Every finding on record at Beach Street Health and Rehabilitation Center

Based on interviews, record review, and a review of the facility's policies and procedures, the facility failed to ensure that residents received proper treatment and assistive devices to maintain vision and hearing abilities for one (Resident #23) of one resident reviewed for vision services. Resident #23's appointment for cataract surgery was delayed for seven weeks. Delaying cataract treatment as vision worsens can lead to permanent vision loss, an increased risk for falls and loss of independence. Resident #23 was not kept informed about the status of his surgery, which negatively impacted his psychosocial well-being. The findings include: During an interview on 06/16/2026 at 11:38 AM, Resident #23 reported having a cataract. He stated he had an eye exam completed at the facility and was informed of retinal bleeding. Resident #23 stated he completed the next appointment with an eye specialist and was informed that he needed cataract surgery. An appointment was scheduled for 05/06/2026. On the day of the appointment, Resident #23 was informed by staff that the appointment was cancelled due to transportation unavailability. When he was asked who was responsible for transporting him to his appointment, he replied that the facility provided his transportation. A review of Resident #23's medical record revealed an admission date of 01/05/2024. His most recent Minimum Data Set (MDS) assessment, a Quarterly review dated 04/09/2026, revealed that he was understood by others and understood others, and was vision impaired with no corrective lenses. A review of his active physician's orders revealed an order for an eye appointment: [Facility name] on 05/06/2026 at 9:00 AM for a consultation for cataract removal. The order was dated 04/23/2026.A review of the resident's active Care Plans revealed a focus area for vision impairment related to a history of age-related nuclear cataracts, bilaterally. Interventions included: Arrange ophthalmologist/optometrist consult as needed, arrange meals in resident's visual field, and maintain clutter free environment.A review of a [Provider Name] psychology note dated 06/11/2026 at 1:00 AM revealed visit details and a chief complaint of Depression. Cognitive Status revealed that Resident #23 had the cognitive capacity to participate in and benefit from psychotherapy. The patient was actively engaged in session and therapist engaged in supportive therapy and CBT (Cognitive Behavioral Therapy) skills to address his psychological distress. The patient did not initially notice the therapist as she approached, explaining that his eyesight has deteriorated to the point where he feels almost blind. He stated he is still waiting to hear when his upcoming eye appointment will be scheduled.A review of a [Provider Name] psychology note dated 06/01/2026 at 1:00 AM, revealed visit details and a chief complaint of Depression. Cognitive Status revealed that Resident #23 had the cognitive capacity to participate in and benefit from psychotherapy. The patient stated that he was frustrated about not yet knowing the date of his next eye appointment. He said he planned to ask this afternoon and continue reminding staff so that transportation could be arranged. The patient reported that last night around 9:00 PM, while looking at a light in the distance, others saw one light, but he perceived eight. He also expressed feeling anxious about his upcoming surgery.A review of a [Provider Name} health note dated 05/16/2026 at 8:15 AM, revealed visit details and a chief complaint of monthly follow-up on Hypertension (HTN). [NAME] and diagnostic code Z98.49 revealed cataract extraction status, unspecified eye: Patient underwent cataract removal on 05/06/2026. Will continue to monitor post-operative recovery and follow up with ophthalmology as needed.A review of a [Provider Name] psychology note dated 05/14/2026 at 1:00 AM, revealed visit details and a chief complaint of Depression. During the session, the patient stated being frustrated that he missed his eye appointment last week and continued to ask staff when the appointment will be rescheduled but has not yet received an answer. He noted it was a shame he missed the appointment due to transportation issues. Additionally, the patient expressed a desire to leave the facility and have a life again. Moreover, the therapist focused on building rapport through active listening and reflection, which encouraged the patient to share personal experiences. The therapist supported the patient in positively reframing a difficult situation, emphasizing potential growth and resilience.A review of a [Provider Name] health note dated 05/08/2026 at 8:30 AM, revealed visit details of a monthly visit noting the resident had a consultation with ophthalmology concerning cataract removal on 05/06/2026. Previously, the resident was seen on 03/11/2026 for a monthly evaluation of chronic conditions where he was noted to be medically stable with no acute concerns. Ophthalmology follow-up for cataract evaluation was pending at that visit.A review of a [Provider Name] psychology note dated 05/07/2026 at 1:00 AM, revealed visit details and a chief complaint of Depression. Therapist noted that the patient reported being upset because he was not able to go to his eye doctor appointment yesterday. He said there was a problem with transportation. He explained