review of the MAR for July 2024 showed: -Paroxetine 10mg - 1 tablet daily orally for Depression -Quetiapine 50mg - 1 tablet daily orally at bedtime for Bipolar Disorder -Trazodone 50mg - 1 tablet daily orally for Depression -Alprazolam 0.5mg - 1 tablet orally three times daily foe Anxiety. Review of the PASRR Level I, dated 04/11/2024 revealed: -Section IA, no Mental Illness, or suspected Mental Illness checked. -Section II 5 primary diagnosis of Dementia checked no. -Section II 6 secondary diagnoses of Dementia checked no. During an interview on 07/29/24 at 3:20 p.m. with the Assistant Director of Nursing (ADON) and the Nursing Home Administrator (NHA), the ADON stated it is all nurses' and the Social Services department's responsibility to ensure the PASRR was correct and present on admission to the facility. The ADON stated following a new diagnosis, it is the registered nurse's (RN) responsibility to ensure the PASRR is updated if they have access to the system The ADON confirmed she was currently the only facility RN with access to update the PASRR. The ADON also confirmed PASRR Level I data are incorrect for a significant number, including those listed. An interview was conducted on 7/30/24 at 10:13 a.m. with the Social Services Director (SSD). She said when a resident gets to the facility, they come with a PASRR from the hospital. She said she looks at them to see if they need a Level II PASRR. She stated she had been doing audits on PASRRs and did not find any issues, except for a few residents that needed a Level II. She confirmed she had not had any PASRR training at the facility. She said if she finds issues, she lets the nurse know. Review of an audit log for June and July 2024 provided by the SSD showed residents had been checked for the presence of a PASRR. The audits did not address the accuracy of the PASRR. Review of a policy titled PASRR (Pre-Admission Screening & Resident Review) Requirements Level I & Level II, dated February 2021, showed: .The screening is reviewed by Admissions for suspicion of serious mental illness & intellectual disability to ensure appropriate placement in the least restrictive environment, and to identify the need to provide applicants with needed specialized services. 2. Determine if a serious mental illness &/or intellectual disability or a related condition exists while reviewing the PASRR for completed by the Acute Care Facility. (Trigger for Level II Completion) If preadmission screening requires a Level II evaluation, submit all required documents to CARES timely, so that a Level II can be completed within the required time frames. 40775 6. A review of Resident #87's medical record revealed Resident #87 was admitted to the facility on [DATE] with a diagnosis of major depressive disorder. A review of Resident #87's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 5/6/2024 revealed under Section I - Active Diagnoses, Resident #87 had a diagnosis of depression. Resident #87's MDS assessment also revealed, under Section N - Medications, Resident #87 received antidepressant medication. A review of Resident #87's physician orders revealed an order, dated 3/18/24 for mirtazapine 15 milligrams (mg), give 0.5 tablet by mouth (PO) at bedtime for depression. A review of Resident #87's PASRR assessment, dated 1/26/24 revealed, under the section titled A. MI (Mental Illness) or suspected MI (check all that apply), the checkbox for the selection Depressive Disorder was not checked. 7. A review of Resident #96's medical record revealed Resident #96 was admitted to the facility on [DATE] with diagnoses of major depressive disorder, anxiety disorder, and other stimulant abuse. A review of Resident #96's Quarterly MDS assessment, with an ARD of 7/12/24 revealed under Section I - Active Diagnoses, Resident #96 had diagnoses of depression and anxiety disorder. Resident #96's MDS assessment also revealed, under Section N - Medications, Resident #96 received antidepressant medication. A review of Resident #96's physician orders revealed an order, dated 7/25/24 for duloxetine hydrochloride (HCl) delayed release sprinkle 60 mg PO at bedtime for depression. A review of Resident #96's PASRR assessment, dated 6/4/24, revealed under the section titled A. MI or suspected MI (check all that apply), the checkboxes for the selections Depressive Disorder, Anxiety Disorder, and Bipolar Disorder were checked. The checkbox for the selection Substance Abuse was not checked. The assessment also revealed Resident #96 did not have a diagnosis or suspicion of SMI or ID and a Level II PASRR evaluation was not required. 8. A review of Resident #53's medical record revealed Resident #53 was admitted to the facility on [DATE] with diagnoses of major depressive disorder, alcohol abuse, and cocaine abuse. A review of Resident #53's Quarterly MDS assessment, with an ARD of 5/8/24 revealed under Section I - Active Diagnoses, Resident #53 had a diagnosis of depression . Resident #53's MDS assessment also revealed, under Section N - Medications, Resident #53 received antidepressant medication. A review of Resident #53's physician orders revealed an order, dated 6/26/24 for duloxetine HCl 30 mg PO one time a day for depression. A review of Resident #53's PASRR assessment, dated 11/1/21 revealed, under the section titled A. MI or suspected MI (check all that apply), the checkbox for the selection Substance Abuse was checked. The checkbox for the selection Depressive Disorder was not checked. 9. A review of Resident #62's medical record revealed Resident #62 was admitted to the facility on [DATE] with a diagnosis of major depressive disorder. A review of Resident #62's Quarterly MDS assessment, with an ARD of 5/7/24 revealed under Section I - Active Diagnoses, Resident #62 had a diagnosis of depression. Resident #62's MDS assessment also revealed, under Section N - Medications, Resident #62 received antidepressant medication. A review of Resident #62's physician orders revealed an order, dated 10/12/23 for mirtazapine 30 mg, give 2 capsules PO one time daily for major depressive disorder. Resident #62's physician orders also revealed an order, dated 10/12/23 for bupropion HCl extended release 150 mg PO one time daily for major depressive disorder. A review of Resident #62's PASRR assessment, dated 8/3/21, revealed, under the section titled A. MI or suspected MI (check all that apply), the checkbox for the selection Depressive Disorder was not checked. 10. A review of Resident #51's medical record revealed Resident #51 was admitted to the facility on [DATE] with a diagnosis of anxiety disorder, major depressive disorder, and bipolar disorder. A review of Resident #51's Quarterly MDS assessment, with an ARD of 4/8/24 revealed under Section I - Active Diagnoses, Resident #62 had a diagnosis of depression, anxiety disorder, and bipolar disorder. Resident #51's MDS assessment also revealed under Section N - Medications, Resident #51 received antianxiety and antidepressant medications. A review of Resident #51's physician orders revealed the following orders: - An order dated 10/13/23 for divalproex sodium 500 mg PO twice daily for bipolar disorder. - An order dated 12/5/23 for lorazepam 0.5 mg PO twice daily for anxiety. - An order dated 7/18/23 for duloxetine HCl 60 mg PO one time a day for depression - An order dated 7/18/23 for trazodone HCl 50 mg PO at bedtime for depression. A review of Resident #51's PASRR assessment, dated 12/4/21 revealed, under the section titled A. MI or suspected MI (check all that apply), the checkboxes for the selections Depressive Disorder, Anxiety Disorder, and Bipolar Disorder were checked. The assessment also revealed Resident #51 did not have a diagnosis or suspicion of SMI or ID and a Level II PASRR evaluation was not required. 38007 11. Review of the Admission Record showed Resident #3 was admitted to the facility on [DATE], with diagnoses to include unspecified psychosis not due to a substance or known physiological condition (12/16/16), unspecified dementia, unspecified severity without behavioral disturbance psychotic disturbance mood disturbance, and anxiety (10/1/22), unspecified mental disorder due to know physiological condition (9/26/17), obsessive-compulsive disorder unspecified (9/26/17), encephalopathy (12/16/16), major depressive disorder recurrent unspecified (12/16/16), unspecified mood (affective) disorder (12/16/16), phobic anxiety disorder unspecified (12/16/16), and anxiety disorder (12/16/16). Review of the July 2024 Medication Administration Record (MAR) showed the physician order for Xifaxan Oral Tablet 550 MG (milligrams) - give 1 tablet by mouth two times a day for hepatic encephalopathy, order date 7/12/24, was administered as ordered. Review of the care plan for Resident #3 showed: -Cognition [Resident #3] has impaired cognitive function/dementia or impaired thought processes r/t (related to) severely impaired: due to baring trauma, initiated 12/29/17 and revised 11/14/23. Review of Resident #3's Minimum Data Set, dated dated [DATE], revealed in Section I - Active Diagnoses the following: Non-Alzheimer's dementia, anxiety, depression, psychotic disorder, unspecified mental disorder due to known physiological condition, and obsessive compulsive disorder. Review of a PASRR Level I for Resident #3, dated 12/29/10, showed diagnoses to include brain injury in MVA (motor vehicle accident), dementia without behavior disturbance and depression. A review of Resident #3's medical chart and electronic medical record revealed the records were silent of a revised PASRR Level I with additional diagnoses or a PASRR Level II. 12. Review of the Admission Record showed Resident #74 was admitted to the facility on [DATE] with an original admitted [DATE]. Resident #74's diagnoses included mixed receptive-expressive language disorder (11/3/21), cognitive communication deficit (11/3/21), generalized anxiety disorder (11/22/22), dementia in other disease classified elsewhere unspecified severity, with other behavioral disturbance (10/1/22), unspecified mood (affective) disorder (6/8/22), and unspecified psychosis not due to a substance or known physiological condition (11/3/21). Review of the medical record for Resident #74 revealed a Certification of Incapacity to Make Informed Healthcare Decisions form signed on 6/28/23. Review of the July 2024 MAR showed physician orders for Lorazepam Oral Tablet .5MG, and Buspirone HCI Oral Tablet 10 MG were administered as ordered. Review of Resident #74's MDS, dated [DATE], revealed in Section I - Active Diagnoses the following: Non-Alzheimer's dementia, anxiety, psychotic disorder, and unspecified mood (affective) disorder. Section N - Medications showed antianxiety medication was administered. Review of a PASRR Level I for Resident #74, dated 12/26/21, showed no diagnoses checked in Section 1A for MI or suspected MI. Section II showed no checked for all questions and Dementia was check as no for the primary diagnoses as well as related neurocognitive disorder. The PASRR Level I dated 7/28/24 and provided for review showed no diagnoses were checked in Section 1A. 13. Review of the Admission Record showed Resident #4 was admitted to the facility on [DATE] with diagnoses to include cognitive communication deficit (6/23/21), pseudobulbar affect (8/19/22), other specified mental disorders due to know physiological condition (6/8/22), major depressive disorder recurrent unspecified (6/8/22), mixed receptive-expressive language disorder (5/30/22), generalized anxiety disorder (3/27/22), unspecified psychosis not due to a substance or known physiological condition (12/27/21), and other stimulant abuse uncomplicated (6/23/21). Review of the MAR for July 2024 showed physician orders for Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG, Ativan Tablet 1 MG, Buspirone HCI 7.5 mg, and Nuedexta Capsule 20-10 MG were administered as ordered. Review of Resident #4's MDS, dated [DATE], revealed in Section I-Active Diagnoses the diagnoses of anxiety, depression, psychotic disorder, cognitive communication deficit, pseudobulbar affect and other mental disorders due to know physiological condition. Section N-Medications showed Resident #4 was administered antianxiety medication. Review of a PASRR Level I for Resident #4, dated 6/28/21, showed in Section 1A only substance abuse was checked for the diagnoses. In Section IB no conditions were checked, and in Section II all of the boxes were checked no. The record was silent of a revised PASRR Level I or a PASRR Level II for the additional diagnoses identified in 2022. 14. Review of the Admission Record showed Resident #66 was admitted to the facility on [DATE] with an original admitted [DATE]. Resident #66's diagnoses included major depressive disorder (5/5/22), other psychoactive substance abuse (5/5/22), bipolar disorder (5/7/21), other specified depressive episodes (5/7/21), generalized anxiety disorder (5/7/21) and traumatic shock (5/7/21). Review of Resident #66's MDS, dated [DATE], showed in Section I-Active Diagnoses the diagnoses of anxiety, depression, bipolar disorder, and other psychoactive substance abuse. Section N-Medications showed Resident #66 was administered antianxiety, and antidepressant medications. Review of the MAR for July 2024 showed physician orders for Duloxetine HCI Oral Capsule Delayed Release Particles 60 MG, Wellbutrin XL Oral Tablet Extended Release 24 Hour 300 MG, and Ativan Oral Tablet .5 MG were administered as ordered. Review of a PASRR Level I for Resident #66, dated 9/12/22 showed no diagnoses checked in Section 1A for MI or suspected MI. In Section IB no conditions were checked, and in Section II all of the boxes were checked no. 15. Review of the Admission Record showed Resident #48 was admitted to the facility on [DATE] with an original admitted [DATE]. Resident #48's diagnoses included generalized anxiety disorder (12/16/22), and other psychoactive substance abuse (11/16/22). Review of Resident #48's MDS, dated [DATE], showed in Section I-Active Diagnoses the diagnoses of anxiety disorder, depression, and other psychoactive substance abuse. Section N-Medications showed Resident #48 was administered antidepressant medication. Review of the MAR for July 2024 showed a physician order for Duloxetine HCI Oral Capsule Delayed Release Particles 60 MG was administered as ordered. Review of a PASRR Level I for Resident #48, dated 11/11/22 showed only substance abuse checked in Section 1A for MI or suspected MI. In Section IB no conditions were checked, and in Section II all of the boxes were checked no. The record was silent of a revised PASRR Level for the additional diagnosis identified in 2022. 46234 16. Record review revealed Resident #31 was admitted to the facility on [DATE] with diagnoses that included mood disorder and unspecified psychosis. On 9/1/2023 anxiety disorder was added as a diagnosis and on 4/1/2023 schizoaffective disorder, bipolar type was added as a diagnosis. Review of the quarterly MDS, dated [DATE], revealed: -Section I: Active Diagnosis- anxiety disorder, depression, psychotic disorder, and schizophrenia. -Section N: Medications administered- antipsychotic and hypnotic. Review of the MAR for July 2024 showed: -Seroquel Oral Tablet 100mg three times a day related to schizoaffective disorder, bipolar type. Review of the PASRR Level I, dated 11/29/2022, revealed: -Section IA, no Mental Illness or suspected Mental Illness checked. 17. Record review revealed Resident #7 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, anxiety disorder, major depressive disorder, and seizures. Review of the quarterly MDS, dated [DATE], revealed: -Section I: Active Diagnosis- anxiety disorder, depression, and bipolar disorder -Section N: Medications administered- antidepressant. Review of the MAR for July 2024 showed: -Depakote Oral tablet delayed release 250mg two times a day related to bipolar disorder. -Duloxetine HCL oral capsule delayed release 20mg. 1 capful two times a day for depression. -Lamotrigine oral tablet 25mg every 12 hours related to seizures. -Aricept oral tablet 5mg one time a day for dementia. Review of the PASRR Level I, dated 1/15/2019 revealed: -Section IA, showed only Depressive disorder. 18. Record review revealed Resident #102 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included major depressive disorder, anxiety disorder, and mood disorder. Review of the quarterly MDS, dated [DATE], revealed: -Section I: Active Diagnosis- anxiety disorder, depression, mood disorder. -Section N: Medications administered- antidepressant and hypnotic. Review of the MAR for July 2024 showed: -Lexapro oral tablet 10mg one time a day for depression. -Lorazepam oral tablet 1mg every eight hours for anxiety. -Diazepam oral tablet 5mg every 12 hours an needed for anxiety. Review of the PASRR Level I, dated 11/20/2023, revealed: -Section IA, no Mental Illness or suspected Mental Illness checked. 19. Record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses that included dementia, altered mental status, major depressive disorder, panic disorder, and anxiety disorder. Review of the quarterly MDS dated [DATE] revealed: -Section I: Active Diagnosis- anxiety disorder and depression -Section N: Medications administered- antipsychotic, antianxiety, antidepressant, Review of the MAR for July 2024 showed: -Sertraline HCL oral tablet 50mg at bedtime for depression. -Xanax oral tablet 0.5mg every eight hours as needed for agitation for 14 days. Review of the PASRR Level I, dated 11/14/2023 revealed: -Section IA, no Mental Illness or suspected Mental Illness checked. 36273 20. Review of the Admission Record for Resident #16, revealed an admission to the facility on [DATE] with diagnoses to include unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (10/1/2022), anxiety disorder unspecified (7/1/2020), schizophrenia unspecified (4/8/2016), profound intellectual disabilities (6/9/2011), bipolar disorder unspecified (6/9/2011), major depressive disorder recurrent unspecified (6/9/2011), unspecified mental disorder due to known physiological condition (6/9/2011), unspecified mood [affective] disorder (6/9/2011), post-traumatic stress disorder unspecified (6/9/2011) and cerebral palsy (6/9/2011). Review of the July 2024 Medication Administration Record (MAR) for Resident #16 revealed the following physician orders were administered as ordered: - Zoloft Oral Tablet 50 MG (milligram) (Sertraline HCl) Give 1 tablet by mouth one time a day for depression, 5/10/2023 -Prazosin HCl Capsule 1 MG Give 1 mg by mouth two times a day for PTSD (post traumatic stress disorder), 8/31/2017. Review of the Quarterly Minimum Data Set (MDS) assessment for Resident #16, dated 07/18/2024, showed: -Section I; Active Diagnoses showed: cerebral palsy, Non-Alzheimer's dementia, seizure disorder or epilepsy, anxiety disorder, depression, bipolar disorder, schizophrenia, and post traumatic stress disorder (PTSD). -Section N-Medications showed: Antianxiety checked, and Antidepressant checked. Review of the Level I PASRR form located in the medical record for Resident #16, dated 05/18/2011, revealed: -Section 1 Part A. marked No for mental illness -Section 1 Part B marked Yes for Mental Retardation -Section II marked No -Section III marked No -Section IV marked No -Section V marked No. The medical record for Resident #16 was silent of an updated Level I PASRR with the new diagnoses. 21. Review of the Admission Record for Resident #20, revealed an admission to the facility on [DATE] with diagnoses to include: alcohol abuse uncomplicated, anxiety disorder unspecified, and bipolar disorder current episode manic without psychotic features unspecified. Review of the July 2024 MAR for Resident #20 revealed the following physician orders were administered as ordered: -Xanax Oral Tablet 0.25 MG (Alprazolam) *Controlled Drug* Give 1 tablet by mouth every 8 hours as needed for anxiety for 14 Days Give at bedtime 7/15/24 ending 7/29/24 -busPIRone HCl Oral Tablet 10 MG (Buspirone HCl) Give 1 tablet by mouth three times a day for anxiety (5/10/24) -QUEtiapine Fumarate Oral Tablet 25 MG (Quetiapine Fumarate) Give 1 tablet by mouth three times a day for bipolar (5/10/24). Review of the MDS assessment for Resident #20, dated 6/10/2024, revealed: Section I: Active Diagnoses- anxiety disorder, and bipolar disorder. Section N: Medications-antipsychotics, antianxiety, hypnotic, and opioid were administered. Review of the Level I PASRR form located in the clinical record for Resident #20, dated 5/8/2024, revealed: Section 1 Part A: other, ETOH (ethyl alcohol) abuse Section 1 Part B: nothing marked Section II: nothing marked Section IV: checked NO. The medical record was silent of a revised Level I PASRR to include the diagnoses of anxiety disorder or bipolar disorder. 22. Review of the Admission Record for Resident #32 revealed an admission to the facility on [DATE] with diagnoses to include: major depressive disorder recurrent unspecified (10/12/2018), schizophrenia unspecified (10/12/2018), adjustment disorder with mixed disturbance of emotions and conduct (10/12/2018), personal history of traumatic brain injury (10/12/2018) and expressive language disorder (11/21/2018). Review of the July 2024 MAR for Resident #32 revealed the physician order for SEROquel Oral Tablet 25 MG (Quetiapine Fumarate) Give 25 mg by mouth two times a day related to schizophrenia was administered as ordered. Review of the MDS assessment for Resident #32, dated 07/05/2024, revealed: Section I-Diagnoses: Depression, and Schizophrenia. Section N-Medications: Antipsychotic. Review of the Level I PASRR form located in the clinical record for Resident #32, dated 04/05/2017, revealed: Section I Part A. nothing marked Section I Part B. traumatic brain injury and seizures marked Section II: all marked No Section III: not a provisional admission Section IV: No diagnosis or suspicion of SMI (serious mental illness) or ID (intellectual disability) indicated. The medical record for Resident #32 was silent of a revised Level I PASRR include the new diagnoses of major depressive disorder, schizophrenia and adjustment disorder with mixed disturbance of emotions and conduct. 23. Review of the Admission Record for Resident #11 revealed an admission to the facility on [DATE] with diagnoses to include: major depressive disorder, recurrent, unspecified (05/13/2019), unspecified psychosis not due to substance or known physiological condition (05/03/2019), generalized anxiety disorder (05/03/2019), schizophrenia, unspecified (05/03/2019), other epilepsy, intractable, without status epilepticus (05/03/2019) and restlessness and agitation (11/10/2020). Review of the Level I PASRR form located in the clinical record for Resident #11, dated 11/19/2018, revealed: Section I Part A-Schizophrenia and insomnia checked Section II: marked no. Review of the care plan located in the clinical record, dated 5/5/2024, revealed: Resident #11 uses psychotropic medications and anticonvulsants to manage seizures. The medical record for Resident #32 was silent of a revised Level I PASRR to include the new diagnoses.

Based on observations, interviews, and record reviews, the facility failed to maintain an effective infection control and prevention program to prevent the spread of infection by 1.) failing to ensure transmission based precautions were implemented in a timely manner for one resident (#323) of one resident under transmission based precautions in the facility, 2.) failed to obtain physician's orders for transmission based precautions upon admission for one resident (#323) of one resident under transmission based precautions in the facility, 3.) failed to ensure appropriate signage for transmission based precautions was displayed outside of resident rooms under transmission based precautions for one resident (#323) of one resident under transmission based precautions in the facility, 4.) failed to implement enhanced barrier precautions during wound care treatment for one resident (#96) of four residents sampled for wound care, and 5.) failed to ensure hand hygiene was performed during meal service by two dietary staff members (P and Q) and random staff members delivering lunch service in the main dining room and one hall (300) of four halls observed. Findings included: 1. A review of Resident #323's medical record revealed Resident #323 was admitted to the facility on [DATE]. A review of Resident #323's physician orders revealed the following orders: - An order dated 7/14/2024 for Vancomycin Hydrochloride 125 milligrams (mg) give 1 capsule by mouth four times a day for clostridium difficile (c. diff) for 14 Days. - An order dated 7/27/2024 for contact isolation precautions for c. diff. A review of Resident #323's Pre-Admission Screening Tool, dated 7/9/24, revealed under the section titled Contact Precautions: Diagnosis a hand written note C Diff positive 7/11/2024. A review of Resident #323's care plan revealed a Focus area as [Resident #323] received antibiotic therapy related to a diagnosis of c. diff. Interventions included initiating contact isolation precautions and monitoring for possible side effects every shift. An observation was conducted on 7/27/2024 at 10:31 a.m. outside of Resident #323's room. No signage indicating Resident #323 was on contact isolation precautions was observed outside of the resident's room and no personal protective equipment (PPE) was observed outside of Resident #323's room. An observation was conducted on 7/29/2024 at 2:20 p.m. outside of Resident #323's room. Signage indicating Resident #323 was on droplet/contact isolation precautions was observed outside of the resident's room. The signage posted outside of the resident's room revealed staff must don an isolation gown, an N95 respirator, eye protection, and gloves before entering the resident's room. An interview was conducted on 7/29/2024 at 2:23 p.m. with the facility's Director of Clinical Services (DCS). The DCS observed the signage on Resident #323's door and addressed the signage should indicate Resident #323 was on contact isolation precautions, not contact/droplet isolation precautions. An interview was conducted on 7/30/2024 at 12:20 p.m. with Staff C, Registered Nurse (RN)/Unit Manager (UM) and the Assistant Director of Nursing (ADON). The ADON stated Resident #323 was on contact isolation precautions due to testing positive for c. diff and was admitted to the facility with the precautions in place. Staff C, RN/UM stated orders for transmission based precautions should be in place upon the resident's admission because they are notified of the need for precautions before the resident is admitted to the facility. The ADON stated proper signage indicating the type of precautions the resident is on should also be posted at the time of the admission. 2. A review of Resident #96's medical record revealed Resident #96 was admitted to the facility on [DATE]. A review of Resident #96's physician orders revealed the following orders: 6/6/2024: Cleanse sacrum with normal saline and apply [brand name] collagenase to wound bed, pack loosely with normal saline moistened gauze, cover with dry dressing, change daily on the evening shift and as needed for soilage or dislodgement. 7/24/2024: Enhanced Barrier Precautions every shift for wounds. An observation of wound care was conducted on 7/29/2024 at 1:14 p.m. for Resident #96 with Staff H, Licensed Practical Nurse (LPN) and Staff I, Certified Nursing Assistant (CNA). Signage outside of Resident #96's room revealed Resident #96 was on Enhanced Barrier Precautions. The signage revealed providers and staff must must wear gowns and gloves for high contact resident care activities, including wound care of any skin opening requiring a dressing. The signage appeared very dark in color and was difficult to read clearly. Staff H, LPN and Staff I, CNA performed hand hygiene and donned gloves before explaining the procedure to Resident #96 and positioning the resident for the procedure. A mesh bag with isolation gowns was observed on the back of Resident #96's door. Staff H, LPN gathered supplies for the procedure and entered Resident #96's room. Staff H, LPN completed the wound care for Resident #96 while Staff I, CNA provided assistance with positioning Resident #96 during the procedure. Staff H, LPN and Staff I, CNA did not don an isolation gown at any time during the wound care procedure. Following the procedure, Staff H, LPN and Staff I, CNA repositioned Resident #96 for comfort, removed their gloves, and performed hand hygiene before exiting the room. An interview was conducted with Staff H, LPN and Staff I, CNA following the procedure. Staff H, LPN observed the signage posted outside of Resident #96's room indicating the resident was under Enhanced Barrier Precautions. Staff H, LPN was not able to explain what Enhanced Barrier Precautions were and was not able to explain why Enhanced Barrier Precautions was implemented. Staff H, LPN had difficulty reading the signage posted outside of Resident #96's room, even with the use of corrective lenses. Staff I, CNA stated Enhanced Barrier Precautions were implemented to keep what's on me on me and to protect the resident from further risk of infection. Staff I, CNA also stated an isolation gown should have been donned prior to performing the wound care procedure. An interview was conducted on 7/29/2024 at 2:03 p.m. with Staff C, RN/UM and the ADON. Staff C, RN/UM stated she has received specialized training related to infection prevention and control and assists the ADON in the duties as the facility's infection preventionist. The ADON stated she conducted education with facility staff related to the use of Enhanced Barrier Precautions, which is used to protect residents at a higher susceptibility of infections. Staff C, RN/UM stated Enhanced Barrier Precautions is used for any resident who has an opening not natural to their body, including wounds. The ADON stated Enhanced Barrier Precautions should be used when giving wound care to a resident. Staff C, RN/UM and the ADON observed the signage posted to Resident #96's door and addressed the signage appeared very dark. A review of the facility policy titled, Barrier Precautions, effective April 2024, revealed contact precautions are used when the employee expects to be in direct or indirect contact with a patient and/or his or her environment including a person's room or objects in contact with the person that has an infection with an organism transmitted fecal-orally, such as clostridium difficile or wound and skin infections or multi-drug resistant bacteria. Personal Protective Equipment (PPE) required before entering a contact precaution designated room is always gloves and a gown. The policy also revealed Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission or multi-drug resistant organisms (MDROs) that employ targeted gown and glove use during high contact activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP is indicated for residents with wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with MDRO. 38007 3. An observation of the lunch meal service in the main dining room on 7/27/24 at 11:29 a.m. prior to the lunch meal arriving a staff member was serving beverages to the residents. She touched her N95 mask by pulling it down to ask a resident if they wanted coffee. She served the coffee and failed to perform hand hygiene prior to serving the coffee. An observation on 7/27/24 at 12:24 p.m. of the lunch trays being delivered on the 300 Hall revealed a lunch tray being delivered to room [ROOM NUMBER] Bed A. The resident's bedside table had multiple personal items on it and it was uneven. The lunch tray was slid onto the table and two staff members were observed touching the bedside table in an attempt to straighten it out for the resident. They left room and each retrieved another tray and delivered those trays to other residetns with no hand hygiene performed. An interview was conducted on 7/28/24 at 3:51 p.m. with Staff M, Certified Nursing Assistant (CNA) who stated they are to hand sanitize before they deliver a tray and after. An interview was conducted on 7/29/24 at 1:48 p.m. with Staff N, Licensed Practical Nurse (LPN) and he confirmed staff should sanitize their hands between tray delivery. An observation of the tray line for lunch on 7/29/24 at 11:10 a.m. revealed Staff P, Dietary Aide with her hands in her pockets as she was waiting for the cook to plate the food. Staff Q, Dietary Aide was observed with her hands placed on her hips multiple times prior to the plating of lunch meal at 11:25 a.m. Staff P and Staff Q did not perform hand hygiene. Staff P was observed at 11:30 a.m. with her hands in her pockets then touched a tray with food to be served without performing hand hygiene. Immediately following this observation an interview was conducted with the Certified Dietary Manager and she confirmed hand hygiene should have been performed after having their hands in pockets and on their clothes.

Based on observation, interview and record review, the facility failed to ensure oxygen therapy was administered as ordered for four residents (#50, #271, #170 and #114) of seven residents sampled. Findings included: 1. Review of the medical record revealed Resident #50 was admitted to the facility on [DATE] with diagnoses to include chronic respiratory failure, and chronic obstructive pulmonary disease (COPD, according to the Admission Record. During an observation on 7/28/24 at 11:00 a.m., the resident's oxygen was observed to be set and administering at 2.5 liters per minute (LPM). (Photographic Evidence Obtained) During an interview with the resident at the time of the observation, the resident stated her oxygen should be at 3 liters all the time. The resident confirmed she had used oxygen for a long time. Review of the current physician's orders for Resident #50 showed: -Oxygen at 4 LPM (liters per minute) Via N/C (nasal cannula) continuously for COPD with humidification. dated 11/25/22. Review of the annual Minimum Data Set (MDS), dated [DATE], revealed: -Section C-Cognitive Patterns: Brief Interview for Mental Status (BIMS) score 15/15, indicating the resident was cognitively intact. -Section O: Oxygen was checked yes. Review of the care plan showed: -Focus: oxygen, with interventions that included but not limited to Administer Oxygen as ordered, dated 11/04/21. On 7/29/24 at 9:41 a.m. an observation was conducted with Staff C, Registered Nurse (RN)/Unit Manager (UM). During the observation Resident #50's oxygen was noted as set on 2.5 LPM. The RN/UM confirmed the setting and stated it was supposed to be at 2 LPM; she decreased the setting to 2 LPM. 2. Review of the medical record revealed Resident #271 was admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (COPD), according to the Admission Record. During an observation on 7/28/24 at 11:35 a.m. the resident's oxygen was noted set and administering at 2 LPM (Photographic Evidence Obtained) During an interview with the resident at the time of the observation, the resident said she was not aware she was on oxygen. Review of the current physician's orders for Resident #271 showed: -Oxygen at 3 LPM Via N/C continuously for COPD dated 11/25/22. Review of the care plan showed: -Focus: oxygen, with interventions that included but not limited to Administer Oxygen as ordered, dated 7/27/24. On 7/29/24 at 9:43 a.m. an observation was conducted with Staff C, RN/UM. During the observation Resident #271's oxygen was noted as set on 2 LPM. The RN/UM confirmed the setting. At the time of the observation, the oxygen nasal cannula and tubing were observed looped over the oxygen concentrator and not on the resident. Review of the policy titled, Oxygen Therapy, dated November 2023, revealed: 1. Verify physician order . 7. Apply device to resident with the appropriate liter flow. On 7/30/24 at 10:43 a.m. an interview was conducted with the Director of Nursing (DON). The DON stated the Respiratory Therapist (RT) is responsible for ensuring the resident's oxygen is set to the correct amount. The DON stated the RT comes to the facility on ce a week, and confirmed in the interim periods the nurse is responsible for ensuring the oxygen is being administered as per the physician's order. She confirmed it was her expectation that oxygen is administered as ordered. 36273 3. Review of the Admission Record for Resident #114 revealed an admission to the facility on [DATE] with diagnoses to include cardiac arrest cause unspecified, and chronic obstructive pulmonary disease with (acute) exacerbation. Review of Resident #114's active physician orders, dated 6/14/24, revealed: Humidified oxygen per trach (tracheostomy) continuously 1 liter. Review of the care plan for Resident #114, dated 6/19/24, revealed: OXYGEN: The resident has Oxygen Therapy r/t SOB (related to shortness of breath) The interventions included: -Administer Oxygen as ordered. (Refer to current POS/MAR [physician orders/medication administration record] for current order) -Give humidified oxygen as prescribed. On 7/28/24 at 10:36 a.m. Resident #114 was observed lying in bed with a trach with oxygen flowing via a concentrator set at 2 liters. On 7/28/24 at 3:26 p.m. Resident #114 was observed lying in bed with a trach with oxygen flowing via a concentrator set at 2 liters. During an interview on 7/29/24 at 2:42 p.m. with Staff L, Registered Nurse, (RN) she confirmed the oxygen order for Resident #114 was for continuous oxygen at 1 liter. 4. Review of the Admission Record for Resident #170 revealed an admission to the facility of 7/24/24 with a diagnosis of pulmonary cryptococcosis, other specified interstitial pulmonary diseases. Review of the July 2024 MAR for Resident #170 revealed: Oxygen at 4 LPM (liters per minute) Via NC (nasal cannula) continuously for SOB. every shift for Shortness of Breath, ordered 7/24/24. Review of the care plan for Resident #170, dated 7/25/24, revealed OXYGEN: The resident has Oxygen Therapy r/t SOB. The interventions included: -Administer Oxygen as ordered. (Refer to current POS/MAR for current order). On 7/28/24 at 9:53 a.m. Resident #170 was observed lying in bed with a nasal cannula with oxygen flowing via a concentrator set at 3 liters. On 7/28/24 at 3:22 p.m. Resident #170 was observed lying in bed with a nasal cannula with oxygen flowing via a concentrator set at 3 liters. During an interview on 7/29/24 at 2:38 p.m. Staff L, RN confirmed the oxygen order for Resident #170 was for continuous oxygen at 4 liters.

Based on observations and interviews, the facility failed to ensure medication was stored properly in two (400 hall and 200 hall) out of two medication carts audited, one out of one medication rooms audited, for one resident (#62) out of 48 sampled residents and on three out of four hallways. Findings included: An observation was conducted on 7/27/24 at 9:29 a.m. of a medication cart unlocked on the 400 hall. The nurse was observed to be in a resident room and no other nurses were in the hall at the time. (Photographic Evidence Obtained) An observation was conducted on 7/27/24 at 9:38 a.m. of a medication cart on the 400 hall with a bag of IV (intravenous) medication (Ceftriaxone) sitting in the side compartment of the medication cart not locked up. There were no nurses in sight of the medication cart. (Photographic Evidence Obtained) An audit was completed on 7/28/24 at 9:10 a.m. of the 200 hall medication cart with Staff A, Registered Nurse (RN). The bottom drawer of the medication cart contained two weekly pill boxes with medication in each compartment. The boxes had no names or labels. An interview was conducted at that time with Staff A. She said the pill boxes belonged to a resident and she doesn't use them. She confirmed the pill boxes were not labeled and dated and she was going to dispose of them. (Photographic Evidence Obtained) An observation was conducted on 7/28/24 at 9:13 a.m. of an IV medication (Vancomycin) sitting on top of a medication cart on the 100 hall. The nurse was observed going in a resident room and then to the medication room leaving the IV medication on top of the cart unsecured. (Photographic Evidence Obtained) An interview was conducted on 7/28/24 at 9:33 a.m. with Staff B, Licensed Practical Nurse (LPN). She said IV medication is typically kept in the medication storage room. She said she had it out trying to catch up to the resident and trying to let it get warmer. When asked if it should be left of top of the medication cart she stated, Should it be locked up? She then proceeded to put it in the medication cart. An interview was conducted on 7/28/24 at 9:44 a.m. with Staff C, RN/Unit Manager (UM). She said the pill boxes in the medication cart were for a resident that was admitted two days ago. She said she does not know what the medication is because it came from the resident's home. She said the pill boxes should not have been in the medication cart, they should have been sent home with family. Staff C said IV medication should be stored in the medication room until it is time to hang up for administration. She said it should not be left on top or in the side compartment of the medication cart. An audit was conducted on 7/28/24 at 9:59 a.m. of the 300/400 unit medication room with Staff D, LPN. The medication refrigerator contained a Basaglar insulin pen with no name or prescription label. Staff D said the pen should have a label on it and she did not know who it belonged to. An audit was conducted on 7/28/24 at 4:00 p.m. of the 300 hall medication cart with Staff D, LPN. Three loose pills were found in the top two drawers in the medication cart. An interview was conducted at that time. Staff D said the night shift nurses are responsible for cleaning the medication carts. She said if she sees loose pills she will take them out and dispose of them properly. She confirmed they should not be in the medication cart. An interview was conducted on 7/30/24 at 11:00 a.m. with the Director of Nursing (DON). She confirmed the night shift nurses clean the medication carts. She said herself, the UM and Assistant Director of Nursing (ADON) check the carts in between. She said there should be no loose or unlabeled medication in the carts. The DON said IV medication should stay in the medication room until it is going to be hung for the resident. Review of a policy titled, Medication Storage, dated 9/18, showed the following: Policy Medication and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures 3. In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aides) are allowed access to medication carts. Medication rooms, cabinets, and medication supplies should remain locked when not in use or attended by persons with authorized access. 40775 2. An observation was conducted on 7/27/24 at 10:31 a.m. in Resident #62's room. Resident #62 was observed resting in bed with his bedside table in front of him. An albuterol inhaler, a vial of eye drops, and a spray bottle of wound cleanser were observed on Resident #62's bedside table. Resident #62 stated he kept the medications in his room and administered the inhaler and eye drops to himself as needed. An observation was conducted on 7/28/24 at 10:22 a.m. in Resident #62's room. Resident #62 was observed resting in bed with his bedside table in front of him. An albuterol inhaler, a vial of eye drops, and a spray bottle of wound cleanser were observed on Resident #62's bedside table. A review of Resident #62's medical record did not reveal an assessment related to Resident #62's ability to self-administer medications. An interview was conducted on 7/30/24 at 12:24 p.m. with the ADON, Staff C, RN/UM and the DON. The ADON stated all resident medications should be stored inside of the medication carts unless a medication needs to be refrigerated and the medication would be stored in the medication refrigerator. Staff C, RN/UM stated the facility did not have any resident's who self-administered medications. Staff C, RN/UM also stated an assessment would need to be performed to determine if a resident would be able to self-administer their own medications. The ADON and the DON both stated medications should not be stored at the resident's bedside and should be removed from the resident's room. The DON stated she would expect Certified Nursing Assistant (CNA) staff to notify the nurse if they observe medication in a resident's room so the medication can be properly stored.