that he was waiting for staff to tell him when the appointment was rescheduled. By using active listening and reflective techniques, the therapist established rapport, which encouraged the patient to be open about personal details.A review of a [Provider Name] psychology note dated 04/30/2026 at 1:00 AM, revealed visit details and a chief complaint of Depression. During the session, the patient stated that he has an eye appointment on 05/06 but is unsure about the planned procedures. He expressed that he is trying to remain hopeful about undergoing eye surgery soon, as he is currently being followed by his doctors. A safe and trusting therapeutic relationship was cultivated through empathetic listening and appropriate non-verbal communication, which contributed to increased patient comfort. Empathic reflection was used to mirror the patient's struggles to help [Resident #23] feel heard and accepted.A review of a [Provider Name] psychology note dated 04/09/2026 at 1:00 AM, revealed visit details and a chief complaint of Depression. The patient reported having an eye doctor appointment next week, stating, they found someone who will do my eye surgery apparently. The patient shared that he has been in the facility for over two years and is looking forward to being able to have a life again if the surgeon is successful in removing his cataracts. He stated that he is especially eager to be able to eat whatever food he wants after he is discharged . Active listening and reflection supported rapport building, which allowed the patient to share personal information more freely. The patient's expressed emotions were reflected within the session to aid in emotional processing.An interview was conducted on 06/17/2026 at 11:35 AM with Unit Manager (UM) J who stated the Director of Nursing (DON) and the Administrator were working together to reschedule Resident #23's appointment. UM J stated the Administrator would inform nursing, the unit manager, and transportation of any new appointments. When UM J was asked who communicated updates with the residents, UM J replied, the nurse. When UM J was asked whether Resident #23 been updated about the status of his eye appointment, she replied, The DON said she told [the resident].An interview was conducted on 06/17/2026 at 3:15 PM with the DON who was asked to explain what had occurred at the time of the 05/06/2026 eye appointment cancellation and between that date and today. The DON stated the problem was related to an insurance issue. Originally, the Social Services Director (SSD) was handling Resident #23's case. The DON took over after the SSD left the facility. A referral was needed and obtained. Resident #23 received an appointment, but the DON was unsure of the date. When she was asked who notified the resident that the appointment was cancelled, she stated at that time the facility had another Unit Manager who notified the resident. The reason for the cancellation was that Resident #23's insurance did not cover the procedure. He was asked if he wanted to pay out of pocket. The DON stated the resident's Nurse Practitioner said he needed a certain referral. The DON said the Nurse Practitioner checked when appointments were scheduled, Unit Manager J followed up behind her, and the facility scheduler checked and scheduled transportation.During an interview on 06/18/2026 at 12:54 PM, Resident#23 reported that he was able to see some things on the television, but he could not see well enough to read. He said he played bingo and the facility provided him with large print cards and books, but he could not read them. Resident #23 stated he felt as though his vision had worsened since he had been residing in the facility. I used to be able to stand in front of my TV and read and use a magnifying glass and read the menus out in the hallways, but I can't anymore. [Another resident] helps me with my menu. When asked if he was experiencing any new or worsening problems, he replied, Nothing new but it's getting worse. Some days it is worse than others. When he was asked if he was currently receiving therapy, he replied, No. Resident #23 recalled that two staff members came to his room yesterday to inform him of his eye appointment scheduled for 06/25/2026 at 12:15 PM. He stated, I can't make out their faces, and I don't have much interaction with the people here. I just know it was two females.An interview was conducted on 06/18/2026 at 1:05 PM with License Practical Nurse (LPN) E, who stated she had only been employed by the facility for four weeks. LPN E confirmed that Resident #23 was vision impaired and that she assisted him when needed. He mostly listened to his music and would ask her what time it was because he smoked. LPN E stated she was not aware of why Resident #23's eye appointment was cancelled.A review of the facility's policy and procedure titled Treatment/Devices to Maintain Hearing/Vision (dated 02/02/2026), revealed:Policy: It is the policy of the facility to ensure it identifies and provides needed care and services that are resident-centered, in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs. Procedure: 1. The facility will ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility will, if necessary, assist the resident: a. in making appointments, and b. by arranging for transportation to and from the office of a practitioner specializing in the provision of vision or hearing assistive devices.