Based on observation, interview, and record review the facility failed to accurately document and promptly resolve a grievance for one resident (#66) out of three sampled residents. Findings included: During an interview on 7/27/24 at 12:03 p.m. Resident #66 stated the night staff saw his [name brand] ear buds and a couple of other items and they were all stolen before noon. He stated he did a grievance and sent the Nursing Home Administrator (NHA) two receipts two months ago and has follow up emails and a text message and nothing has been done. He stated the other items he replaced himself, but the only reason he didn't replace the ear buds was because he used a $100 credit plus $69 to purchase them. He tried to explain this to the NHA and provided the receipts. A review of the Grievance Logs from January 2024 to July 2024 revealed no grievances related to the missing property for Resident #66. An interview was conducted with Staff M, Certified Nursing Assistant (CNA) on 7/28/24 at 3:51 p.m. She stated a couple of weeks ago Resident #66 filed a grievance about another resident and was not aware of the missing items. During an interview on 7/29/24 at 1:29 p.m. Staff N, Licensed Practical Nurse (LPN) stated he turned in a grievance to the NHA on behalf of Resident #66 approximately two weeks ago related to the missing ear buds. He stated he filled the form out for him and placed it in the Social Services Director's office. Review of the Admission Record for Resident #66 showed he was admitted to the facility on [DATE] with diagnoses to include quadriplegia C1-C4 incomplete, major depressive disorder, generalized anxiety disorder. Review of Resident #66's Minimum Data Set, dated dated [DATE], showed in Section C-Cognitive Patterns a Brief Interview for Mental Status score of 15, indicating intact cognition. Review of a Grievance/Concern Report for Resident #66 and provided by the Social Services Director was dated 7/27/24. The report for Resident #66 read as follows: Receipt of Grievance/Concern Section: silent of who the concern was reported to. Description of Grievance/Concern Section documented: Resident stated that he is missing his [name brand speaker]. Facility Use Only: Facility Follow Up Section revealed: Resident was informed that he needed to provide a receipt and we can replace it. Grievance is ongoing. Date Assigned: 7/22/24. This section was silent of what action was taken to resolve the grievance/concern, result of action taken, if the care plan was updated, and if this was an allegation of abuse, neglect, exploitation or misappropriation. Review of a Grievance/Concern Report, dated 7/22/24, filed on behalf of Resident #66 read as follows: Receipt of Grievance/Concern Section showed the concern was reported to Staff O, Business Office Assistant. Description of Grievance/Concern Section documented: Resident stated that he is missing his [name brand speaker]. Facility Use Only: Facility Follow Up Section revealed: resident needs to submit receipt for the purchase of the [name brand speaker] which we're waiting on once received it will be processed by business office. Grievance is ongoing as of now. This section was silent of the date assigned, what action was taken to resolve the grievance/concern, result of action taken, if the care plan was updated, and if this was an allegation of abuse, neglect, exploitation or misappropriation. An interview was conducted on 7/30/24 at 1:27 p.m. with the Social Services Director (SSD). The SSD stated as of 7/27/24 we still haven't received a receipt. We follow up every three days. I will follow up to show it was attempted. She stated on 7/22/24 the concern was reported to [Staff O]. She stated she thought it was just the [name brand speaker]. She stated she needed a receipt because it needs to be signed off on. She reviewed the grievance form and confirmed the earbuds were not included on it. She stated she missed it. An interview was conducted with the NHA on 7/30/24 starting at 1:50 p.m. He confirmed he spoke with Resident #66 and requested the receipts. He stated Resident #66 mentioned the [name brand speaker] but did not mention the earbuds. He confirmed the Grievance/Concern report should show the progress, and he would expect notes. Review of the facility policy titled, Grievance/Concern Management, effective February 2021, revealed the policy as: Residents/representative has the right to present concerns on behalf of themselves, and/or others to the staff and/or administrator of the facility, to governmental officials, or to any other person. The concern may be filed verbally or in writing, and the reporter may request to remain anonymous .These rights also include the right to prompt efforts by the facility to resolve resident concerns, including concerns/grievances with respect to the behavior of other residents. Topic - Grievance/Concern Management A reasonable expected time for completing a review of the concern . 4. NHA is responsible for oversight of the concern process. 5. The Social Services Representatives/Grievance Official in collaboration with the NHA will be responsible for assigning the concern to the appropriate department for investigation. Social Services will monitor and document resident/family satisfaction upon completion of the investigation and the summary of findings/conclusion. 5.[sic] The facility leadership team will review and discuss concerns and the progress of an investigation(s) and resolutions(s) . 12. Complete a concern report investigation with summary and conclusion. 13. Social Services staff will provide information regarding compliance line information for unresolved concerns.

Based on observation, interview, and record review the facility did not ensure a safe, clean, and homelike environment in two resident rooms housing a total of four residents (Rm 311 and Rm 316) related to windows not being completely sealed shut and for two residents (#30 and #3) related to unclean equipment and broken equipment out of a sample of 48 residents. Findings included: 1. An observation made on 7/27/24 at 11:20 a.m. revealed the window in room [ROOM NUMBER] was floor height and not sealed shut with an approximate opening of a half inch. One of the two residents who resided in the room was in bed watching television. An observation made on 7/28/24 at 9:25 a.m. revealed the window in room [ROOM NUMBER] was floor height and not sealed shut with an approximate opening of half an inch. The resident in the B bed was observed sleeping in a low bed next to the window. An observation on 7/28/24 at 10:02 a.m. revealed the window in room [ROOM NUMBER] was not sealed shut with an approximate opening of one inch. The resident in the B bed was sleeping in his bed in the lowest position and next to the window. During an interview with Staff R, Certified Nursing Assistant (CNA) on 7/29/24 at 12:20 p.m. she confirmed the opening of the window in room [ROOM NUMBER] and stated she hasn't enter any [electronic work order system] orders recently. She stated, I noticed that too. (Photographic Evidence Obtained) 2. An interview attempt and observation was made on 7/27/24 at 10:36 a.m. of Resident #30 while in his bed. Resident #30 did not respond to questions when asked. Resident #30's feeding pump attached to the intravenous (IV) pole was observed to have drops of a dry cream colored liquid on the face of it, on the IV pole and on the floor. The tube feeding was not hung at the time. (Photographic Evidence Obtained) Review of the Admission Record for Resident #30 revealed his diagnoses to include displacement of other gastrointestinal prosthetic devices, implants and grafts, and cerebral palsy. Review of the current care plan for Resident #30 revealed a nutritional focus of [Resident #30] has a potential nutritional problem r/t (related to) receives TF (tube feeding) in addition to PO (oral intake) diet. An observation made on 7/28/24 at 9:25 a.m. of Resident #30's tube feeding pole revealed it had drops of a dry cream colored liquid on the face of it and on the floor. 3. An observation on 7/27/24 at 10:59 a.m. revealed Resident #3 was being placed in his specialized wheelchair and the foot and leg rest were crooked. The resident was nonverbal but making noises. An additional observation on 7/27/24 at 2:06 p.m. revealed Resident #3 in his specialized wheelchair and the foot and leg rest of the chair were crooked. Review of the Admission Record for Resident #3 revealed he had diagnoses to include functional quadriplegia, foot drop of right and left foot, contracture of muscle for multiple sites, low back pain and hemiplegia and hemiparesis affecting the left non-dominant side, and seizures. Review of the Kardex for Resident #3 revealed in the Resident Care section the resident was totally dependent on staff for ADLs (activities of daily living). During an observation and interview on 7/29/24 at 1:46 p.m. Resident #3 was observed in bed with his specialized chair in the room. Staff N, LPN observed the specialized chair and confirmed the specialized chair's foot and leg rest were crooked. During an interview with Staff M, CNA on 7/28/24 at 3:51 p.m. she stated she would tell the housekeeper on the hall for that day if there was a concern related to housekeeping in a resident room or leave a note for the head of housekeeping. For maintenance issues, she would use the [electronic work order system]. During an interview with Staff D, Licensed Practical Nurse (LPN) on 7/28/24 at 4:00 p.m. she stated if there was an issue with maintenance she would put a work order in [electronic work order system]. A review of the work orders from June 2024 to July 2024 revealed it was silent of any work orders for windows not sealing shut and Resident #3's crooked foot rest on his wheelchair. During an interview on 7/29/24 at 12:25 p.m. the Director of Housekeeping stated housekeeping goes into rooms once a day. They have a whole section and should clean something if they see something that needs cleaning. Durning an interview with the Maintenance Director on 7/30/24 at 11:59 a.m. he stated the expectation is a work order is to be put in [electronic work order system] and he had not received anything related to the windows or Resident #3's wheelchair. He confirmed he does not check the windows and that is done during concierge rounds and he should be notified if there is a concern. He stated there are clips at the top to prevent the windows from opening any further. Review of a procedure titled, Housekeeping Procedures, revised 9/5/21, showed for the section of Daily Patient Room Cleaning that every room was to be cleaned is that resident's home - treat it as such.

Based on observations, interviews, and record review facility failed to develop and implement care plans for two residents (#90 and #18) out of forty eight sampled residents. Findings included: 1. Review of a progress note for Resident #90, dated 7/3/24, showed Notified by CNA [Certified nursing assistant] staff that resident lying on the floor between bed and bedside table. Assess the resident no signs of pain or distress noted and no injury, used [mechanical]lift, MD [Medical doctor] notify, and the family notify. Review of a progress note, dated 7/5/24 showed the resident had a fall from bed during care. Review of the Admission Record showed Resident #90 was admitted on [DATE] with diagnoses including tracheostomy status, morbid obesity, reduced mobility, lack of coordination, muscle wasting and atrophy, and unspecified sequelae of other cerebrovascular disease. Review of Resident #90's Minimum Data Set (MDS), dated [DATE], Section GG, Functional Abilities and Goals showed resident has upper and lower extremity impairment on both sides. Review of Resident #90's care plan showed a focus area of ADL [Activities of Daily Living]: The Resident has an ADL Self Care Performance Deficit. Interventions included BED MOBILITY: Assist of 2 to turn and/or reposition, dated 6/9/23 and revised on 4/3/24. An interview was conducted on 7/29/24 at 9:33 a.m. with Staff D, Licensed Practical Nurse (LPN). She confirmed Resident #90 had fallen out of her bed during care. She said she was not present at the time, but was told the CNA rolled the resident and she just kept rolling off the bed. She said the resident did not have any injuries. An interview was conducted on 7/29/24 at 2:55 p.m. with the Assistant Director of Nursing (ADON). She said Resident #90 had a fall on 7/3/24 while the CNA was providing care. She said the CNA rolled the resident toward himself to change her and the resident rolled off the bed. The ADON said in his statement the CNA said he rolled the resident toward himself, and the resident's upper body rolled off the bed. He said he grabbed her by the waist but couldn't lift her, so he lowered her to the floor. The ADON confirmed only one staff member was in the room and providing care for Resident #90. The ADON said the CNA should not have been providing care by himself and he did not follow the care plan. She confirmed Resident #90 should have had two staff members assisting with rolling and/or repositioning according to the care plan at the time of the fall. The CNA involved in the incident was unable to be reached. 2. An observation was conducted on 7/27/24 at 2:42 p.m. of Resident #18. The resident was in bed with the head of the bed elevated. He did not have anything in his hands and was constantly moving his hands, and pulling at the bed control and call bell and trying to grab things around him. Review of the Admission Record for Resident #18 showed he was admitted on [DATE] with diagnoses including lack of coordination, muscle wasting and atrophy, reduced mobility, cognitive communication deficit, mixed receptive-expressive language disorder, cerebral infarction, and tracheostomy status. Review of Resident #18's MDS, dated [DATE], Section C - Cognitive Patterns, showed he had a Brief Interview for Mental Status (BIMS) score of 13, indicating he was cognitively intact. Section GG, Functional Abilities and Goals showed he was dependent for rolling left and right and sitting to lying. Review of progress notes for Resident #18 showed he had a change of condition due to a fall on 7/22/24 and again on 7/23/24. A progress note, dated 7/23/24, showed the resident was observed on the floor with the top of his body on the floor and the bottom half of his body on the bed. The resident had a hematoma and orders were received to send him to the hospital. An observation was conducted on 7/28/24 at 11:35 a.m. and 1:09 p.m. of Resident #18. During both observations the resident was constantly fidgeting and grabbing at things. He pulled on his bed control and call bell and hit the buttons on the control raising and lowering the head of the bed and the bed height. An interview was conducted on 7/29/24 at 1:22 p.m. with Staff J, LPN. She confirmed Resident #18 had two falls. She said the resident sometimes throws himself out of the bed when he can't have what he wants. An interview was conducted on 7/20/24 at 11:02 a.m. with Staff G, CNA. She said she regularly cares for Resident #18 and the resident had been fidgeting and grabbing at things for quite some time. Staff G said she always tried to give him his tablet or phone to occupy his hands so he wouldn't mess with the cords and remotes. She said Resident #18 fell a couple of times because he kept messing with stuff. Staff G said when the resident's phone and tablet were charging, he would pull and mess with everything around him. She said he likes for his hands to be busy. An interview was conducted on 7/29/24 at 4:21 p.m. with the ADON. She said the resident didn't really throw himself out of the bed but would push buttons that would raise the head of the bed, be pulling at cords, or trying to reach for something and fall. She said Resident #18 fidgeting until he fell out of bed was a newer thing. She confirmed the resident had fallen out of bed multiple times due to his fidgeting and messing with the bed controls and it should probably be care planned. She said she had looked at it as anxiety versus a behavior. The ADON said since the fidgeting had reached the point the resident had been found multiple times half out of his bed on the floor it should be care planned. Review of Resident #18's care plan did not address his fidgeting/restless behavior. There was a care plan for the resident being at risk for falls or fall related injury because of deconditioning. There was no mention of his fidgeting/restless behavior and no interventions in place to address the behavior. The interventions of bolsters for the bed and a medication review were added on 7/25/24. Resident #18 did have a behavior care plan in place, but it did not address fidgeting/restless behavior. Resident #18 had a care plan in place for psychotropic medication related to anxiety to manage anxiety/restlessness, but there were no goals or interventions listed on the care plan. An interview was conducted on 7/30/24 at 10:35 a.m. with Staff K, Clinical Reimbursement Director. She said if Resident #18's fidgeting/restlessness is leading to him falling out of bed yes, he should be care planned for it. She said falls are discussed in the morning meeting and nursing and herself discuss interventions that would be beneficial. She said the resident went out to the hospital after his fall so interventions were not put in place immediately. Staff K reviewed Resident #18's medical record and confirmed he returned from the hospital on 7/23/24, the same day he fell the second time. She also confirmed the resident's care plan did not address his fidgeting/restlessness or anxiety. She said at the meeting to discuss the resident's falls she was told the reason he fell was that he put the head of the bed up with his remote, there was no mention of fidgeting/restlessness. Staff K said if nursing would have told her Resident #18's fidgeting/restlessness was leading to him pushing the buttons and putting the head of the bed up, she would have put interventions in place. Staff K reviewed the resident's care plan for psychotropic medication related to his anxiety/restlessness and said there should most definitely be goals and interventions in place. Review of a facility policy titled Care Plan-Interdisciplinary Plan of Care from Interim to Meeting, dated 2/24, showed the following: Policy The facility shall support that each resident must receive, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility shall assess and address care issues that are relevant to individual residents, to include, but are not limited to, monitoring resident condition, and responding with appropriate interventions. The comprehensive care plan is an interdisciplinary communication tool. It includes measurable objectives and time frames and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan is reviewed and revised periodically, and the services provided or arranged are consistent with each resident's written plan of care. The overall care plan should be oriented towards: 1. Preventing avoidable declines in functioning or functional levels or otherwise clarifying why another goal takes precedence (e.g., palliative approaches in end-of-life situation, coordination with Hospice plan of care). Managing risk factors to the extent possible or indicating the limits of such interventions.

Based on observations, interviews, and record reviews, the facility failed to ensure care for an indwelling catheter was provided in accordance with professional standards of practice for one (#87) of one resident sampled for urinary catheters. Findings included: A review of Resident #87's medical record revealed Resident #87 was admitted to the facility on [DATE]. A review of Resident #87's physician orders revealed an order dated 7/9/2024 for urinary catheter care daily and as needed. Resident #87's physician orders also revealed an order dated 7/25/2024 for metronidazole 500 milligrams (mg) by mouth two times a day for 7 days due to vaginal discharge. An observation was conducted on 7/27/2024 at 10:45 AM in Resident #87's room. Resident #87 was observed resting in bed with a urinary catheter bag hanging from the right side of the bed. The urinary catheter bag was observed resting on the floor while hanging from the bed. The urine observed in Resident #87's catheter tubing appeared cloudy, thick, and with a moderate amount of sediment. An observation was conducted on 7/28/2024 at 10:36 AM in Resident #87's room. Resident #87 was observed resting in bed with a urinary catheter bag hanging from the right side of the bed. The urinary catheter bag was observed resting on the floor while hanging from the bed. An observation was conducted on 7/29/2024 at 9:21 AM in Resident #87's room. Resident #87 was observed resting in bed with a urinary catheter bag hanging from the right side of the bed. The urinary catheter bag was observed resting on the floor while hanging from the bed. An observation of catheter care for Resident #87 was conducted on 7/29/2024 at 10:21 AM with Staff F, Certified Nursing Assistant (CNA) and Staff G, CNA. Staff F, CNA and Staff G, CNA conducted hand hygiene and donned an isolation gown and gloves prior to providing catheter care. Staff G, CNA gathered several towels, washcloths, and basins with clean water and soapy water. Staff G, CNA explained the procedure to Resident #87 prior to starting and confirmed a comfortable water temperature with the resident. Staff F, CNA removed Resident #87's brief and assisted the resident to a comfortable position. Staff G, CNA placed a washcloth in the soapy water basin and began to clean Resident #87's peri area and catheter tubing using appropriate technique throughout and changing washcloths out with each pass. Staff G, CNA then placed a clean wash cloth into the basin of clean water to rinse off each area previously cleaned, including the catheter tubing. Staff G, CNA did not change gloves or perform hand hygiene after cleaning Resident #87 or before rinsing the previously cleaned areas. Staff G, CNA used a clean washcloth to dry the previously cleaned areas and did not change gloves or perform hand hygiene prior to drying the the areas. A clean brief was placed on Resident #87 and the resident was repositioned for comfort. Both staff members doffed their gowns and gloves and performed hand hygiene before exiting the room. An interview was conducted with Staff G, CNA and Staff F, CNA following the procedure. Staff G, CNA addressed she did not changed gloves and perform hand hygiene after cleaning Resident #87's peri area and catheter tubing before rinsing the areas. Staff F, CNA stated catheter bags are to be kept below the level of the bladder and should not be touching the floor. An interview was conducted on 7/30/2024 at 12:14 PM with the Assistant Director of Nursing (ADON), Staff C, Registered Nurse (RN)/Unit Manager (UM) and the Director of Nursing (DON). Staff C, RN/UM stated catheter bags should be stored below the level of the bladder and should not be touching the floor. The ADON stated she would expect nursing staff to change gloved and perform hand hygiene in between washing dirty areas and rinsing clean areas and stated staff are taught to do so during competency training. A review of the facility competency titled, Competency: Perineal Care/Catheter Care revealed the following steps under the section titled Female Resident: - Apply a small amount of liquid soap to each wash cloth as it is being used. - Clean in a downward motion from front to back. - Changes water and repeats procedure to remove soap, change gloves, wash hands, and re-glove.

Based on observation, interview, and record review, the facility failed to provide Quality Assurance and Performance Improvement (QAPI) practice that demonstrated identification, monitoring and implementation of an effective action plan to correct citations related to ensuring care for an indwelling catheter was provided in accordance with professional standards of practice for two (#7 and #8) of two residents sampled for urinary catheters (F690) during the revisit survey conducted on 9/9/2024. Findings included: A review of Resident #7's medical record revealed Resident #7 was admitted to the facility on [DATE]. A review of Resident #7's physician orders revealed an order dated 7/30/2024 for urinary catheter care daily and as needed. An observation of catheter care for Resident #7 was conducted on 9/9/2024 at 1:54 PM with Staff A, Certified Nursing Assistant (CNA) with the facility's Director of Nursing (DON) observing the procedure. Staff A, CNA conducted hand hygiene and donned an isolation gown and gloves prior to providing catheter care. Staff A, CNA gathered several towels, washcloths, soap, and a basin with clean water. Staff A, CNA explained the procedure to Resident #7 prior to starting and confirmed a comfortable water temperature with the resident. Staff A, CNA removed Resident #7's brief and assisted the resident to a comfortable position. Staff A, CNA placed a washcloth in the water basin and added soap to the washcloth. Staff A, CNA began to clean Resident #7's peri area using appropriate technique throughout and using a clean side of the washcloth with each pass. Staff A, CNA removed his gloves and donned clean gloves before continuing the procedure. Staff A, CNA did not perform hand hygiene after doffing dirty gloves or before donning clean gloves. Staff A, CNA placed a washcloth in the water basin and added soap to the washcloth. Staff A, CNA began to clean Resident #7's catheter tubing using appropriate technique throughout and using a clean side of the washcloth with each pass. Staff A, CNA removed his gloves and donned clean gloves before continuing the procedure. Staff A, CNA did not perform hand hygiene after doffing dirty gloves or before donning clean gloves. Staff A, CNA placed a washcloth in the water basin and rinsed the previously cleaned areas using appropriate technique throughout and using a clean side of the washcloth with each pass. Staff A, CNA removed his gloves and donned clean gloves before continuing the procedure. Staff A, CNA did not perform hand hygiene after doffing dirty gloves or before donning clean gloves. Staff A, CNA used a clean towel to dry the previously rinsed areas using proper technique. Staff A, CNA removed his gloves and donned clean gloves before continuing the procedure. Staff A, CNA did not perform hand hygiene after doffing dirty gloves or before donning clean gloves. The DON donned an isolation gown and gloves and assisted Staff A, CNA with incontinence care for Resident #7. After gathering trash, both staff members doffed their gowns and gloves and performed hand hygiene before exiting the room. An interview was conducted with Staff A, CNA and the DON following the observation. Staff A, CNA stated he had received in-service training related to conducting hand hygiene in between glove changes and stated I completely forgot. The DON stated facility nursing staff were provided in-service education related to proper hand hygiene and personal protective equipment (PPE) usage. A review of Resident #8's medical record revealed Resident #8 was admitted to the facility on [DATE]. A review of Resident #8's physician orders revealed an order dated 8/24/2024 for urinary catheter care daily and as needed. An observation of catheter care for Resident #8 was conducted on 9/9/2024 at 2:41 PM with Staff B, CNA with the facility's DON observing the procedure. Staff B, CNA conducted hand hygiene and donned an isolation gown and gloves prior to providing catheter care. Staff B, CNA gathered several towels, washcloths, soap, and a basin with clean water. Staff B, CNA explained the procedure to Resident #8 prior to starting and confirmed a comfortable water temperature with the resident. Staff B, CNA added soap to the basin of water prior to starting the procedure. Staff B, CNA removed Resident #8's brief and assisted the resident to a comfortable position. Staff B, CNA placed a washcloth in the soapy water basin and began to clean Resident #8's peri area and catheter tubing using appropriate technique throughout and using a clean side of the washcloth with each pass. Staff B, CNA then placed a clean wash cloth into the same basin of water used to wash the resident to rinse off each area previously cleaned, including the catheter tubing. Staff B, CNA did not change gloves or perform hand hygiene after cleaning Resident #8 or before rinsing the previously cleaned areas. Staff B, CNA removed her gloves and donned clean gloves before continuing the procedure. Staff B, CNA did not perform hand hygiene after doffing dirty gloves or before donning clean gloves. Staff B, CNA used a clean towel to dry the previously rinsed areas using proper technique. After the procedure, Staff B, CNA doffed the PPE and exited the room. An interview was conducted with Staff B, CNA following the procedure. Staff B, CNA stated they would normally use two basins when performing catheter care on a resident but she was in a hurry and needed to leave a 3:00 PM. Staff B, CNA also stated two basins, one to wash the resident and one to rinse the resident, should have been used during the procedure. Staff B, CNA stated she was not able to perform hand hygiene throughout the procedure because the resident's bathroom was occupied. Staff B, CNA was not able to explain why she did not change gloves after cleaning the resident and before rinsing the resident. An interview was conducted on 9/9/2024 at 6:00 PM with the facility's DON and Nursing Home Administrator (NHA). The NHA stated findings of the previous survey were discussed following the survey to discuss a plan of corrections with the interdisciplinary team (IDT). Facility policies and procedures were used as a basis to determine the education needed to corrected the identified deficiencies or the previous survey. The DON stated nursing staff received in-service education related to proper catheter care technique using a mannequin and walked through the procedure with the nursing staff. Following the in-service education, audits were conducted during resident catheter care to ensure nursing staff were conducting catheter care using proper technique. The NHA and DON stated no concerns were identified during the audit process. A review of the facility's in-service training record revealed Staff A, CNA and Staff B, CNA received in-service education on 8/14/2024 related to catheter care procedures and hand hygiene procedures during catheter care. Review of the facility's competency training record revealed Staff A, CNA completed the competency titled Competency: Perineal Care/Catheter Care on 8/14/2024 and Staff B, CNA completed the same competency on 8/15/2024, with no concerns identified during the observation. A review of the facility competency titled, Competency: Perineal Care/Catheter Care revealed the following steps under the section titled Male Residents: - Clean in a downward motion from top to bottom. - Changes water and repeats procedure to remove soap, change gloves, wash hands, and re-glove. The competency also revealed, under the section titled Catheter Care: Male and Female, CNA uses a wash cloth for the cleaning with soap and rinsing with changed water. A review of the facility policy titled Quality Assessment and Assurance (QA&A) Compliance, effective July 2022, revealed under the section titled Policy, the purpose of the committee is to review and analyze facility related data, evaluate improvement plans effectiveness, and direct appropriate actions for the facility response. The policy also revealed under the section titled Procedure, department heads/disciplines are required to develop department specific audit plans and report activities and audit findings to the committee at intervals determined by risk analysis, and at the direction of the NHA. Negative findings are addressed through education, development of a Performance Improvement Plan, or other means as indicated.

Based on observation, interview, and record review, the facility failed to provide Quality Assurance and Performance Improvement (QAPI) practice that demonstrated identification, monitoring and implementation of an effective action plan to correct citations related to ensuring care for an indwelling catheter was provided in accordance with professional standards of practice for two (#7 and #8) of two residents sampled for urinary catheters (F690) during the revisit survey conducted on 9/9/2024. Findings included: A review of Resident #7's medical record revealed Resident #7 was admitted to the facility on [DATE]. A review of Resident #7's physician orders revealed an order dated 7/30/2024 for urinary catheter care daily and as needed. An observation of catheter care for Resident #7 was conducted on 9/9/2024 at 1:54 PM with Staff A, Certified Nursing Assistant (CNA) with the facility's Director of Nursing (DON) observing the procedure. Staff A, CNA conducted hand hygiene and donned an isolation gown and gloves prior to providing catheter care. Staff A, CNA gathered several towels, washcloths, soap, and a basin with clean water. Staff A, CNA explained the procedure to Resident #7 prior to starting and confirmed a comfortable water temperature with the resident. Staff A, CNA removed Resident #7's brief and assisted the resident to a comfortable position. Staff A, CNA placed a washcloth in the water basin and added soap to the washcloth. Staff A, CNA began to clean Resident #7's peri area using appropriate technique throughout and using a clean side of the washcloth with each pass. Staff A, CNA removed his gloves and donned clean gloves before continuing the procedure. Staff A, CNA did not perform hand hygiene after doffing dirty gloves or before donning clean gloves. Staff A, CNA placed a washcloth in the water basin and added soap to the washcloth. Staff A, CNA began to clean Resident #7's catheter tubing using appropriate technique throughout and using a clean side of the washcloth with each pass. Staff A, CNA removed his gloves and donned clean gloves before continuing the procedure. Staff A, CNA did not perform hand hygiene after doffing dirty gloves or before donning clean gloves. Staff A, CNA placed a washcloth in the water basin and rinsed the previously cleaned areas using appropriate technique throughout and using a clean side of the washcloth with each pass. Staff A, CNA removed his gloves and donned clean gloves before continuing the procedure. Staff A, CNA did not perform hand hygiene after doffing dirty gloves or before donning clean gloves. Staff A, CNA used a clean towel to dry the previously rinsed areas using proper technique. Staff A, CNA removed his gloves and donned clean gloves before continuing the procedure. Staff A, CNA did not perform hand hygiene after doffing dirty gloves or before donning clean gloves. The DON donned an isolation gown and gloves and assisted Staff A, CNA with incontinence care for Resident #7. After gathering trash, both staff members doffed their gowns and gloves and performed hand hygiene before exiting the room. An interview was conducted with Staff A, CNA and the DON following the observation. Staff A, CNA stated he had received in-service training related to conducting hand hygiene in between glove changes and stated I completely forgot. The DON stated facility nursing staff were provided in-service education related to proper hand hygiene and personal protective equipment (PPE) usage. A review of Resident #8's medical record revealed Resident #8 was admitted to the facility on [DATE]. A review of Resident #8's physician orders revealed an order dated 8/24/2024 for urinary catheter care daily and as needed. An observation of catheter care for Resident #8 was conducted on 9/9/2024 at 2:41 PM with Staff B, CNA with the facility's DON observing the procedure. Staff B, CNA conducted hand hygiene and donned an isolation gown and gloves prior to providing catheter care. Staff B, CNA gathered several towels, washcloths, soap, and a basin with clean water. Staff B, CNA explained the procedure to Resident #8 prior to starting and confirmed a comfortable water temperature with the resident. Staff B, CNA added soap to the basin of water prior to starting the procedure. Staff B, CNA removed Resident #8's brief and assisted the resident to a comfortable position. Staff B, CNA placed a washcloth in the soapy water basin and began to clean Resident #8's peri area and catheter tubing using appropriate technique throughout and using a clean side of the washcloth with each pass. Staff B, CNA then placed a clean wash cloth into the same basin of water used to wash the resident to rinse off each area previously cleaned, including the catheter tubing. Staff B, CNA did not change gloves or perform hand hygiene after cleaning Resident #8 or before rinsing the previously cleaned areas. Staff B, CNA removed her gloves and donned clean gloves before continuing the procedure. Staff B, CNA did not perform hand hygiene after doffing dirty gloves or before donning clean gloves. Staff B, CNA used a clean towel to dry the previously rinsed areas using proper technique. After the procedure, Staff B, CNA doffed the PPE and exited the room. An interview was conducted with Staff B, CNA following the procedure. Staff B, CNA stated they would normally use two basins when performing catheter care on a resident but she was in a hurry and needed to leave a 3:00 PM. Staff B, CNA also stated two basins, one to wash the resident and one to rinse the resident, should have been used during the procedure. Staff B, CNA stated she was not able to perform hand hygiene throughout the procedure because the resident's bathroom was occupied. Staff B, CNA was not able to explain why she did not change gloves after cleaning the resident and before rinsing the resident. An interview was conducted on 9/9/2024 at 6:00 PM with the facility's DON and Nursing Home Administrator (NHA). The NHA stated findings of the previous survey were discussed following the survey to discuss a plan of corrections with the interdisciplinary team (IDT). Facility policies and procedures were used as a basis to determine the education needed to corrected the identified deficiencies or the previous survey. The DON stated nursing staff received in-service education related to proper catheter care technique using a mannequin and walked through the procedure with the nursing staff. Following the in-service education, audits were conducted during resident catheter care to ensure nursing staff were conducting catheter care using proper technique. The NHA and DON stated no concerns were identified during the audit process. A review of the facility's in-service training record revealed Staff A, CNA and Staff B, CNA received in-service education on 8/14/2024 related to catheter care procedures and hand hygiene procedures during catheter care. Review of the facility's competency training record revealed Staff A, CNA completed the competency titled Competency: Perineal Care/Catheter Care on 8/14/2024 and Staff B, CNA completed the same competency on 8/15/2024, with no concerns identified during the observation. A review of the facility competency titled, Competency: Perineal Care/Catheter Care revealed the following steps under the section titled Male Residents: - Clean in a downward motion from top to bottom. - Changes water and repeats procedure to remove soap, change gloves, wash hands, and re-glove. The competency also revealed, under the section titled Catheter Care: Male and Female, CNA uses a wash cloth for the cleaning with soap and rinsing with changed water. A review of the facility policy titled Quality Assessment and Assurance (QA&A) Compliance, effective July 2022, revealed under the section titled Policy, the purpose of the committee is to review and analyze facility related data, evaluate improvement plans effectiveness, and direct appropriate actions for the facility response. The policy also revealed under the section titled Procedure, department heads/disciplines are required to develop department specific audit plans and report activities and audit findings to the committee at intervals determined by risk analysis, and at the direction of the NHA. Negative findings are addressed through education, development of a Performance Improvement Plan, or other means as indicated.

Based on interview and record review, the facility failed to ensure a significant medical change in condition was acted upon in a timely manner for one (Resident #2) of three residents sampled, as evidence by, labored breathing for five hour hours and twenty one minutes. Findings Included: Review of Resident #2's Admission Record revealed she had resided at the facility for a couple of months for short term care. The resident was admitted with diagnoses of pneumonia, respiratory failure, type 2 diabetes mellitus, hypo-osmolality and hyponatremia, hypertension, and heart failure. A review of progress notes from 03/03-03/08/2023 revealed the following: 03/03/2023 at 3:23 p.m. (15:23), revealed resident in bed head of bed (HOB) elevated no difficulty with breathing noted. Alert with some confusion new order for potassium 20 meq for 2 days then recheck potassium level on Monday per MD order. On 03/04/2023 at 9:35 p.m. (21:35), Cipro oral tablet 500 mg. Give 500 mg via G-Tube (Gastrostomy tube) every 12 hours for Coccyx wound infection for 14 (days). On 03/05/2023 at 3:05 p.m. (15:05), resident in bed resting, HOB elevated, no distress noted, gtube flushed/patent, tolerated meds well, Antibiotic (ABT) in progress for bacteria, no signs or symptoms (s/s) noted. Position changed while in bed assist of 2. respirations (Resp) even unlabored. Total care per (via) staff. Author: [Staff A, Licensed Practical Nurse]. On 03/06/2023 at 3:43 p.m. (15:43), in bed HOB elevated, resting comfortably, no distress noted, no s/s of hypoglycemia noted. At 10:01 p.m. (20:01) potassium level 8.4 Physician (MD)/Advanced Practical Registered Nurse (APRN) notified orders for kayexalate 30 ml three times a day (TID) for 3 days electrocardiogram (EKG) and potassium levels in the am. On 03/07/2023 at 06:25 a.m., The Resident is confused Author: [Staff A]. At 3:44 p.m. (15:44) Wound Care Note Location: Sacrum Acquired: Present on Admission Exudate Amount: Moderate, Type: Serosanguineous, Odor noted after cleaning: Strong, Progress: Stalled. A review of Medical record did not reflect notification to the Physician related to the coccyx wound continued with a strong odor. On 03/08/2023 at 12:32 a.m. (00:32), Resident, resp uneven and labored at this time, HOB elevated., tolerated feeding well, gtube flush/patent, vital signs taken (blood pressure) 74/68 pulse/heart rate (P)110 oxygen saturation rate (02 Sat) 92% respirations (R) 22 blood sugar (B/S) 308/dl. Standing orders applied of Oxygen SpO2 02 at 2 liters (L) per nasal cannula (VIA n/c) insulin sliding scale. Author: [Staff A] Signs of Respiratory Distress Learning the signs of respiratory distress: People having trouble breathing often show signs that they are having to work harder to breathe or are not getting enough oxygen, indicating respiratory distress . https://www.hopkinsmedicine.org/health/conditions-and-diseases/signs-of-respiratory-distress. On 03/08/2023 at 05:53 a.m. Resident has difficulty arousing, uneven & labored breathing notes. Blood sugar 287 mg/dl at this time, BP 67/59, P111, R22, 02 Sat 96%, MD called, requested to send to emergency room (ER) for evaluation due to (D/T) abnormal EKG & Labs. At 5:57 a.m. 911 called. At 6:09 a.m. resident left facility via stretcher with 02 via n/c. At 6:15 a.m. Report given to ER nurse. Author [Staff A] A review of the physician orders revealed Accu-check (blood sugar) per order for diabetic monitoring of Hypo/Hyperglycemia activity one time a day every Wed for monitor order date 02/13/2023. A review of the medication administration record (MAR) reflected an Accu-check reading that was performed on 02/15/2023 with result of 124, on 02/22/2023 result of 169, and on 03/01/2023 result of 169, on 03/08/2023 at 12:32 a.m. blood sugar 308. Further review of Physician orders revealed two different breathing treatments, one for Albuterol sulfate solution to administer every 6 hours for shortness of breath (SOB) start date 02/08/2023 that required a documented heart rate (pulse) and respiration, a second breathing treatment for Pulmicort two times a day for SOB with required documentation of pulse rate and respirations start date 02/08/2023. Review of the MAR from 02/08/2023 reflected Residents #2 highest pulse rate was at 80, on 03/08/2023 documented pulse rate at 110. Tachycardia: Tachycardia ([NAME]-ih-[NAME]-[NAME]-uh) is the medical term for a heart rate over 100 beats a minute. https://www.mayoclinic.org/diseases-conditions/tachycardia/symptoms-causes/syc-20355127. On 04/06/2023 at 1:12 p.m., an interview was conducted with Staff A, Licensed Practical Nurse (LPN). She said she recalled Resident #2 and had sent her to the hospital. Staff A reviewed her documented notes in the medical record and stated, I thought it was an issue when I seen her Pulse at 111, and her oxygen saturation (SpO2) level was at 92%. She stated, I started oxygen at that time, the patient is declining I feel that there was something going on. She said the resident had a wound and along with the vital signs changing she stated, I feel like it had something to with her wound. Staff A at denied Resident #2 had used oxygen in the past nor used it routinely. Staff A stated, I called the Physician before 5:56 a.m., but I don't know the time. She confirmed she failed to document the first time she called and notified the physician of Resident #2's change in condition. Staff A said during the 5 hours and 21 minutes after she had identified a change in Resident #2's condition, she stated, I gave her a breathing treatment and insulin, I stayed by the resident watching her. I was like a one on one with her that night. The Director of Nursing was present at and stated she was not employed at the facility on 03/08/2023. She would need to read the medical record. On 04/06/2023 at 2:29 p.m., a phone call was placed to Resident #2's physician (Medical Director) a voice message was left asking for a return call. A second phone call attempt to the Medical Director was conducted at 3:14 p.m. No return phone call was ever received. Review of the policy titled STANDARD Effective October 2021 TOPIC: Notification of Resident/Patient Change in Condition Procedure: Notify the Physician if there is a significant change in condition regardless of the time of day. Review of Job Description Position: Licensed Practical Nurse (LPN) did not contain a date. Summary of position: The Licensed Practical Nurse is responsible for delivering care to residents utilizing the nursing process of assessment, planning, intervention, implementation and evaluation; and effectively interacts with residents/patients, family members, and other health team members while maintaining standards of professional nursing. Essential Duties and Responsibilities: Direct Care/ Patients Responsibilities Handles emergency situations in a prompt, precise, and professional manner. Maintains accurate, detailed reports and records. Monitors, record and reports symptoms and changes in residents conditions. Reports all changes in residents condition to supervisor timely.