Based on food service observations, staff interviews, facility documentation, and a review of the facility's policies and procedures, the facility failed to follow proper temperature documentation requirements for food safety to prevent bacterial growth and the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility. The facility failed to consistently monitor, verify, and document accurate operating temperatures and sanitizer concentrations for the mechanical dish machine. A malfunctioning dishwasher poses a significant health hazard. It can lead to bacterial cross-contamination and dangerous foodborne illness outbreaks. The findings include:A tour of the kitchen was conducted on 06/15/2026 at 11:20 AM. During the tour, Dietary Aide (DA) G demonstrated how the dish machine worked. He stated the final rinse should be 130 with a sanitizer concentration between 50 - 200 parts per million (ppm). Observation of the low-temperature dish machine sanitizer log from 06/10/2026 to 06/12/2026 and again on 06/15/2026 revealed consistent wash water temperatures (140 degrees) and sanitizer concentrations (200 ppm) across all recorded cycles. Further review of the low temperature dish machine sanitizer logs revealed identical concentration levels and water temperatures were recorded consistently across all operating days from 01/2026 through 06/9/2026. Test 1 of the dish machine revealed a final wash temperature of 162 and a sanitizer concentration between 50 - 100 parts per million (ppm). A subsequent test revealed a final wash temperature of 164 with a sanitizer concentration of 100 ppm. A review of the low temperature dish machine sanitizer log instructions revealed the minimum wash solution temperature must be 120 (49 C) or above and Chlorine concentration must be between 50-100 ppm. Dish machine temperature logs were found missing for a total of 32 specific dates, between 01/01/2026 and 6/14/2026. (Photographic evidence obtained)An interview was conducted on 06/18/2026 at 10:15 AM with Staffing Coordinator F. She was asked to explain the exact steps taken to measure and record dish machine temperatures. Employee F replied that she had never set the machine's temperature; however, she was aware that it must be at least 140 . If the temperature fell short, she would contact the manager to verify accuracy and log it. She further confirmed that she monitored the temperature between washes. Staffing Coordinator F stated she was unsure of whether the machine was a high-temperature or low-temperature dish machine. She stated she was unfamiliar with using chemical test strips to verify that the sanitizer reached the correct ppm.An interview was conducted on 06/18/2026 at 10:25 AM with Dietary Aide G who was asked to explain the exact steps for measuring and recording temperatures. Dietary Aide G replied, Plug the machine in, drain it, ensure it is clean, fill with water, run wash and rinse cycles to increase the temperature, check the gauge on the bottom to ensure 130 F - 140 F with 50 - 100 ppm, and log the temperature on the sheet. If the levels are too high or too low, the manager is informed. Dietary Aide G confirmed that there was no mixing of the sanitizer solution. It is already mixed for the machine. When asked if he was aware that intentionally logging temperatures or concentrations without taking the measurement was considered falsification of official records, he replied, I was not aware until now. I always thought the temperature should be a high temperature, so I documented a high temperature to ensure that it was documented rather than not documenting at all.An interview was conducted on 06/18/2026 at 10:42 AM with Certified Dietary Manager (CDM) I, who was asked to explain the exact steps for measuring and recording temperatures. He stated, The wash temperature must be at 120 - 140 , use the test strips and hold for 10 seconds to verify that the sanitizer reaches 50 - 100 ppm. If the levels are too high or too low, the manager is informed. Check the sanitizer container, contact maintenance or the service provider, shut the dish machine down, and switch to paper products until the issue is fixed. The chemical sanitizer concentration is tested at the beginning of every meal. When asked if he was aware that intentionally logging temperatures or concentrations without taking the measurement was considered falsification of official records, he replied, I am now. He was asked who was assigned to monitor when he was not working. He replied, the [NAME] or the Regional Manager.A review of the facility's policy and procedure titled, Ware Washing (undated), revealed: Policy Statement: It is the center policy that all dishware and service ware will be cleaned and sanitized after each use. Action Steps 1. The Dining Services Director ensures that the nutrition service staff is knowledgeable in proper technique for processing dirty dishware to clean through the dish machine and proper handling of sanitized dishware. 2. The Dining Services Director ensures that all the dish machine water temperatures are maintained in accordance with manufacturer recommendations for high temperature or low temperature machines. 3. The Dining Services Director is responsible for ensuring appropriate completion of temperature and/or sanitizer concentration logs as appropriate.