Based on observations, record reviews, and interview, the facility failed to follow the standard of care related to obtaining orders for an indwelling catheter for one (Resident #3) of one sampled resident. Findings included: On 01/04/23 at 11:17 a.m., Resident #3's catheter was observed with no concerns. The resident reported the catheter was put in on December 13th [2022]. She stated she was not receiving catheter care. Sometimes, the urine bag was so full she was afraid it was going to back up because it was not emptied. A review of the Admission Record revealed Resident #3 was initially admitted into the facility on [DATE] with a primary diagnosis of muscle wasting and atrophy, not elsewhere classified, multiple sites. Section C Cognitive Patterns of the Minimum Data Set (MDS) dated [DATE] revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating cognitively intact. Section H Bladder and Bowel indicated the resident had an indwelling catheter. A review of the Order Listing Report for active orders revealed for the following order related to the catheter: 12/22/22- Perform Foley catheter hygiene three times a day for Foley care. Resident #3 did not have orders in place related to changing the bag or tubing of the catheter and monitoring the urinary appearance. A review of the Kardex indicated to provide catheter care daily and as needed. The resident did not have a care plan in place related to the indwelling catheter. On 01/04/23 at 12:45 p.m., the Director of Nursing (DON) confirmed Resident #3 had a catheter. She had an order for the catheter dated December 22 [2022] related to hygiene. She reported they usually place a batch order for catheter care that consisted of multiple orders. The DON confirmed there was only documentation related to the hygiene. She reported she was not sure if it was protocol to have other catheter care orders in the system. She said the CNAs knew the resident had a catheter and they documented care was being done. The DON confirmed the resident should have had a care plan in place related to catheter care. On 01/04/23 at 12:45 p.m., a list of the batch orders for catheter care was requested but not provided.

Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5%. A total of 37 medication administration opportunities were observed with 13 medication errors for 2 residents (#9 and #10) of 4 residents sampled for medication administration, which resulted in a medication administration error rate of 35.14%. Findings included: A review of Resident #9's medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #9's Physician's Orders revealed an order, dated 08/18/2021, for [MEDICATION(S)] 5 milligrams (mg) by mouth two times a day. An observation of medication administration was conducted on 10/28/2022 at 08:33 AM with Staff A, Licensed Practical Nurse (LPN). Staff A, LPN was observed removing 4 medications from the medication cart from sealed containers and placing them into a medication cup for administration to Resident #9. Staff A, LPN was observed picking up a small medication box and putting a small, red colored medication from the box into a medication cup along with 4 other medications for Resident #9. Staff A, LPN stated the medication was [MEDICATION(S)] and that it was the last one Resident #9 had in the medication cart. The medication was not inside of a sealed package and was loose inside of the medication box. After the medications were gathered, Staff A, LPN administered 5 medications to Resident #9 without difficulty and exited the room. An interview was conducted with Staff A, LPN following the observation of medication administration. Staff A, LPN stated the medication that was administered to Resident #9 was a loose pill inside of a medication box, but since it was inside of a box, it was OK to assume that it was Resident #9's ordered [MEDICATION(S)]. Staff A, LPN stated I know the meds and she was able to identify the medication visually to confirm she was administering the correct medication, even if it was not in a sealed container. Staff A, LPN also stated she would not administer a loose medication from the medication cart if it was not inside of a medication box. A review of Resident #10's medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #9's Physician's Order revealed the following orders: - An order, dated 08/24/2022, for Aspirin 81 mg by mouth one time a day at 09:00 AM. - An order, dated 09/23/2022, for [MEDICATION(S)] delayed release particles 30 mg, give 2 capsules one time a day at 09:00 AM. - An order, dated 09/21/2022, for [MEDICATION(S)] 2.5 mg by mouth one time a day at 09:00 AM. - An order, dated 08/24/2022, for [MEDICATION(S)] 50 mg by mouth one time a day at 09:00 AM. - An order, dated 08/24/2022, for [MEDICATION(S)] 100 mg by mouth one time a day at 09:00 AM. - An order, dated 08/29/2022, for Vitamin D3 50 micrograms (mcg) by mouth one time a day at 09:00 AM. - An order, dated 09/03/2022, for Insulin [MEDICATION(S)] 15 units subcutaneously two times a day at 09:00 AM and 05:00 PM. - An order, dated 08/31/2022, for [MEDICATION(S)] 500 mg by mouth two times a day at 09:00 AM and 05:00 PM - An order, dated 08/24/2022, for [MEDICATION(S)] 25 mg by mouth two times a day at 09:00 AM and 05:00 PM. - An order, dated 09/27/2022, for [MEDICATION(S)] 10 grams per 15 milliliter (ml) solution, give 60 ml by mouth three times a day at 09:00 AM, 01:00 PM, and 05:00 PM. An observation of medication administration was conducted on 10/28/2022 at 10:46 AM with Staff C, LPN. Staff C, LPN gathered the following medications for administration to Resident #10: - Aspirin 81 mg 1 tablet. - [MEDICATION(S)] 30 mg 1 tablet. - [MEDICATION(S)] 2.5 mg 1 tablet. - [MEDICATION(S)] 50 mg 1 tablet. - [MEDICATION(S)] 100 mg 1 tablet. - Vitamin D3 50 mcg 1 tablet. - Insulin [MEDICATION(S)] 15 units. - [MEDICATION(S)] 500 mg 1 tablet. - [MEDICATION(S)] 25 mg 1 tablet. - [MEDICATION(S)] solution 15 ml. After the medications were gathered, Staff C, LPN administered 10 medications to Resident #10 without difficulty and exited the room. An interview was conducted following the observation with Staff C, LPN. Staff C, LPN reviewed Resident #10's physician's orders and stated she did not administer enough [MEDICATION(S)] to Resident #10 because she only removed one 30 mg tablet from the medication cart instead of two as ordered. Staff C, LPN also stated she only administered 15 ml of [MEDICATION(S)] solution to Resident #10 instead of the ordered dose of 60 ml. Staff C, LPN stated she should have verified the entire physician's order before administering medications to Resident #10 because he received the wrong doses. Staff C, LPN stated all 10 medications that were administered to Resident #10 were administered late because they only had 3 nurses in the facility at the time. Staff C, LPN stated they had from 08:00 AM to 10:00 AM to administer 09:00 AM medications to residents and if a medication is going to be administered late they are to inform the resident's physician before administering the medication. Staff C, LPN was not able to state why she did not inform Resident #10's physician of the late administration before administering the medications. An interview was conducted on 10/28/2022 at 02:45 PM with Staff E, Registered Nurse (RN) and Unit Manager (UM). Staff E, RN UM who stated nurses should be using the 5 rights of medication administration when conducting medication administration, which include the right dose, right medication, right route, right resident, and right time. Staff E, RN UM also stated nursing staff are allowed to administer medications within 30 minutes prior and one hour after the scheduled medication administration time. If a medication is to be administered late, the nurse should contact the resident's physician immediately before administering the medication and documenting the communication in the resident's progress notes. Staff E, RN UM stated she would not expect for staff to administer loose medications from the medication cart to residents, even if it was inside of a medication box with a label. A telephone interview was conducted on 10/28/2022 at 03:38 PM with the facility's Manager for Consultant Pharmacists (MCP). The MCP stated she would not expect the nursing staff to administer loose medications from the medication cart and any loose medications found in the medication cart should be destroyed. A review of the facility policy titled Medication Administration, dated 09/2018, revealed under the section titled Policy medications are administered as prescribed in accordance with manufacturer's specifications, good nursing principles and practices, and only by persons legally authorized to do so. The policy also revealed under the section titled Medication Preparation, prior to administration, review and confirm MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy revealed under the section titled Medication Administration, medications are administered in accordance with written orders of the prescriber. Verify medication is correct three (3) times before administering the medication: when pulling medication package from the med cart, when dose is prepared, and before dose is administered. Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on meal times. The policy also revealed under the section titled Documentation, once removed from the package/container, unused medication doses shall be disposed of according to the nursing care center policy.

Based on observation, interview, and record review, the facility failed to honor a resident's repeated request for a wheelchair to accommodate needs for one resident (#7) out of eight residents sampled. Findings included: An interview was conducted with Resident # 7 on 10/27/22 at 10: 22 p.m. Resident #7 stated she was unable to walk significant distances due to her [CONDITION(S)] ( [CONDITION(S)]), and her use of oxygen. She stated she wears oxygen at 4 liters per minute( LPM) continuously and she had been asking for a wheelchair with an oxygen tank holder on it so she can leave her room. She stated she has been promised a wheelchair would be provided but this has not occurred. She stated she told the Nurse Practitioner ( NP) about her need for a wheelchair last week and the NP told her she would write an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 7 stated she had a wheelchair when she was first admitted in 2021, however, it disappeared. A review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of a quarterly Minimum Data Set (MDS) assessment, dated 7/15/22 indicated a Brief Interview for Mental Status ( BIMS)score of 15, which indicated the resident was cognitively intact. A Care Plan for activities of daily living, dated 12/20/21 with a revision date of 5/1/22, revealed Resident # 7 was independent with bed mobility and transfers. Locomotion was indicated as, [NAME] 4 wheeled. A review of the care KARDEX utilized by the CNA's ( Certified Nursing Assistants) revealed under mobility, [NAME] 4 wheeled. A review of an 8/2/22 Care Plan/ IDT note revealed, Care plan held at bedside with resident. She voices concern for a wheelchair - therapy contacted to assess. No further concerns at this time. A review of Resident # 7's medical record revealed no documentation from therapy related to this request for a wheelchair. A review of a 9/6/22 Nursing Quarterly Data Collection form indicated Resident # 7 utilizes a rolling walker. A review of a nursing progress note dated 10/10/22 at 10: 42 a.m. revealed Resident is able to voice needs, 02 at 4 LPM , took meds without difficulty, ambulates with rolling walker, appetite good. A review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with the Unit Manager /Acting DON ( Director of Nursing ) on 10/27/22 at 1: 30 p.m. She reviewed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with the Director of Therapy on 10/27/22 at 2:10 pm. He stated therapy does not need to assess an existing resident who requests a wheelchair. He stated, if we have one for therm , we will get it for them. The Director of Therapy stated he just brought a wheelchair with an 02 holder to Resident # 7. He stated he thinks she had one before but it may have been misplaced or lost, I can't say what happened or when she had one. An interview was conducted with Staff, G, CNA on 10/27/22 at 4:00 p.m. Staff G stated she regularly works on the unit where Resident # 7 resides. She stated Resident # 7 has not had a wheelchair before today. An interview was conducted with Resident # 8, the roommate of Resident # 7, on 10/28/22 at 3: 05 p.m. She stated since Resident #7 has been in the room with her she has never seen a wheelchair for Resident # 7. A review of a 8/14/22 quarterly MDS assessment revealed a BIMS score of 15 (cognitively intact) for Resident # 8. A follow up interview was conducted with Resident # 7 , on 10/28/22 at 3: 00 p.m. Resident # 7 stated she was very pleased to have a wheelchair. A review of the record for Resident # 7 revealed she moved into her current room with Resident # 8 on 8/25/22.

Based on observation, interview, and record review, the facility failed to provide and maintain a safe, clean, and homelike environment for two residents (#1 and #11) out of 11 residents sampled for environmental concerns. Findings included: An interview was conducted on [DATE] at 02:42 PM with Resident #1 at his bedside. Resident #1 stated he had seen insects that resemble wasps inside of his room several times and he had been stung by the insects before. Resident #1 stated there's one right there and pointed to the window next to his bed. An observation of the widow next to Resident #1's bed revealed a black colored, six legged, flying insect with a visible [NAME] on the tail end of it crawling on the inside of the window. A second insect was observed on the left side of the widow sill. The insect appeared black in color with six legs and wings with a visible [NAME] on the tail end. The insect appeared to be deceased and was not moving. Resident #1 stated he observed several dead wasps inside of the ceiling light above his bed a few days ago, but the maintenance director cleaned them all out. An inspection of the widow next to Resident #1's bed revealed a large open area in the wall on the right side of the widow sill. An interview was conducted with Resident #11, who was Resident #1's roommate. Resident #11 stated he is blind and he hears insects buzzing around his head at time. An observation was conducted on [DATE] at 03:35 PM outside of the facility near Resident #1 and Resident #11's room window. An inspection of the widow screen revealed a small open area where the line that holds the screen to the screen frame separated. Inspection of the front of the roof in front of the widow revealed 6 small holes drilled into the metal portion of the facility roof. An interview was conducted on [DATE] at 09:17 AM with Staff F, Certified Nursing Assistant (CNA). Staff F, CNA stated she had seen wasps in the same hall as Resident #1 and Resident #11's room recently and informed the housekeeping staff and the maintenance staff about the finding. An interview was conducted on [DATE] at 01:34 PM with Staff A, Licensed Practical Nurse (LPN). Staff A, LPN stated if there was a concern with pests in the facility, it is reported to upper management as well as maintenance staff but not usually documented anywhere. A review of the facility's pest control service inspection report, dated [DATE] at 06:40 AM revealed a call-back service for wasps was performed by a third party company. The reported revealed the property was surveyed for wasp nests or activity and interviews were conducted with the facilities Nursing Home Administrator (NHA) and maintenance staff. An interview was conducted on [DATE] at 01:39 PM with the facilities Maintenance Director (MD) and Physical Plant Consultant (PPC). The MD stated the facility hires a service to come to the facility on ce a week to assess the facility for pests and replenish any traps or baits for pests. A log book for any concerns related to pests is kept at each nurse's station and if the nursing staff identify a concern related to pests, they are to document the concern and the room number. The MD stated the nursing staff should also notify him directly of any concerns related to pests and document the findings in the log book. The MD stated there had not been any concerns related to pests for the past 2 weeks and he was not aware of a service call related to wasp activity in the facility. The MD stated about a month ago, he discovered dead wasps in the light fixture in Resident #1 and Resident #11's room after Resident #1 brought it to his attention. The light fixture was cleaned, but the pest control company was not notified of a concern related to wasps. The MD stated he would not typically log findings of pests in the facilities log book and was not able to state how he was able to keep track of any pest concerns in the facility. An interview was conducted on [DATE] at 02:04 PM with Staff D, CNA. Staff D, CNA stated when there is a concern related to pests, they only notify the maintenance department. Staff D, CNA also stated they were aware they were supposed to log any findings of pests in the log book, but we don't. A review of the facility's pest sighting log on [DATE] did not reveal any sightings of wasps in the facility. An interview was conducted on [DATE] at 02:45 PM with Staff E, Registered Nurse (RN) and Unit Manager (UM). Staff E, RN UM stated each nurses station had a pest control log book but was not able to state the process for reporting pests in the facility. Staff E, RN UM also stated any pest sightings should be reported to the administration. A review of the facility policy titled Pest Control, effective [DATE], revealed under the section titled Policy, the maintenance staff shall make every effort to inspect, identify, monitor, evaluate, and control pests as well as their methods of entry into the building.

Based on observation, interview, and record review, the facility failed to maintain proper labeling and storage of medications and biologicals in two medication carts (200 unit and 300 unit) of four medication carts sampled. Findings included: An observation of medication administration was conducted on 10/28/2022 at 09:05 AM on the 200 unit of the facility with Staff B, Licensed Practical Nurse (LPN). During the observation, Staff B, LPN was observed disposing of a medication cup of unknown medications into the sharps container on the medication cart. Staff B, LPN stated the medications that were disposed of were Benadryl and Aspirin. Staff B, LPN stated it was common practice for over-the-counter medications to be shared between the medication carts by placing a small amount from the bottle inside one medication cart and putting it inside of a medication cup and labeling the cup with what medication it was holding. This was done when the nurse was not able to locate a new bottle of a certain medication. Staff B, LPN stated whenever she discovered a cup of loose medications in her cart, she disposes of it and reports the findings to either the Unit Manager (UM) or the Director of Nursing (DON). Staff B, LPN stated if a nurse needed a medication then they should locate a new, sealed bottle of the medication to put inside of the medication cart instead of putting loose medications into a medication cup and putting it in the medication cart because the nurse would not be able to properly identify the medication if it was not inside of a properly labeled bottle. An inspection of a medication cart on the 200 unit of the facility was conducted on 10/28/2022 at 09:45 AM with Staff B, LPN. The following were discovered during the inspection of the medication cart: - An open vial of [MEDICATION(S)] N insulin with a green label on the bottle that read discard 31 days after opening. The vial did not contain documentation of the date it was opened. - An open vial of Insulin [MEDICATION(S)] with a yellow label that read discard after 28 days. The lines on the label that read date opened and date expired were both blank. - An open vial of [MEDICATION(S)] insulin with a hand written date of 9/27. The date 9/27 was also labeled on the manufacturer's box holding the insulin vial. A yellow label that on the insulin vial read discard after 28 days. Based on the labeling of the vial, the insulin expired on 10/25/2022. - Two open Insulin [MEDICATION(S)] Kwikpens which had a yellow label affixed to it that read discard after 28 days. The lines on the labels that read date opened and date expired were both blank. - An open [MEDICATION(S)] Kwikpen which had a red label affixed to it that read discard after 30 days. The lines on the labels that read date opened and date expired were both blank. A label on the medication storage bag read Store in very cool place. May refrigerate. - An open bottle of [MEDICATION(S)] eye drops which had a yellow label affixed to it that read discard after 28 days. The lines on the labels that read date opened and date expired were both blank. - 11 loose medications were discovered in various drawers during inspection of the medication cart. - A locked drawer of the medication cart, containing several miscellaneous items, including an unlabeled and open bottle of Dakins full strength solution, several loose 4 by 4 gauze pads, several bottles of over-the-counter medications, a tube feeding syringe, and various wound dressings. An interview was conducted with Staff B, LPN following the inspection of the medication cart. Staff B, LPN stated she tries to inspect her assigned medication cart after every shift to ensure proper labeling and storage of medications and if any medications need to be re-ordered or re-stocked. Medications should not be loose inside of the medication cart and should be stored in a proper labeled container. Staff B, LPN stated everything in the medication cart should be labeled with the date it was opened and instructions on the label should be followed. Staff B, LPN stated if she discovered a medication was not properly labeled after being opened, she would dispose of the medication and order a replacement from pharmacy. An inspection of a medication cart on the 300 unit of the facility was conducted on 10/28/2022 at 12:38 PM with Staff A, LPN. The following were discovered during the inspection of the medication cart: - A medication cup in the top drawer of med cart contained 4 white colored pills. The medication cup was labeled with a black marker and read Vit C. - An unopened vial of [MEDICATION(S)] insulin labeled with instruction that read refrigerate until opened then store at room temperature. - An unopened vial of Insulin [MEDICATION(S)] with instruction that read refrigerate until opened then store at room temperature. - A [MEDICATION(S)] inhaler labeled with a hand written date of 5-9-22 on the manufacturer's box holding the inhaler. A green label on the inhaler read Discard 90 days after opening. Based on the labeling on the medication, the medication expired on 08/07/2022. - A locked drawer of the medication cart containing several miscellaneous items, including tube feed sets, several bottles of over-the-counter medications, and various dressing supplies. During the inspection of the medication cart, Staff A, LPN walked away from the medication cart several times. An interview was conducted following the inspection of the medication cart with Staff A, LPN. Staff A, LPN stated she was responsible for the medication cart during her assigned shift. Staff A, LPN also stated it was common practice in the facility for over-the-counter medications to be shared between the medication carts by placing a small amount from the bottle inside one medication cart and putting it inside of a medication cup and labeling the cup with what medication it was holding. Staff A, LPN also stated it was OK to dispense the medication to residents as long as the medication cup was labeled with the medication contained inside of the cup. Staff A, LPN stated the [MEDICATION(S)] inhaler was expired and should have been discarded. Staff A, LPN stated the insulins that were not refrigerated had not been inside of the medication cart very long, so it was OK to keep them unrefrigerated in the medication cart, even if the label instructions indicated to keep them refrigerated until opening. An interview was conducted on 10/28/2022 at 02:45 PM with Staff E, Registered Nurse (RN) UM. Staff E, RN UM stated she would not expect nurses to borrow medications between medication carts and that over-the-counter medications were stocked inside of the medication rooms on each unit. Staff E, RN UM stated she would expect for nurses to administer medications from a sealed and labeled contained rather than from a medication cup because the medication could not be properly identified. Nurses should inspect the medication carts every shift for presence of loose medications, expired medications, and to ensure medications were properly stocked. Staff E, RN UM stated she would expect the nurses to properly fill out any labels on the medication vials or boxes and to follow any instructions included with the medication. She stated if a medication is not properly labeled with the date it was opened on, the medication should be discarded because the medication could be expired. A telephone interview was conducted on 10/28/2022 at 03:38 PM with the facility's Manager for Consultant Pharmacists (MCP). The MCP stated monthly visits to the facilities were conducted by the assigned Consultant Pharmacist to identify irregularities, such as expired medications, proper medication labeling, loose medications, and any other compliance issues. The MCP stated she would expect for any medication with a short life, such as insulin and inhalers, to be dated with the date it was opened and that instructions on the medication are followed. She stated any loose medications inside of the medication cart should be destroyed and not administered to residents because the medication label should be matched to the residents Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility policy titled Medication Administration, dated 09/2018, revealed under the section titled Documentation, once removed from the package/container, unused medication doses shall be disposed of according to the nursing care center policy. A review of the facility policy titled Storage of Medication, dated 09/2018, reveled under the section titled Policy medications and biologicals are stored properly, following manufacturer's or provided pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The policy also revealed, under the section titled Procedures insulin products should be stored in the refrigerator until opened. Note the date on the label for insulin vials and pens when first used. Outdated, contaminated, discontinued, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock and disposed of according to procedures for medication disposal.