Based on record reviews, interviews and a review of the facility's policies and procedures, the facility failed to provide a Notice of Medicare Non-Coverage (NOMNC), CMS (Centers for Medicare and Medicaid Services) Form 10123, to three (Residents #11, #28 and #72) of three residents reviewed for Beneficiary Notices, at least two days before the end of a Medicare covered Part A stay or when all of Part B therapies ended. This failure denied the beneficiaries' right to an expedited review by a Quality Improvement Organization. The findings include:On [DATE] at 11:00 AM, during the facility's entrance conference with the Director of Nursing (DON) in person and with the Administrator via telephone, they were asked to complete the Beneficiary Notice - Residents discharged Within the Last Six Months survey worksheet. The worksheet instructions requested a list of residents who were discharged from a Medicare-covered Part A stay with benefit days remaining in the past six months. The worksheet instructions requested that the facility indicate if the resident was discharged home or remained in the facility, and a note on the worksheet asked that beneficiaries who received Medicare Part B services only, were covered under Medicare Advantage insurance, were expired, or were transferred to an acute care facility or another Skilled Nursing Facility (SNF) during the sample date range, be excluded.On [DATE] at 1:07 PM, the facility provided a list of 15 residents. A sample of three residents (#11, #28 and #72) was selected for review to evaluate the facility's compliance with the requirements to notify Medicare beneficiaries when the facility determined that Medicare Part A coverage was ending or when services would no longer be covered. SNF Beneficiary Protection Notification Review forms (Form CMS 20052) were initiated for each of the three sampled residents, and the forms were then provided to the DON to complete and provide evidence of a Notice of Medicare Non-Coverage (NOMNC) (CMS Form 10123) having been issued. On [DATE] at 1:38 PM, the DON returned the completed forms indicating that the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) had been issued to all three sampled residents, but the Notice of Medicare Non-Coverage (NOMNC) (CMS Form 10123) forms had not been issued. On [DATE] at 1:40 PM the DON was interviewed. She confirmed that it was not the facility's process to issue a NOMNC, only the SNF ABN. She was unable to explain the reason the NOMNC had not been provided to the sampled residents. She stated, I thought we went over this the last time.A review of Resident #11's record revealed an admission date of [DATE], with a discharge from Part A Services on [DATE]. The electronic medical record (EMR) did not contain evidence of a NOMNC CMS Form 10123 having been issued even though Part A benefits had not been exhausted. A review of Resident #28's record revealed an admission date of [DATE], with a discharge from Part A Services date of [DATE]. The EMR did not contain evidence of a NOMNC CMS Form 10123 having been issued even though Part A benefits had not been exhausted. A review of Resident #72's record revealed an admission date of [DATE], with a discharge from Part A Services on [DATE]. The EMR did not contain evidence of a NOMNC CMS Form 10123 having been issued even though Part A benefits had not been exhausted. On [DATE] at 2:04 PM, an interview was conducted with Business Office Manager/Human Resources Staff C, who confirmed that the facility had not issued a NOMNC to Residents #11, #28 or #72, although these residents had not exhausted their Part A benefits. She confirmed that she had recently been educated that the NOMNC should have been issued and moving forward, they would be issued as appropriate. On [DATE] at 9:06 AM an interview was conducted with the Administrator, who confirmed that the facility did not have a Social Services Director at this time. She also confirmed the facility had not issued a NOMNC to Residents #11, #28 or #72. She stated the facility was only required to issue the SNF ABN. She provided a policy and procedure titled Resident Right-Medicaid/Medicare Coverage/Liability Notice (Issued: [DATE]). The policy did not address the facility's responsibility to issue the NOMNC.The Administrator also provided a CMS document titled Notice Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123. (Undated), which read,A Medicare provider/plan (Medicare Advantage plans and cost plans, collectively referred to as plans) must deliver a completed copy of this notice to beneficiaries/enrollees receiving covered skilled nursing, home health, comprehensive outpatient rehabilitation facility, and hospice services. The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily.