Based on observation, staff and family interview, and record review the facility failed to resolve three of three grievances related to ADL assistance with toileting for one resident (#2) out of nine sampled residents. Findings included: On 08/29/22 at 12:00 p.m. Resident #2 was observed in the dining room visiting with his family. Resident #1 had been observed seated in the dining area all morning. Resident #2 was not interviewable. On 08/29/22 at 1:45 p.m., an interview was conducted with Resident #2's family member. The family member stated their main concern was with toileting. Resident #2's family member said, We have been here since 10 a.m. this morning and no one has come to check on the Resident or ask if he needed to be changed. This happens all the time. They just leave him in wet briefs. If they can do that when we are here, imagine what happens when we are not. The family member stated the resident has sat in wet briefs for more than 6 hours before. The family member stated she did not know the last time the resident was changed. The family member stated the facility does not do anything unless she asks. The family member stated they had filed grievances and spoken to the facility multiple times. The family member stated the facility is very dismissive. The family member said, they think we complain all the time. See for yourself. A review of Resident #2's admission record revealed the resident was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An MDS, dated [DATE], revealed in Section C-Cognitive Function: Resident #2 had a BIMS score of 03, indicating severe cognitive impairment. In Section G-Functional Status: Resident #2 required extensive assistance with ADLs with a 2+ persons physical assistance, and Resident #2 was totally dependent on staff for toilet use. A review of the care plan for Resident #2, initiated on 04/21/22, revealed an incontinence focus area indicating Resident #2 was incontinent of bladder and bowel and was not a candidate or toileting program related to involuntary or unpredictable bladder and bowel elimination. The goal indicated the resident will maintain dignity, minimize the risk of infection and skin breakdown. The interventions included: Check for incontinence with routine care upon arising, before and after mealtime, at bedtime, and as needed; Provide incontinence care as indicated. An additional care plan focus area revealed Resident #2 had impaired cognition function / dementia or impaired thought process related to severe cognitive impairment. Interventions included: To anticipate and meet resident's needs per physical or non-verbal indications of discomfort/distress and follow-up as needed. On 08/29/22 at 1:55 p.m. an interview was conducted with Staff F, CNA who was assigned to care for Resident #2. Staff F stated Resident #2 was last toileted shortly before 10 a.m. She stated it was before his family arrived at the facility for the visit. She stated Resident #2 does not communicate very well but he will holler if he needs something. Staff F stated sometimes Resident #2 fights and screams. Staff F said, I did not ask him if he needed to use the bathroom. I have not checked on him. He is with his family. Staff F stated the expectation was for them to check if a resident needs toileting at least every 2 hours. Staff F said, I should have asked him. I did not. On 08/29/22 at 1:50 p.m. an interview was conducted with Staff E, Registered Nurse (RN), Unit Manager. Staff E stated she expects toileting to be done constantly. Staff E said, There is no set time. We respond to the resident's needs. Staff E stated CNAs document on the ADL care task logs with each care episode, or at least once during the shift. An interview was conducted on 08/29/22 at 1:58 p.m. with Staff C, LPN assigned to care for Resident #2. Staff C stated she did not know the last time the resident was toileted. Staff C stated she would check with the CNA who is assigned. Staff C said, We should be asking if he [Resident #2] needs to be toileted even if he is with family. We should initiate. I don't know if anyone checked on him. A follow -up interview was conducted with the Nursing Home Administrator (NHA) and the DON on 08/29/22 at 2:05 p.m. The NHA stated Resident #2 has an active family. The NHA stated the family visits all the time and between her and the DON, someone is interacting with the family all the time. The NHA stated the family complains all the time and they address their concerns on an - ongoing basis. The NHA stated the family has had problems with staff interrupting their visit. The NHA stated the family should tell the staff if the resident needed to be toileted. The NHA stated this was not documented in the resident's care plan, but they had agreed on it. The NHA said, how often a resident is toileted depends on if the resident needed to be toileted or not. The NHA stated the family has not complained about the resident needing to be toileted. The NHA stated they have had conversations with the family about letting the staff know. The NHA stated they [family] should let us know. On 08/29/21 at 2:21p.m., Resident #2 was observed being escorted to his room. Resident #2 had not been toileted for almost four and half hours, from around 9:45 a.m. to 2:21 p.m. On 08/30/22 at 9:42 a.m., an interview was conducted with Staff G, CNA. Staff G stated the residents are toileted or checked on at least every 2 hours. She stated she works with Resident #2. She stated his family is here quite often and the family has never said no to her removing the resident for care. Staff G stated the family never said to not interrupt their visit. Staff G said, I just go to them, I whisper to him and ask him if he wants to use the restroom or be changed. If he says yes, I take him to his room. I ask the family to wait in the lobby. They never said no. They just thank me for taking care of him. On 08/30/22 at 9:58 a.m., an interview was conducted with the Social Services Director (SSD). The SSD stated Resident #2's family has filed grievances about care before. The SSD stated the family reported the staff was not helping with care. The SSD stated she took the complaints to the DON so she could address them. The SSD stated they review all grievances in their daily meeting. The SSD stated the grievances are turned over to the relevant department to resolve. The resolution is documented on the grievance form. A review of the grievance log revealed Resident #2 had three grievances on file related to care, dated 4/7/22, 7/26/22 and 8/17/22. The grievances revealed unresolved on-going care concerns. A review of the grievances was conducted with the SSD and DON during an interview on 08:30/22 at 10:20 a.m. The grievance reports revealed the following: On 4/7/22: Concerns with ADL care, family stated Resident was left in the common area too long and ADL care was not being provided. Facility verified that ADL care was being provided., education was provided to the CNAs and care plan updated. On 7/26/22: Resident's family member stated resident needed brief change. Also, resident's skin was dry. Action taken: Verified with CNAs that they are doing routine checks and changes. Conclusion: DON and unit manager checked him and noted that he was not needing a brief change. Assessed the resident asked to the staff and they said he did not need to be changed. On 8/17/22: Resident's family member stated staff was not helping patient brush his teeth. Action taken: Spoke with CNAs regarding oral care. CNAs acknowledged understanding. Unit manager followed up with family, updated care plan, CNAs do assist him as necessary. An interview was continued with the DON on 08/30/22 at 11:20 a.m. The DON stated the facility did not have a policy related to ADL care. She stated it is based on patient centered care and is individualized on Kardex for each resident. The DON stated the expectation is for staff to follow the Kardex for the specific resident. The DON stated it was a generalized rule to check and change a resident every two hours. She stated their policy is the residents are routinely rounded on and checked every two hours. The DON stated the CNAs should document only if they are performing a care task. A review of the CNA task log documentation with a print date of 08/30/22 at 10:38 a.m., revealed Resident #2 was last toileted on 8/28/22 at 6:59 a.m. The review revealed Resident's #2's care was not completed or documented per facility expectations. A follow -up interview was conducted with the NHA on 08/30/22 at 11:43 a.m. The NHA stated they do not have an ADL, dignity policy, or a policy on CNA documentation. The NHA stated they use the CNA job description and their orientation program to outline the expectations. The NHA said, CNAs should follow their job description. A follow-up was conducted with the facility's Regional Nurse Consultant (RNC) on 08/30/22 at 12:00 p.m. The RNC stated they have a very basic ADL policy which won't tell you the practice of ADLs and it just states care expectations in general terms. The RNC said, We use the Kardex. Kardex is a basic expectation, it is our policy. It says what the resident needs. The CNAs should follow that. The RNC stated staff should follow basic standards of care, address the resident's needs in a timely manner. The RNC stated their goal is to document as quickly as possible. The RNC stated they address dignity concerns by educating staff on resident rights when they are hired and any time there is a concern. The RNC stated they did not have a dignity policy and provided a copy of document titled, Bill of Rights. A follow -up interview was conducted on 8/30/22 at 2:37 p.m. with Resident #2's family. The family was observed in the dining room. The family member stated today was the first time a staff came and asked him [Resident #2] if he needed to use the bathroom. The family member stated the resident said yes, and they took him to his room without concern. The family member said, they are just doing this because you are here. I doubt things will change. We'll see. A review of a job description titled, Certified Nursing Assistant (CNA), dated 07/01/2019, indicated the following: Ensure each resident's personal care needs are being met in accordance with the resident's / patient's wishes. Adheres to the facility bowel and bladder program for resident / patients. Keeps residents / patients dry and clean. Assists with bed pans, urinals, and commodes. Accurately records the amount indicated and report any irregularities. Answers call bell lights promptly and resolves resident's patient's requests or needs. A review of a document provided by the facility titled Resident Rights, undated, revealed every resident has the right to: (a) . be free from abuse and neglect. (b)Be treated with consideration and respect and with due recognition of personal dignity, individuality, and the need for privacy . (j) Access to adequate and appropriate healthcare . (i) Present grievances and . Each facility shall establish a grievance procedure to facilitate the resident's exercise of this right. A review of a facility policy titled, ADL: Supervision / Assistance, dated July 2021, revealed the following: (1) resident will be encouraged to be independent as possible with ADLs. (2) Staff will provide assistance with ADL's whenever requested by resident.

Based on observation, staff and family interview, and record review the facility failed to ensure Activites of Daily Living (ADL) for dependent residents received toileting assistance in a timely manner for two residents (#6 and #2) of nine residents sampled. Findings included: During a facility tour on 08/29/22 at 11:01 a.m., Resident # 6 was observed in her room in bed. Resident #6 stated she had been sitting in a wet brief all morning. The resident stated she was last changed by the night shift and did not know what time it had been. Resident #6 stated she was uncomfortable sitting in a wet brief. Resident #6 said, it is such an uncomfortable feeling. I wish people understood. Resident #6 stated she did not enjoy her breakfast because she needed to be changed. The resident stated Staff A, Certified Nurse Aide (CNA) had come into the room around 7 a.m. and offered her breakfast and she had not interacted with her since. Resident #6 stated Staff A had returned to the room again around 8 a.m. because her roommate had turned on the call light. Resident #6 stated Staff A stated to both residents she would return but had not made it back as of 11 a.m. A review of Resident #6's admission record indicated the resident was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission MDS (minimum data set) dated 08/23/22 revealed under Section C-Cognitive Function: Resident #6 had a BIMS (brief interview of mental status) score of 15, indicating intact cognition. Section G-Functional Status: revealed Resident #6 required extensive assistance for bed mobility, transfers, dressing, toileting, and personal hygiene and was dependent on 2+ persons for physical assistance. A review of the care plan for Resident #6, dated 08/18/22, revealed the resident had a self-care deficit with interventions to include: assist of one for toileting with bedpan; dependent assist of two to turn and reposition and transfer. An additional focus area revealed Resident #6 was incontinent of bladder and bowel and was to be evaluated for the ability to participate with a toileting program. The goal indicated Resident #6 would establish specific toileting program to support highest level of continence functioning, reduce risk of infection, skin impairment and improve self-esteem. On 08/29/22 at 11:06 a.m. an interview was conducted with Staff B, CNA who was observed in the hallway outside Resident #6's room. Staff B stated the expectation is to check on the residents quite frequently. Staff B stated that meant at least 2 hours or more often if needed. An interview was conducted on 08/29/22 at 11:12 a.m. with Staff A, CNA. Staff A stated she was assigned to care for Resident #6. Staff A stated at around 7:15 a.m. she did her rounds and asked the residents if they were okay. Staff A stated one of the residents had pulled the call light and she had told them she would be back. Staff A stated she was working her way to the room. Staff A stated, Bed A [Resident #6] spoke up about wanting to use the bed pan. I told her I'd be back to change her. Staff A stated third shift staff will usually toilet residents just before they leave. Staff A stated she did not know what time Resident #6 was last toileted. Staff A said, I had to do an assigned smoke break for the smokers from 6.45 a.m. to 7.45 a.m. and after that I went to assist other residents. I was going to get to her. Staff A stated they are expected to check on the residents every two hours at least. Staff A said, I care for my residents, no, they should not sit in soiled briefs. On 08/29/22 at 11:16 a.m., an interview was conducted with Staff C Licensed Practical Nurse (LPN). The nurse stated residents should be assisted with toileting whenever they ask. Staff C stated if the assigned CNA is not available, anyone including the nurses can help. Staff C stated the facility policy is to check the residents every 2 hours or as needed. An interview was conducted on 08/29/22 at 11:20 a.m. with Staff D, LPN assigned to Resident #6. Staff D was notified Resident #6 had not received incontinence care all morning and it had been more than four hours. Staff D stated the CNA was busy all morning assisting other residents. Staff D stated she did not know the resident needed to be toileted. Staff D said, I administered her meds this morning. I did not ask her if she needed to be changed. Staff D stated she had noticed a call light on, around 8 a.m., but was not sure what the resident wanted. Staff D stated she saw the CNA [Staff A] answer the call light and come out of the room shortly. Staff D said, It is not acceptable for our residents to sit in soiled briefs. She should have asked for help. I will check on the resident right now. Staff D stated CNAs document whenever they provide assistance. Staff D proceeded to Resident #6's room. A follow up was conducted on 08/29/22 at 11:24 a.m. with the Director of Nursing (DON). The DON stated they check on their residents all the time. The DON stated, No, a resident should not wait that long. Yes, we have an expectation, to provide care as soon as the resident asks. The DON stated the CNAs document in the task log each time a resident is assisted. A review of the CNA task log dated 08/18/22 - 08/30/22 revealed one entry per day related to CNA's assistance with incontinence care for Resident #6. The document revealed Resident #6 was last toileted on 08/28/22 at 09:54 p.m. On 08/29/22 at 12:00 p.m. Resident #2 was observed in the dining room visiting with his family. Resident #1 had been observed seated in the dining area all morning. Resident #2 was not interviewable. On 08/29/22 at 1:45 p.m., an interview was conducted with Resident #2's family member. The family member stated their main concern was with toileting. Resident #2's family member said, We have been here since 10 a.m. this morning and no one has come to check on the Resident or ask if he needed to be changed. This happens all the time. They just leave him in wet briefs. If they can do that when we are here, imagine what happens when we are not. The family member stated the resident has sat in wet briefs for more than 6 hours before. The family member stated she did not know the last time the resident was changed. The family member stated the facility does not do anything unless she asks. The family member stated they had filed grievances and spoken to the facility multiple times. The family member stated the facility is very dismissive. The family member said, they think we complain all the time. See for yourself. A review of Resident #2's admission record revealed the resident was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An MDS, dated [DATE], revealed in Section C-Cognitive Function: Resident #2 had a BIMS score of 03, indicating severe cognitive impairment. In Section G-Functional Status: Resident #2 required extensive assistance with ADLs with a 2+ persons physical assistance, and Resident #2 was totally dependent on staff for toilet use. A review of the care plan for Resident #2, initiated on 04/21/22, revealed an incontinence focus area indicating Resident #2 was incontinent of bladder and bowel and was not a candidate or toileting program related to involuntary or unpredictable bladder and bowel elimination. The goal indicated the resident will maintain dignity, minimize the risk of infection and skin breakdown. The interventions included: Check for incontinence with routine care upon arising, before and after mealtime, at bedtime, and as needed; Provide incontinence care as indicated. An additional care plan focus area revealed Resident #2 had impaired cognition function / dementia or impaired thought process related to severe cognitive impairment. Interventions included: To anticipate and meet resident's needs per physical or non-verbal indications of discomfort/distress and follow-up as needed. On 08/29/22 at 1:55 p.m. an interview was conducted with Staff F, CNA who was assigned to care for Resident #2. Staff F stated Resident #2 was last toileted shortly before 10 a.m. She stated it was before his family arrived at the facility for the visit. She stated Resident #2 does not communicate very well but he will holler if he needs something. Staff F stated sometimes Resident #2 fights and screams. Staff F said, I did not ask him if he needed to use the bathroom. I have not checked on him. He is with his family. Staff F stated the expectation was for them to check if a resident needs toileting at least every 2 hours. Staff F said, I should have asked him. I did not. On 08/29/22 at 1:50 p.m. an interview was conducted with Staff E, Registered Nurse (RN), Unit Manager. Staff E stated she expects toileting to be done constantly. Staff E said, There is no set time. We respond to the resident's needs. Staff E stated CNAs document on the ADL care task logs with each care episode, or at least once during the shift. An interview was conducted on 08/29/22 at 1:58 p.m. with Staff C, LPN assigned to care for Resident #2. Staff C stated she did not know the last time the resident was toileted. Staff C stated she would check with the CNA who is assigned. Staff C said, We should be asking if he [Resident #2] needs to be toileted even if he is with family. We should initiate. I don't know if anyone checked on him. A follow -up interview was conducted with the Nursing Home Administrator (NHA) and the DON on 08/29/22 at 2:05 p.m. The NHA stated Resident #2 has an active family. The NHA stated the family visits all the time and between her and the DON, someone is interacting with the family all the time. The NHA stated the family complains all the time and they address their concerns on an - ongoing basis. The NHA stated the family has had problems with staff interrupting their visit. The NHA stated the family should tell the staff if the resident needed to be toileted. The NHA stated this was not documented in the resident's care plan, but they had agreed on it. The NHA said, how often a resident is toileted depends on if the resident needed to be toileted or not. The NHA stated the family has not complained about the resident needing to be toileted. The NHA stated they have had conversations with the family about letting the staff know. The NHA stated they [family] should let us know. On 08/29/21 at 2:21p.m., Resident #2 was observed being escorted to his room. Resident #2 had not been toileted for almost four and half hours, from around 9:45 a.m. to 2:21 p.m. On 08/30/22 at 9:42 a.m., an interview was conducted with Staff G, CNA. Staff G stated the residents are toileted or checked on at least every 2 hours. She stated she works with Resident #2. She stated his family is here quite often and the family has never said no to her removing the resident for care. Staff G stated the family never said to not interrupt their visit. Staff G said, I just go to them, I whisper to him and ask him if he wants to use the restroom or be changed. If he says yes, I take him to his room. I ask the family to wait in the lobby. They never said no. They just thank me for taking care of him. An interview was continued with the DON on 08/30/22 at 11:20 a.m. The DON stated the facility did not have a policy related to ADL care. She stated it is based on patient centered care and is individualized on Kardex for each resident. The DON stated the expectation is for staff to follow the Kardex for the specific resident. The DON stated it was a generalized rule to check and change a resident every two hours. She stated their policy is the residents are routinely rounded on and checked every two hours. The DON stated the CNAs should document only if they are performing a care task. A review of the CNA task log documentation with a print date of 08/30/22 at 10:38 a.m., revealed Resident #2 was last toileted on 8/28/22 at 6:59 a.m. The review revealed Resident's #2's care was not completed or documented per facility expectations. A follow -up interview was conducted with the NHA on 08/30/22 at 11:43 a.m. The NHA stated they do not have an ADL, dignity policy, or a policy on CNA documentation. The NHA stated they use the CNA job description and their orientation program to outline the expectations. The NHA said, CNAs should follow their job description. A follow-up was conducted with the facility's Regional Nurse Consultant (RNC) on 08/30/22 at 12:00 p.m. The RNC stated they have a very basic ADL policy which won't tell you the practice of ADLs and it just states care expectations in general terms. The RNC said, We use the Kardex. Kardex is a basic expectation, it is our policy. It says what the resident needs. The CNAs should follow that. The RNC stated staff should follow basic standards of care, address the resident's needs in a timely manner. The RNC stated their goal is to document as quickly as possible. The RNC stated they address dignity concerns by educating staff on resident rights when they are hired and any time there is a concern. The RNC stated they did not have a dignity policy and provided a copy of document titled, Bill of Rights. A follow -up interview was conducted on 8/30/22 at 2:37 p.m. with Resident #2's family. The family was observed in the dining room. The family member stated today was the first time a staff came and asked him [Resident #2] if he needed to use the bathroom. The family member stated the resident said yes, and they took him to his room without concern. The family member said, they are just doing this because you are here. I doubt things will change. We'll see. A review of a job description titled, Certified Nursing Assistant (CNA), dated 07/01/2019, indicated the following: Ensure each resident's personal care needs are being met in accordance with the resident's / patient's wishes. Adheres to the facility bowel and bladder program for resident / patients. Keeps residents / patients dry and clean. Assists with bed pans, urinals, and commodes. Accurately records the amount indicated and report any irregularities. Answers call bell lights promptly and resolves resident's patient's requests or needs. A review of a facility policy titled, ADL: Supervision / Assistance, dated July 2021, revealed the following: (1) resident will be encouraged to be independent as possible with ADLs. (2) Staff will provide assistance with ADL's whenever requested by resident.