Based on record reviews, interviews, and a review of the facility's policies and procedures, the facility failed to provide transfer/discharge notification to the Long-Term Care (LTC) Ombudsman's office prior to or as soon as practicable for three (Residents #11, # 28 and #72) of four residents reviewed for transfer/discharge. Appropriate notification of the LTC Ombudsman's office provides added protection for residents from being inappropriately transferred or discharged , provides residents with access to an advocate who can inform them of their options and rights, and ensures that the LTC Ombudsman's office is aware of facility practices and activities related to transfers and discharges. The findings include:A review of Resident #11's record revealed an admission date of 05/12/2026 and a discharge/transfer date of 06/04/2026. A review of the Nursing Home Transfer and Discharge Notice (AHCA Form 3120-0002) revealed that the section for Date Notice is Given was blank where a date should have been entered. The section for Effective Date was blank where a date should have been entered. The form noted that the resident went for procedure, kept at hospital for monitoring. The section of the form for Notice given to Local Long-Term Care Ombudsman Council was blank where a date should have been entered. There was no indication in the resident's record that the transfer/discharge form had been provided to the LTC Ombudsman's office as required. A review of Resident #28's record revealed an admission date of 05/23/2020 and a discharge/transfer date of 01/30/2026. A review of the Nursing Home Transfer and Discharge Notice (AHCA Form 3120-0002) revealed that the section for Date Notice is Given was blank where a date should have been entered. The section for Effective Date was blank where a date should have been entered. The form was checked off indicating, Your needs cannot be met in this facility. The section of the form for Notice given to Local Long-Term Care Ombudsman Council was blank where a date should have been entered. There was no indication in the resident's record that the transfer/discharge form had been provided to the LTC Ombudsman's office as required. A review of Resident #72's record revealed an admission date of 04/30/2026 and a discharge/transfer date of 5/28/2026. A review of the Nursing Home Transfer and Discharge Notice (AHCA Form 3120-0002) revealed that the notice was given on 05/28/2026, with an effective date 05/28/2026. The form was checked off indicating, Your health has improved sufficiently so that you no longer need the services provided by this facility. The section of the form for Notice given to Local Long-Term Care Ombudsman Council was blank where a date should have been entered. There was no indication in the resident's record that the transfer/discharge form had been provided to the LTC Ombudsman's office as required. On 06/18/2026 at 10:27 AM, an interview was conducted with the Administrator. She was asked who was responsible for providing transfer/discharge notifications to the LTC Ombudsman's Office. She replied that it was a collection between herself, the Director of Nursing (DON) and the Social Services Director (SSD); however, the SSD position was currently vacant. She said she was not sure of whether the actual transfer/discharge forms had been sent to the Ombudsman's office, but she could verify that emails were sent indicating which residents had been transferred/discharged . I just sent an email last week on a whole lot of discharges, and [contact name] over at the Ombudsman's office said that would be fine.A review of the e-mail communication provided by the Administrator and dated 06/15/2026 to the District Ombudsman Manager read, Enclosed are the discharges. I am currently in transition with the Social Services Director position and am submitting all discharges that have occurred since January 2026 to ensure submissions. The e-mail included the facility's Admission/Discharge To/From Report for 01/01/2026 through 05/30/2026. There was no evidence that copies of the individual transfer/discharge forms were provided to the Ombudsman's office.On 06/18/2026 at 3:15 PM, an email received from the Ombudsman's office confirmed their office had not received copies of the actual transfer/discharge forms for Resident's #11, #28 or #72. A review of the facility's policy and procedure titled Transfer and Discharge (including AMA (against medical advice) - (Effective: 11/3/2020), revealed:Policy Explanation and Compliance Guidelines:5) Generally, the notice must be provided at least 30 days prior to a facility-initiated transfer or a discharge of the residents. Exceptions to the 30-day requirement apply when the transfer or discharge is affected because: a. The health and/or safety of individuals in the facility would be endangered due to the clinical or behavioral status of the resident; b. The resident's health improves sufficiently to allow a more immediate transfer or discharge; c. An immediate transfer or discharge is required by the resident's urgent medical needs; or d. A resident has not resided in the facility for 30 days.6) In these exceptional cases, the notice must be provided to the resident, resident's representative if appropriate, and the LTC Ombudsman as soon as practicable before the transfer or discharge.7) The facility will maintain evidence that the notice was sent to the Ombudsman.

Based on record reviews, observations, staff interviews and a review of the facility's policies and procedures, the facility failed to ensure that residents who required respiratory therapy received such care, consistent with professional standards of practice, for two (Residents #1 and #13) of eleven residents on oxygen therapy. Residents #1 and #13 were not receiving oxygen at the flow rate ordered by their physicians. Oxygen not administered as per the physicians' orders can lead to hypoxia (too little oxygen) or oxygen toxicity (lung and cellular damage). The findings include: 1. On 6/15/26 at 12:47 PM upon entering Resident #1's room, he was observed in bed with his eyes closed wearing his nasal cannula. He did not respond when greeted. His oxygen concentrator was running and infusing oxygen at a flow rate of three liters per minute. (Photographic evidence obtained) On 6/16/26 at 11:36 AM upon entering Resident #1's room, he was observed wearing his nasal cannula. His oxygen concentrator was infusing oxygen at a flow rate of 2.5 liters per minute. (Photographic evidence obtained) On 6/17/26 at 12:42 PM upon entering Resident #1's room, he was observed wearing his nasal cannula with oxygen infusing at 2.5 liters per minute via his oxygen concentrator. (Photographic evidence obtained) A review of Resident #1's medical record found an order dated 1/21/26 for oxygen to be set at a flow rate of two liters per minute via nasal cannula as needed. Oxygen was to be administered as needed for shortness of breath and/or when the resident's oxygen saturation level was less than 90%. A review of Resident #1's active care plans revealed a focus area for respiratory complications related to a history of respiratory infection and ascites (abnormal buildup of fluid in the abdomen - symptoms include shortness of breath due to pressure on the diaphragm). The care plan was initiated on 9/22/25 and revised on 2/9/26. On 6/17/2026 at 1:45 PM, Licensed Practical Nurse (LPN) K was interviewed and stated when she completed her rounds, she checked the oxygen settings for residents who received supplemental oxygen. She further stated if the resident's orders were incorrect, she would call the physician to validate the orders. She stated she thought Resident #1 was to receive oxygen continuously. LPN K reviewed Resident #1's physician's orders and confirmed that he was to receive oxygen as needed and not continuously. She confirmed that his oxygen flow rate should be set at two liters per minute. LPN K was accompanied to Resident #1's room at 1:55 PM. She observed the resident, his oxygen concentrator and the concentrator's oxygen flow rate. Resident #1 was in bed wearing his nasal cannula with oxygen infusing at 2.5 liters per minute. LPN K confirmed that the flow rate setting on the concentrator was incorrect. A review of the facility's policy and procedure titled Oxygen Administration (effective 2/1/2026), revealed: Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under orders of a physician, except in the case of an emergency. In such cases, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. 2.On 6/15/26 at 2:25 PM, Resident #13 was observed lying in bed, alert, awake and wearing his nasal cannula (NC). His oxygen concentrator was infusing oxygen at 2 liters per minute (L/min). (Photographic evidence obtained) On 6/17/26 at 9:13 AM, LPN E confirmed that Resident #13's physician prescribed oxygen at 3L/min. LPN E stated the prescribed order and oxygen concentrator setting were verified during bedside shift report. At 11:00 AM, Resident #13 was again observed in bed wearing his NC with the oxygen concentrator's oxygen flow rate set at 2L/min. (Photographic evidence obtained) A review of the resident's electronic medical record (EMR) revealed current oxygen orders for Oxygen at 3L/min via NC, every shift for shortness of breath, initiated on 5/13/26. A review of Resident #13's medical record revealed an admission date of 5/13/26. Diagnoses included chronic obstructive pulmonary disease (COPD), atelectasis (partial or complete collapse of a lung or part of a lung), pleural effusion (buildup of excess fluid in the pleural space (thin, fluid-filled potential space between the two membranes that surround the lungs), pulmonary edema (excess fluid in the lungs), aspiration pneumonia (infection of the lungs caused by accidentally inhaling foreign materials), and chronic respiratory failure on oxygen. A review of most recent Minimum Data Set (MDS) assessment, dated 5/4/26, revealed that Resident #13 received oxygen continuously. A review of the care plan focuses and goals, dated 5/7/26, indicated that Resident #13 received oxygen therapy and would have no signs or symptoms of poor oxygenation absorption through the next review date. Interventions included: Administer oxygen per MD (physician's) orders; oxygen settings as ordered. A review of the resident's May and June 2026 Medication Administration Record (MAR) revealed the resident was receiving Oxygen at 3L/min via NC, every shift for shortness of breath per the 5/13/26 physician's order. A review of a Provider Progress Note dated 6/10/26 and authored by the resident's physician revealed that the resident required supplemental oxygen due to chronic respiratory failure. On 6/17/26 at 11:05 AM, LPN was accompanied to Resident #13's room. LPN E confirmed that the resident's oxygen concentrator was set with an oxygen flow rate of 2L/min. LPN E stated the current physician's order for Resident #13's oxygen instructed that he be administered oxygen at a flow rate of 3 L/min. The resident's oxygen flow rate was adjusted by LPN E to align with the physician's order of 3 L/min. On 6/17/26 at 3:30 PM, the Director of Nursing (DON) stated oxygen orders were to be carried out per the physician's order and verified during bedside shift report.