Based on record reviews and interviews the facility failed to ensure treatment and care in accordance with professional standards of practice related to not ensuring a Hospital Transfer Evaluation form accurately assessed the condition of one resident (#36) and failed to ensure the resident's (#36) blood glucose levels were documented as ordered out of thirty-five sampled residents. Findings included: A review of the Admission Record revealed Resident #36 was admitted on [DATE]. The Admission Record included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review identified a Hospital Transfer Evaluation Summary, dated 4/5/22 at 9:13 a.m., that indicated the resident was transferred to an acute facility for altered mental status on 4/5/22. The Key Clinical Information showed the following vital signs: - Most recent Glucose: 164 taken on 4/4/222 at 5:06 a.m. - Blood Pressure: 124/78 taken on 4/3/22 at 7:35 a.m. - Heart Rate: 80 taken on 4/3/22 at 7:35 a.m. - Respiration Rate: 18 taken on 4/3/22 at 7:34 a.m. - Temperature: 97.6 taken on 4/3/22 at 7:34 a.m. - O2 (oxygen) saturation: 98.0% on 4/4/22 at 10:09 p.m. On 4/8/22 at 3:44 p.m., the Director of Nursing (DON) identified Resident #36 had a change in condition on Tuesday, April 5th as the nurse had noted Resident #36 had an altered mental status with a slight tremor. She stated she (DON) assessed the resident and the resident was sent to the hospital. The DON reviewed the vital signs documented as the most recent, Hospital Transfer Evaluation Summary, and confirmed they were documented as taken on 4/3/22, and were not current at the time of the resident's change in condition. She confirmed nurses were responsible for inputting the Change in Condition and completing the transfer forms. The DON stated a current blood glucose should have been documented as tremors and altered mental status were indicative of a low blood glucose level. The facility provided a policy titled, Notification of Resident/Patient Change in Condition, effective October 2021. The procedure identified staff would Notify the Physician resident/resident representative, and case management when indicated, if there is a significant change in condition, regardless of the time of day. A review of Resident #36's Order Listing Report identified a physician order, dated 3/11/22, for staff to obtain an accucheck two times a day for DM2 (Diabetes Mellitus 2), if less than 60 or greater than 400 contact physician. A review of the April 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The order for [MEDICATION(S)] insulin was started on 1/11/22. The April MAR for Resident #36 identified staff did not document blood glucose levels twice a day at 6:00 a.m. and 4:30 p.m. as scheduled. The March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The Blood Sugar Summary, dated 4/8/22, for Resident #36 indicated staff had documented one time a day blood glucose levels on 3/1/22 - 3/7/22, 3/9/22-3/10/22, 3/14/22-3/16/22, 3/18/22-3/19/22, 3/26/22, 3/29/22, 4/3/22, and 4/4/22. Staff documented twice daily blood glucose levels on 3/21/22. During an interview on 4/8/22 at 3:44 p.m., the DON reviewed the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . She confirmed staff were not documenting blood glucose levels consistently and the order should have supplemental space to document the values. A policy titled, Physician Orders, effective October 2021, identified that At the time each resident is admitted , the facility will have physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The procedure indicated, Medications that require monitoring will need to be entered into the electronic medical record.

Based on observations, record reviews, and interviews the facility failed to ensure physician ordered laboratory work was obtained for one resident (#90) out of thirty-five sampled residents. Findings included: A review of the Admission Record revealed Resident #90 was admitted on [DATE]. The Admission Record included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted on 4/5/22 at 12:01 p.m. with Resident #90 lying flat in bed and wearing a nasal cannula that was delivering 2 liters of oxygen per minute. The resident reported to having a grand mal [CONDITION(S)] last week. A review of Resident #90's February and March 2022 Medication Administration Records (MAR) identified the resident had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] Tablet Delayed Release ([MEDICATION(S)]) - Give 500 mg (milligram) by mouth two times a day for [CONDITION(S)]. Check for [MEDICATION(S)] levels. Dated 9/29/2021. - [MEDICATION(S)] Tablet 750 mg - Give 1 tablet by mouth two times a day for [CONDITION(S)]. Dated 5/14/21. The February 2022 Treatment Administration Record (TAR) indicated the following: - CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel), [MEDICATION(S)] level, (and) [MEDICATION(S)] level every 4 month(s) starting on the 20th for 1 day. Ordered 10/20/21. The February 2022 TAR indicated Resident #90's laboratory bloodwork was scheduled and administered during the night shift on 2/20/22 and the day shift on 2/21/22. A review of Resident #90's medical record did not include any CBC, CMP, [MEDICATION(S)] and [MEDICATION(S)] laboratory levels from 2/20/22 or 2/21/22. A review of an electronic transfer form for Resident #90 identified the reason for the transfer was due to [CONDITION(S)] activity. The March 2022 TAR indicated a CBC, CMP, TSH ([CONDITION(S)]-Stimulating Hormone), Lipids, Vitamin D2, [MEDICATION(S)], [MEDICATION(S)] level, and [MEDICATION(S)] level was ordered for one day on Thursday 3/24 and Friday 3/25/22. A review of the blood work obtained from Resident #90 on 3/26/22 included Vitamin D, CBC, TSH, CMP, and [MEDICATION(S)] levels. The report did not include the resident's [MEDICATION(S)] level. On 4/8/22 at 1:00 p.m. the Director of Nursing (DON) stated the laboratory bloodwork scheduled for February 2022 was not drawn. She confirmed staff had signed off on the February MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . She confirmed the March results did not include the resident's [MEDICATION(S)] level. A review on 4/8/22 at 3:36 p.m. of Resident #90's active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's policy titled, Lab Process, undated, indicated the process as follows: - 1. Obtain the order for labs from the MD (medical doctor). - 2. Complete the lab log sheet in the lab book. - 3. Complete the Requisition sheet and place it behind lab log sheet under the day the lab should be drawn. - 5. Upon receiving the results notify the MD and RP (Responsible Party) of results and file the lab in the medical record under LABS. - 6. Document the labs you received and reported to include any additional follow up in a progress note.

Based on interview and record review, the facility failed to provide care and services for one ( #7) of 11 sampled residents related to a change in condition. Resident #7 was newly admitted , with medications and a handwritten list of doses provided from home, which the nurse used to administer insulin, without verifying the medications and doses with a physician. The insulin was administered two hours after a meal and within 3-4 hours after the administration of the insulin the resident was lethargic and and sent to the hospital with a low blood glucose. Findings included: Resident # 7 was admitted to the facility at approximately 10:30 a.m., on 03/20/2019 as a Hospice/respite resident for a five day stay. In an interview conducted on 03/22/2019 beginning at 10:55 a.m., with the nurse who admitted him to the facility, Nurse K, reported that she went to speak with the resident on 03/20/2019 shortly after his arrival to ask him to sign a consent to treat form. She reported that she had to repeat herself, loudly, but he seemed to understand her intent and signed the consent form. She then asked the resident's aide, Aide N, to accompany her during the assessment as she would need assistance in turning the resident to assess his skin. The nurse reported that the resident needed incontinence care as he was very wet and soiled and she assisted the aide in cleaning and providing a clean brief for the resident. She reported that she was concerned the resident would have no pants to wear, but the aide reminded her that the family said they would come in with clothes for the resident. By 12:00 p.m., on 03/20/2019, the family had arrived with clothing and a small box of pill bottles and a piece of yellow notebook paper with handwritten medication orders. Per interview with another aide who was working on that same resident hall, Aide M, (on 03/22/2019 beginning at 1:50 p.m.), reported that she visited with the family who were standing at the door to the resident's room, holding the resident's personal items. She reported that she provided incontinence care to the resident while the family was filling in the inventory sheet and talking with the nurse about the resident's medications. Nurse K confirmed that she received the resident's medications from the family and she compared a handwritten list from the family with the typewritten list she had received in the information packet from Hospice that arrived with the resident. Per the typed medication list from Hospice, the resident was to receive: -Cipro ([MEDICATION NAME] HCL) 500 mg tablet - take 1 tablet orally twice a day for urinary tract infection -[MEDICATION NAME] HFC ([MEDICATION NAME] sulfate) 90 mcg hfa aer ad - inhale 2 puff orally every 4 hours for shortness of breath -[MEDICATION NAME] 5 tab ([MEDICATION NAME]) 5 mg tablet dr - take 2 tablet ever day as needed for constipation -[MEDICATION NAME] ([MEDICATION NAME] HCL) 50 mg tablet - take 1 tablet orally every 6 hours as needed for pain -[MEDICATION NAME] ([MEDICATION NAME] HCL) 25 mg tablet - take 1 tablet orally every day for depression -[MEDICATION NAME] ([MEDICATION NAME]) 100 mg capsule - take 1 capsule orally three times a day for cough -Bactrim DS ([MEDICATION NAME]/[MEDICATION NAME]) 800-160 mg tablet - take 1 table orally every day for urinary tract infection -[MEDICATION NAME] ([MEDICATION NAME] B sulfate/tmp) 10k/ml-0.1 drops - instill 1 drop(s) in each eye four times a day for eye infection -Mucus Relief (mucus relief ER 600 mg tablet) 600 mg tab ER 12h - take 1 tablet orally 2 times a day for congestion -[MEDICATION NAME] (tamsulosin HCL) 0.4 mg cap ER 24h - take 1 capsule orally every day for [MEDICAL CONDITION] -[MEDICATION NAME] ([MEDICATION NAME]) 5 mg tablet - take 1 tablet orally every day for [MEDICAL CONDITION] -[MEDICATION NAME] 10 supp ([MEDICATION NAME]) 10 mg supp, rect - Insert 1 suppository rectally ever day as needed for constipation -[MEDICATION NAME] (atorvastatin calcium) 20 mg tablet - take 1 tablet orally every day for high cholesterol -ASA 81 (aspirin) 81 mg table dr - take 1 tablet orally every day for stroke prevention -[MEDICATION NAME] ([MEDICATION NAME]) 5 mg tablet - take 1 tablet orally every day for hypertension -Senna S (sennosides/[MEDICATION NAME] sodium) 8.6-50 mg tablet - take 2 tablet orally twice a day for constipation -Tresiba (degludec) 100 u/ml inj - Inject 30 unit subcutaneously every evening for diabetes -[MEDICATION NAME] (insulin [MEDICATION NAME]) 100/ml Insuln pen - Inject 15 unit subcutaneously after meals for diabetes -[MEDICATION NAME] 10 ([MEDICATION NAME]) 10 mg tablet - take 1 tablet orally twice a day for shortness of breath -[MEDICATION NAME] ([MEDICATION NAME]) 600 mg tablet - take 1 tablet orally three times a day for pain -[MEDICATION NAME] ([MEDICATION NAME]) 2 mg/ml oral conc. - Take .25 ml sublingually 2 times a day as needed for agitation -Theolair-SR ([MEDICATION NAME] anhydrous) 300 mg tab, sr 12h - take 1 tablet orally every day for shortness of breath -[MEDICATION NAME] ([MEDICATION NAME]/[MEDICATION NAME] sulfate) 0.5-3 mg/3 ampul/neb - inhale 1 vial via nebulizer four times a day for shortness of breath -[MEDICATION NAME] ([MEDICATION NAME] HCL) 50 mg tablet - take 1 tablet orally every 6 hours as needed for pain -[MEDICATION NAME] HFA ([MEDICATION NAME] sulfate) 90 mcg hfa aer ad - Inhale 2 puffs orally every 4 hours as needed for shortness of breath -Senna (sennosides) 8.6 mg tablet - take 2 tablets orally twice a day as needed for constipation -Oxygen ((compound)) air - inhale 3 L/min via nasal cannula continuously for shortness of breath -[MEDICATION NAME] ([MEDICATION NAME] sulfate) 20 mg/ml solution - (comfort pak) take 0.25 ml (5 mg) by mouth or under the tongue every 3 hours as needed for pain -[MEDICATION NAME] ([MEDICATION NAME] HCL) 500 mg tablet - take 1 tablet orally every day for diabetes -[MEDICATION NAME] ([MEDICATION NAME]) 10g/15 ml solution - take 30 mls orally three times daily as needed for constipation -[MEDICATION NAME] ([MEDICATION NAME]) 30 mg tablet - take 1 tablet orally every day for chest pain -[MEDICATION NAME] ([MEDICATION NAME]) 800 mg tablet - take 1 tablet orally three times a day as needed for pain -[MEDICATION NAME] 5 ([MEDICATION NAME] BIT/acetominophen) 5 mg-325 mg tablet - take 1 tablet orally every 8 hours for pain -[MEDICATION NAME] (polyethylene [MEDICATION NAME] 3350) 17g/dose powder - take 17 grams orally every day for constipation -Uristat ([MEDICATION NAME] HCL) 95 mg tablet - take 1 table orally every 6 hours as needed for pain -[MEDICATION NAME] ([MEDICATION NAME]) 0.5 mg tablet - take 1 tablet sublingually every 3-4 hours as needed for shortness of breath -[MEDICATION NAME] 20 ([MEDICATION NAME]) 20 mg tablet - take 2 tablets orally every day for shortness of breath -[MEDICATION NAME] ([MEDICATION NAME] B sulfate/tmp) 10k/ml-0.1 drops - instill 2 drop(s) in each eye every 4 hours for [MEDICAL CONDITION] -[MEDICATION NAME] ([MEDICATION NAME]) 250 mg tablet - take 2 tablet orally on the first day and 1 tablet on days 2-5, for respiratory infection -Cipro ([MEDICATION NAME] HCL) 500 mg tablet - take 1 tablet orally twice a day for urinary tract infection -[MEDICATION NAME] (tamsulosin HCL) 0.4 mg cap ER 24h - take 2 capsules orally every day for urinary frequency The handwritten list was requested but was not presented at the time of the survey. Nurse K reported that Unit Manager P told her to compare the two lists of medications, and if they were different to use the handwritten copy provided by the facility. Nurse K did not report any differences between the two lists. She confirmed at that time that she did not verify the medications with either the Hospice nursing team or a physician. Nurse K reported that she provided the resident with 20 units of [MEDICATION NAME]between 2:00 p.m. and 2:30 p.m. per the daughter's instructions. She reported that since she didn't know the resident, she tested his blood glucose and found it to be 298. She confirmed there wasn't a sliding scale for the insulin, but the daughter had told her that her father got 20 units three times a day - at 8 am, 2 pm, and 10 pm. She said she gave the insulin, and within the hour greeted the incoming nurse, explained the new admission and where his medications were stored, and left for the day. She said she saw that the resident was sleeping when she left at about 3:00 p.m. In an interview with Aide N, on 03/22/2019 beginning at 1:40 p.m., she confirmed she had provided incontinence care several times during her shift to Resident #7, noted that he had eaten less than half of the lunch meal, and left at 3:00 p.m., noting that the resident seemed sleepy. In an interview with the 3 to 11 aide, on 03/22/2019 beginning at 12:40 p.m., Aide L confirmed that she had worked with Resident #7 on 03/20/2019. She reported that she provided incontinence care before dinner and returned to the resident's hall about 6:00 p.m. when she provided Resident #7 with his dinner. She reported that she was not able to wake him, even with shaking him, so she told her nurse, Nurse D. She reported that she was assisting other residents with dinner, and at approximately 6:30 p.m., she saw that family for Resident #7 were in his room and seemed very upset, yelling for the nurse, and making a call to 911. Nurse D checked the resident's blood glucose and found it to be 40, and administered a shot of [MEDICATION NAME], per the nurse's notes in the resident's medical record. Review of the nursing notes revealed the resident was transferred to the hospital, leaving the facility at 7:30 p.m., on 03/20/2019. review of the resident's medical record revealed [REDACTED]. In a phone conversation with the physician, on 03/27/2019 beginning at 10:25 a.m., the physician reported that he was not familiar with Resident #7 and wouldn't have changed medications for a resident that he did not know. In an interview with a Hospice patient care administrator, on 03/25/2019 beginning at 4:50 p.m., she confirmed that Resident #7 had a sliding scale to determine the amount of insulin to give and the dose wasn't always '20 units.' After reviewing the list of medications that was provided to the nursing home, she agreed that the sliding scale hadn't been included. She reported that she was sure the family would have been aware of the sliding scale and could have reported it to the nurses at the nursing home. In an interview with the family of Resident #7 on 03/25/2019 beginning at 3:20 p.m., the family member confirmed that the [MEDICATION NAME]was based on a sliding scale which she verbally gave to the nurse when she handed over the resident's medicine. She reported that she explained the blood sugar was to be checked before his meal and insulin given based on the result and the sliding scale. Review of the facility policy for Medications Brought to Nursing Care Center by Resident or Responsible Party, included in the Policy section was the statement: Medications brought into the nursing care center by a resident or responsible party are accepted only with a current order by the resident's prescriber, after the contents are verified by the nurse, and if the packaging meets the state, federal and pharmacy's guidelines. In an interview with Nurse A, on 03/22/2019 beginning at 4:10 p.m., after reviewing Resident #7's medical record, she reported that Nurse P signed as having given the family the medications that they had brought in. Review of the document, Diabetes Management, from the Clinical Guidelines Manual, provided by the facility as reference material available to the nurses, revealed on page 11 of 18, a reference to Appendix 1 which explained 'times of administering insulin in relationship to eating a meal. Appendix 1 described 'Rapid Acting' insulin, such as [MEDICATION NAME] or [MEDICATION NAME], as having onset time of 10-20 minutes, peak time at 40-50 minutes and duration of 3-5 hours. The Role in Blood Sugar Management was explained as, rapid acting insulin covers insulin needs for meals eaten at the same time as the injection. This type of insulin is used with longer-acting insulin.