Based on observation, interview, and record review, the facility failed to ensure proper sanitation and food storage practices were adhered to in order to prevent the outbreak of foodborne illnesses. The findings include: During an initial tour of the kitchen with the Certified Dietary Manager on 9/23/2024, beginning at 11:00 AM, the following was observed: Three (3) salads prepared on individual plates with no date or label in reach in refrigerator #1. Two (2) undated cut halves of honey dew melon, 2 undated cut quarter slices of honey dew melon and 1 undated cut half of a watermelon without dates stored in the produce refrigerator. One (1) undated and unlabeled bag of diced vegetables stored in the produce refrigerator. Five (5) undated and unlabeled 5-ounce containers of pureed fruit in the pastry freezer. One (1) uncovered, undated and unlabeled picture of a red drink. Two (2) undated and unlabeled pitchers of beverages stored underneath raw meat products in the meat freezer. During an interview on 9/23/2024 beginning at 11:00 AM, the Certified Dietary Manager acknowledged not all food items stored in the kitchen were labeled and dated. She confirmed all food items should be labeled, dated and covered. She confirmed beverages should not be stored underneath raw meat products. Documentation provided by the facility related to facility practices of storage for Temperature Control for Safety (TCS) Foods, undated, read, Labeling and storing of TCS food correctly ensures our ingredients are safe to use in food served to our customers. All TCS food we prepare and keep for over 24 hours must be labeled and used within 7 days. The document continued Transfer or rewrite labels with the original Use By date from the first container if you move labeled items to different containers. Put Ready-to-Eat food on top, raw meat and fish below and raw poultry on bottom.

Based on observation, interview, and policy and procedure review, the facility failed to maintain an infection prevention and control program designed to help prevent the transmission of communicable diseases and infection, by 1) failing to perform appropriate hand hygiene during medication administration for four (Residents #51, #80, #238, and #71) of eight residents observed for medication administration, and 2) failed to follow acceptable standards of care for enhanced barrier precautions for a central venous catheter for one (Resident #237) resident during medication administration from a total survey sample of 37 residents. Failure to follow proper infection control standards increases the risk of adverse health outcomes for facility residents, staff, and other facility occupants. The findings include: 1. During an observation of medication administration on 9/23/2024 at 12:03 PM, Staff B, Registered Nurse (RN), returned to the medication cart from the nurses station, removed medication cart keys from their pocket, unlocked the medication cart, activated the computer and typed on the computer. Then Staff B, RN removed insulin from the medication cart, and went to Resident #51's room, entered the room without performing hand hygiene, did not don gloves and administered insulin to Resident #51. Exited the residents room and returned to the medication cart without performing hand hygiene. During an interview on 9/23/2024 at 12:08 PM, Staff B, RN stated, I don't know why I didn't wash my hands or put gloves on. I guess you just make me nervous. I should have done that, I should have washed my hands and put on gloves before I gave him (Resident #51) the insulin. During an observation of medication administration on 9/24/2024 at 8:05 AM, Staff A, Licensed Practical Nurse (LPN) returned to the medication cart from a residents room, reached into pocket for keys unlocked the medication cart and began to prepare medications for Resident #80 without performing hand hygiene. Staff A entered Resident #80's room without performing hand hygiene and administered medications to the resident. Staff A exited the room without performing hand hygiene and returned to the medication cart. During an observation of medication administration on 9/24/2024 at 8:23 AM, Staff A, LPN returned to the medication cart, reached into pocket removed keys and unlocked the medication cart, Staff A prepared medications for Resident #238 without performing hand hygiene, entered Resident #238's room without performing hand hygiene, administered medications to the resident and exited the room returning to the medication cart and began preparing another residents medications without performing hand hygiene. During an interview on 9/24/2024 at 8:28 AM, Staff A, LPN stated, I should have washed my hands, I'm not sure why I didn't, I guess I was just nervous. During an observation of medication administration on 9/24/2024 at 9:00 AM, Staff A, LPN returned to the medication cart from the nurses station, reached in her pocket, removed keys, unlocked the medication cart, activated the computer and typed on the computer keyboard. Staff A prepared medications for Resident #71 without performing hand hygiene, entered Resident #71's room without performing hand hygiene and administered Resident #71's medications. Staff A exited the residents room and returned to the medication cart without performing hand hygiene. 2. During an observation of medication administration on 9/24/2024 at 1:27 PM there was enhanced barrier precautions signage on Resident #237's doorway, but there was no personal protective equipment of gowns available either inside or outside of the room. Staff E, LPN assembled all supplies to administer an Intravenous (IV) antibiotic and prepared the IV antibiotic to infuse. Staff did not perform hand hygiene and donned gloves; staff did not don a gown. Staff E went to cleanse the needleless connector and there was no needleless connector on the Peripherally inserted central catheter. Staff E, LPN reached into pocket with gloved hand and got a needleless connector attached it to the peripherally inserted catheter and administered 5 milliliters of normal saline without cleansing the needleless connector with alcohol and attached the intravenous tubing and began to infuse the antibiotic. During an interview on 9/24/2024 at 1:38 PM, Staff E, LPN stated, I should have washed my hands before I put my gloves on. He is on enhanced barrier precautions so I should have also had on a gown. I'm not sure why I didn't do these things. During an interview on 9/24/2024 at 2:05 PM, the Director of Nursing stated,I expect all staff will follow our infection control policies for hand washing and enhanced barrier precautions. Review of the policy and procedure titled, Medication Administration last approval date of 1/25/2024 reads, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy explanation and compliance guidelines: 4. Wash hands prior to administering medication per facility policy. Review of the policy and procedure titled, Hand Hygiene last approval date of 1/25/2024 reads, Policy: Staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Policy explanation and compliance guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. Hand hygiene table documents: Between resident contacts; Before applying and after removing personal protective equipment (PPE) including gloves; and before preparing or handling medications. Review of the policy and procedure titled Flushing midline and central line IV catheters last approval date of 1/25/2024 reads, Procedure: 1. Perform hand antisepsis. [NAME] non-sterile gloves. 2. Disinfect needleless connection device with antiseptic solution.