Based on interview and record review the facility failed to ensure staff followed the plan of care for one (#1) of 4 sampled residents and failed to provide care in accordance with the residents needs for assistance which resulted in the resident sustaining a fall with a [MEDICAL CONDITION]. Findings include: Per the facility face sheet resident #1 was initially admitted to the facility on [DATE]. Her cumulative [DIAGNOSES REDACTED]. A record review conducted on 11/06/12 at 12:30 p.m. revealed the resident had a fall on 10/10/12 which resulted in a left [MEDICAL CONDITION]. An extensive interview and further review of the facility records including the resident's medical record was conducted on 11/06/12 from approximately 12:45 p.m. to 1:45 p.m. with the Risk Manager and the DON ( Director of Nurses). The Risk Manager confirmed the fall details as follows: On 10/10/12 the resident sustained [REDACTED]. Per a facility report provide to the Agency the resident "was alert and able to make needs known." Staff interviews were conducted following the fall and it was discovered that the CNA providing care to the resident on 10/10/12 "took the resident near her room, told her she would be back to assist her...in a matter of minutes the resident got up unassisted which led to the event of the fall. The resident is normally continent of bowel and bladder and normally will take direction from staff. The resident was recently started on a diuretic. Resident at risk for falls." The nurse's progress notes for 10/10/12 documented at 1:45 p.m. "Pt (patient) found on floor screaming 'I'm tangled up. I'm all tangled up.' Pt had oxygen tubing tangled around her. Asked pt what she was doing. 'Using the bathroom' c/o rt complaint of right leg/hip." The nurses' notes further document at 1:50p. "911 called; 1:55p family notified of the above; 2p ER notified; 2:05p ER nurse notified; 2:08p ARNP notified." The Risk Manager (RM) detailed that the resident was found on the floor "partly in the bathroom." She was "assessed and her left leg was externally rotated. 911 was called." She further added: On that day she seemed more 'antsy' and asking for water. We had just gotten a new order for [MEDICATION NAME] (diuretic) on 09/30/12 because of her recurrent pneumonia." Staff interviews were conducted as part of a follow-up investigation in to the fall. RM stated the CNA who was caring for the resident on the date of the fall was interviewed on 10/17/12 and "finally admitted that she left the resident at the door to the room. (The resident) told her she needed to use the bathroom. The CNA told the resident to wait and that she would be right back. When (the resident) attempted to go to the bathroom by herself, that's when she fell . Her wheel chair was found in the room. The CNA admitted that she left the resident 'for 5 or 10 minutes.' We asked her to write a statement as to what happened. She left the facility without providing a statement and has not returned and will not return phone calls." The DON interjected that the CNA "was terminated on 10/23/12 for failing to give us the written report." A care plan for incontinence dated 08/09/12 was reviewed. An intervention included on both the Individualized Care Plan and the Maintenance ADL and Safety Care Plan and Communication Tool dated 08/11/12 (which is placed in the Cardex and used as a staff reference for resident care and services) both noted the resident was to follow a toileting schedule at 3 a.m., 7 a.m., 1 p.m., 4 p.m., 6 p.m., 9 p.m. The resident was found attempting to use the bathroom sustaining a fall at 1:45 p.m. A review of the resident's Annual (and most recent ) MDS dated [DATE] reveals the following: Section G0110 Functional Status requires 1 person physical assist for (B) transfers, (C) walking in room and (I) toilet use. Section G0300 Balance during transitions and walking are coded as 2. Not steady, able only to stabilize with staff assistance for walking and turning around and coded as 1. Not steady, but able to stabilize without staff assistance for moving from seated to standing position, moving on and off toilet and surface-to-surface transfer. Both the the DON and the Risk Manager concurred with the findings related to the CNA's failure to care for resident #1 at the conclusion of the interview and record review at 1:45 p.m. on 11/6/12.

Based on observation, interview and record review the facility failed to prevent falls for two (#1, 2) of 4 sampled residents by not ensuring staff followed the plan of care for toileting for resident #1 as needed and failed to update the care plan to include the residents' complete fall histories and initiate additional fall prevention interventions after a fall for resident #2. Failure to provide updated information specific to resident care and needs caused bath residents to sustain falls resulting in fractures. Findings include: 1. Per the facility face sheet resident #1 was initially admitted to the facility on [DATE]. Her cumulative [DIAGNOSES REDACTED]. A record review conducted on 11/06/12 at 12:30 p.m. revealed the resident had a fall on 10/10/12 which resulted in a left hip fracture. An extensive interview and further review of the facility records including the resident's medical record was conducted on 11/06/12 from approximately 12:45 p.m. to 1:45 p.m. with the Risk Manager and the DON ( Director of Nurses). The Risk Manager (RM) confirmed the fall details as follows: On 10/10/12 the resident sustained [REDACTED]. Per a facility report provide to the Agency the resident "was alert and able to make needs known." Staff interviews were conducted following the fall and it was discovered that the CNA providing care to the resident on 10/10/12 "took the resident near her room, told her she would be back to assist her...in a matter of minutes the resident got up unassisted which led to the event of the fall. The resident is normally continent of bowel and bladder and normally will take direction from staff. The resident was recently started on a diuretic. Resident at risk for falls." The nurse's progress notes for 10/10/12 documented at 1:45 p.m. "Pt (patient) found on floor screaming 'I'm tangled up. I'm all tangled up.' Pt had oxygen tubing tangled around her. Asked pt what she was doing. 'Using the bathroom'... complaint of right leg/hip." The nurses's notes further document at 1:50p. "911 called; 1:55p family notified of the above; 2p ER notified; 2:05p ER nurse notified; 2:08p ARNP notified." The Risk Manager detailed that the resident was found on the floor "partly in the bathroom." She was "assessed and her left leg was externally rotated. 911 was called." She further added: On that day she seemed more 'antsy' and asking for water. We had just gotten a new order for Lasix (diuretic) on 09/30/12 because of her recurrent pneumonia." The RM stated that staff interviews were conducted as part of a follow-up investigation in to the fall. The CNA who was caring for the resident on the date of the fall was interviewed on 10/17/12 and "finally admitted that she left the resident at the door to the room. (The resident) told her she needed to use the bathroom. The CNA told the resident to wait and that she would be right back. When (the resident) attempted to go to the bathroom by herself, that's when she fell . Her wheel chair was found in the room. The CNA admitted that she left the resident 'for 5 or 10 minutes.' We asked her to write a statement as to what happened. She left the facility without providing a statement and has not returned and will not return phone calls." The DON interjected that the CNA "was terminated on 10/23/12 for failing to give us the written report." A review of the hospital records was also conducted with the Risk Manager and the DON. Four physician reports dated 11/11/12 were reviewed: an admission report indicating ICU admission and plan of care noting "The patient does have multiple comorbid conditions"; a pulmonary consultation for respiratory failure; a nephrology report for acute renal failure and an orthopedic report for the left hip fracture. A review of the resident's Annual (and most recent ) MDS dated [DATE] revealed the following: Section G0110 Functional Status requires 1 person physical assist for (B) transfers, (C) walking in room and (I) toilet use. A care plan for incontinence dated 08/09/12 was reviewed. An intervention included on both the Individualized Care Plan and the Maintenance ADL and Safety Care Plan and Communication Tool dated 08/11/12 (which was placed in the Cardex and used as a staff reference for resident care and services) both noted the resident was to follow a toileting schedule at 3 am, 7 am, 1 pm, 4 pm, 6 pm, 9 pm. The area for toileting noted that she required assist of 1; toilet/check and change upon arising, before and after meals, at bedtime and as needed. The resident was found attempting to use the bathroom sustaining a fall at 1:45 p.m. on 10/10/12. Both the DON and the Risk Manager concurred with the findings related to the CNA's failure to care for resident #1 at the conclusion of the interview and record review at 1:45 p.m. 2. Resident #2 had a recent history of having a fall with a left hip fracture. Per the facility facesheet, the resident was initially admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted to the hospital 9/30/12 after a fall on 9/29/12 which resulted in fractured ribs and a left hip fracture. The resident was readmitted to the facility 10/12/12. On 11/6/12 the resident was observed up and dressed, at 9:45 a.m., in his wheel chair which was positioned next to his bed. A CNA (Certified Nurse's Assistant) was observed in the room. He stated that he had asked the CNA to put him back to bed. "I had a doctor's appointment but I didn't feel good and want to go back to bed." The resident was observed with a lap belt that "he can undo himself" per the CNA attending to the resident. The resident also had a chair alarm attached to the chair but unclipped from his shirt in preparation of going into bed. It was observed that he had a low bed with scoop mattress and floor pads on both sides of the bed. A bed alarm was also observed. The resident stated that "I can stand but I have to have help getting into bed. I can't walk on my own. See, I can take off this belt, but I don't get up without help." He demonstrated unclipping the lap belt without difficulty. The resident appeared tired and the interview was terminated as the CNA proceeded to assist the resident. An extensive interview was conducted with the Risk Manager starting at 10:45 a.m. and concluding at 12:15 p.m. The DON (Director of Nurses), joined the interview at 11:35 a.m. She related from her incident report notes that on 09/29/12 at 3:15 p.m. a CNA heard the bed alarm sounding from the resident's room. She entered the room; saw him on the floor mat on his right side between his bed and that of his roommate. She made sure the resident was secure and immediately went for help. The CNA stated that on return the resident was sitting on the floor on his buttocks. "That day he was confused. His bed was in the low position and his call light was within reach. He had just been put back to bed at 3:05 p.m. He complained about pain on the left side of his ribs when the nurse did an assessment. His daughter and ARNP were called. The ARNP ordered bilateral chest x-rays. At 10 p.m. the x-ray results were received and his doctor was called. The x-rays verified he had fractured ribs. (The resident ) still seemed confused but he didn't complain of any other pain. His daughter came in on 11-7 shift and again at 10:30 the next morning. She requested that resident be sent to the hospital. He gave a telephone order to transfer. Per the nurse's notes he "left in stable condition." And he was then transferred to hospital for the fractured ribs (right side 8th, 9th and 10th). The x-ray also revealed he had a recurrence of his chronic pneumonia." "(The resident) was assessed on admission to the hospital on [DATE] and was admitted for treatment related to "right rib and left hip pain." It was not until he was in the hospital that he stated he had pain in his left hip. The x-rays that had been done here were only for the ribs. He had not complained of any other pain at any time after the fall while still here in the facility. An x-ray was done and it was determined that he had a fracture of the left hip left hip and an ORIF was done. The resident stayed in the hospital until he returned to the facility on [DATE] and where he is currently receiving PT and OT services." A review of the resident's records further revealed that the resident had had 2 prior falls on 05/30/12 and on 09/05/12. "After the first fall (05/30/12) we put the floor mats into place. On 09/05/12 he was found on the floor mats. He sustained a skin tear to his right arm. No other injuries were found during an assessment done by the nurse. The doctor and his family were notified. After the most recent fall on 09/29/12 we started using the quick release lap belt as a safety measure. He can take it off by himself. We aren't really sure whether he sustained the fractured ribs from the fall onto the floor mats on 09/29/12 or if he actually had fractured the ribs with excessive coughing from his COPD." "On 10/21/12 at 5:30 a.m. he also slid off the side of the bed while trying to use the urinal. The nurse was in the room with him. He slid onto the floor mats and didn't sustain an injury. No injuries reported. A full assessment was completed by the nurse. The family and the doctor were notified. He is currently in PT and OT for strengthening and safety awareness. He had a history of [REDACTED]." At 12:10 p.m. the DON stated "He never complained of any hip pain until he was in the hospital the next day. His assessment there, like ours initially had no indications of a problem with the hip. " The risk manager concluded with the statement that "his safety awareness has improved and he is very aware of his lap belt. He knows not to get up without help." The interview with the Risk Manager and the DON was concluded at 12:15 p.m. During the course of the record review conducted in conjunction with the interview the following care plan omissions were identified for resident #2: -On the Maintenance ADL and Safety Care Plan & Tool Communication Form initiated on the resident's initial admission 04/13/12 there was no documentation of the use of the quick release safety belt under the safety interventions area. This form is generally referred to as the Cardex and is the reference guide for the staff including CNA's and nurses to provide appropriate interventions and care for the residents. -On the Individualized Care Plan for Fall/Fall Risk form there is no documentation of the fall that had occurred on 09/29/12 which had resulted in the rib and left hip fractures. No additional interventions were documented after this second fall. -The Standards of Care initiated 4/13/12, under the Falls section does indicate on "5/30/12-Found on floor-low bed floor mat, bed alarm" "9/5/12 Noted on floor" "9/29/12-on floor" the next entry is "10/15/12 low bed, fall mattress, bed alarm, chair alarm". There were no additional interventions between 5/30/12 and 10/15/12. Both the DON and the Risk Manager concurred with the findings related to the care plans for resident #2 at the conclusion of the interview and record review at 12:15 p.m.

Based on observation interview and record review the facility failed to ensure Individualized Care Plans for one (#2) of 4 sampled residents was updated to include the residents' complete fall histories, all fall prevention interventions to be followed resulting in a fall with fractures. Findings include: Resident #2 had a recent history of having a fall with a left [MEDICAL CONDITION]. Per the facility facesheet, the resident was initially admitted on [DATE] with [DIAGNOSES REDACTED]. He was admitted to the facility following a hospital admission for pneumonia. The resident was observed up and dressed, at 9:45 a.m. on 11/6/12, in his wheel chair at which was positioned next to his bed. A CNA (Certified Nurse's Assistant) was observed in the room. He stated that he had asked the CNA to put him back to bed. "I had a doctor's appointment but I didn't feel good and want to go back to bed." The resident was observed with a lap belt that "he can undo himself" per the CNA attending to the resident. The resident also had a chair alarm attached to the chair but unclipped from his shirt in preparation of going into bed. It was observed that he had a low bed with scoop mattress and floor pads on both sides of the bed. A bed alarm was also observed. The resident stated that "I can stand but I have to have help getting into bed. I can't walk on my own. See, I can take off this belt, but I don't get up without help." He demonstrated unclipping the lap belt without difficulty. The resident appeared tired and the interview was terminated as the CNA proceeded to assist the resident. An extensive interview was conducted with the Risk Manager starting at 10:45 a.m. and concluding at 12:15 p.m. The DON (Director of Nurses), joined the interview at 11:35 a.m. She related from her incident report notes that on 09/29/12 at 3:15 p.m. a CNA heard the bed alarm sounding from the resident's room. She entered the room; saw him on the floor mat on his right side between his bed and that of his roommate. She made sure the resident was secure and immediately went for help. The CNA stated that on return the resident was sitting on the floor on his buttocks. "That day he was confused. His bed was in the low position and his call light was within reach. He had just been put back to bed at 3:05 p.m. He complained about pain on the left side of his ribs when the nurse did an assessment. His daughter and ARNP were called. The ARNP ordered bilateral chest x-rays. At 10 p.m. the x-ray results were received and his doctor was called. The x-rays verified he had fractured ribs. (The resident ) still seemed confused but he didn't complain of any other pain. His daughter came in on 11-7 shift and again at 10:30 the next morning. She requested that resident be sent to the hospital. He gave a telephone order to transfer. Per the nurse's notes he "left in stable condition." And he was then transferred to hospital for the fractured ribs( right side 8th, 9th and 10th). The x-ray also revealed he had a recurrence of his chronic pneumonia. "(The resident) was assessed on admission to the hospital on [DATE] and was admitted for treatment related to "right rib and left hip pain." It was not until he was in the hospital that he stated he had pain in his left hip. The x-rays that had been done here were only for the ribs. He had not complained of any other pain at any time after the fall while still here in the facility. An x-ray was done and it was determined that he had a [MEDICAL CONDITION] hip left hip and an ORIF was done. The resident stayed in the hospital until he returned to the facility on [DATE] and where he is currently receiving PT and OT services. A review of the resident's records further revealed that the resident had had 2 prior falls on 05/30/12 and on 09/05/12. "After the first fall (05/30/12) we put the floor mats into place. On 09/05/12 he was found on the floor mats. He sustained a skin tear to his right arm. No other injuries were found during an assessment done by the nurse. The doctor and his family were notified. After the most recent fall on 09/29/12 we started using the quick release lap belt as a safety measure. He can take it off by himself. We aren't really sure whether he sustained the fractured ribs from the fall onto the floor mats on 09/29/12 or if he actually had fractured the ribs with excessive coughing from his [MEDICAL CONDITION]." "On 10/21/12 at 5:30 a.m. he also slid off the side of the bed while trying to use the urinal. The nurse was in the room with him. He slid onto the floor mats and didn't sustain an injury. No injuries reported. A full assessment was completed by the nurse. The family and the doctor were notified. He is currently in PT and OT for strengthening and safety awareness. He had a history of [REDACTED]." At 12:10 p.m. the DON stated "He never complained of any hip pain until he was in the hospital the next day. His assessment there, like ours initially had no indications of a problem with the hip." The risk manager concluded with the statement that "his safety awareness has improved and he is very aware of his lap belt. He knows not to get up without help." The interview with the Risk Manager and the DON was concluded at 12:15 p.m. During the course of the record review conducted in conjunction with the interview the following care plan omissions were identified for resident #2: On the Maintenance ADL and Safety Care Plan & Tool Communication Form initiated on the resident's initial admission 04/13/12 there was no documentation of the use of the quick release safety belt under the safety interventions area. This form is generally referred to as the Cardex and is the reference guide for the staff including CNA's and nurses to provide appropriate current interventions and care for the residents. The Standards of Care initiated 4/13/12, under the Falls section does indicate on "5/30/12-Found on floor-low bed floor mat, bed alarm" "9/5/12 Noted on floor" "9/29/12-on floor" the next entry is "10/15/12 low bed, fall mattress, bed alarm, chair alarm". There were no additional interventions between 5/30/12 and 10/15/12. On the Individualized Care Plan for Fall/Fall Risk form there is no documentation of the fall that had occurred on 09/29/12 which had resulted in the rib and left [MEDICAL CONDITION]. On the Individualized Care Plan for Pain an entry dated 10/31/12 notes the location of the resident's pain as chest and leg. The Care Plan fails to specifically note the location of the pain sites as the left ribs and post-surgical left [MEDICAL CONDITION]. Both the the DON and the Risk Manager concurred with the findings related to the care plans for resident #2 at the conclusion of the interview and record review at 12:15 p.m.