Based on observation and interview, the facility failed to provide a safe, functional, and comfortable environment for residents, by not ensuring proper repair of hand rails in the north and south wings of the facility. The findings include: During an observation on 9/23/2024 at 11:59 AM of railings on South [NAME] wing, four caps were observed missing off of the end of the railing in the hall. The opened area of the rail was observed to have jagged metal exposed. During an observation on 9/24/2024 at 11:10 AM of railings on North [NAME] wing, three caps were observed missing off of the end of the railing in the hall. The opened area of the rail was observed to have jagged metal exposed. During an observation on 9/24/2024 at 11:40 AM with the Director of Maintenance, he confirmed the railings in South [NAME] and North [NAME] wing had missing caps with jagged metal exposed. During an interview with the Administrator on 9/24/2024 at 1:17 PM, the administrator stated, I know all of these need to be fixed. Review of the facilities policy and procedure titled Safe and Homelike Environment dated 1/25/2024 read In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment . This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk .3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment.

Based on interview and record review, the facility failed to ensure that residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition were referred for a Level II evaluation and examination for two (Residents #67 and #60) of 37 residents sampled for Preadmission Screening and Resident Review (PASARR). The findings include: 1. Review of Resident #67's PASARR dated 5/10/22 documented a negative Level 1 with no mental illness or intellectual disability listed. Review of the admission record for Resident #67 revealed an initial admitted [DATE] and a re-admitted [DATE]. Diagnosis listed on the admission record included other specified anxiety disorders dated 5/5/23. Review of the psychiatry note for Resident #67 dated 7/10/23 read, This is a [AGE] year-old patient with past history of anxiety and insomnia. On 5/5/23 patient was anxious. Patient was presented with compulsive behaviors of touching and playing with stomach. Patient reported itching around the site. Presented increased or worsening depression. Started Sertraline at 50 mg QD (milligrams every day) for anxiety and Hydroxyzine at 10 mg Q12H PRN (milligrams every 12 hours as needed) for anxiety and itching. DX (diagnosis): Other specified anxiety disorders. Review of the minimum data set quarterly assessment dated [DATE] documented Resident #67 active diagnosis included anxiety disorder and psychotic disorder. Review of Resident #67's clinical record failed to show documentation that the resident had been referred for a Level II PASARR evaluation following the diagnosis of other specified anxiety disorders on 5/5/23. During an interview on 9/24/24 at 1:17 PM, the Director of Nursing confirmed the facility should have done a new screening when the resident received the new diagnosis. 15234 2. Review of Resident #60's Level I PASARR screening, dated 12/20/2022, showed anxiety disorder and depressive disorder documented in Section I: PASRR Screen Decision-Making A. MI [Mental Illness] (check all that apply). Review of Resident #60's admission record, initial date of admission 12/13/2022, revealed Resident #60 had diagnoses that included other bipolar disorder, onset date 12/13/2022 and brief psychotic disorder, on set date 3/6/2023. Review of Resident #60's clinical records failed to show documentation Resident #60 had been referred for a Level II PASARR evaluation following the diagnoses of other bipolar disorder, onset date 12/13/2022 and brief psychotic disorder, on set date 3/6/2023. During an interview on 9/24/2024 at 2:10 PM, the Director of Nursing confirmed Resident #60 had not been referred for a Level II PASARR after he was identified with a newly evident or possible serious mental disorder. Review of the policy titled, Resident Assessment - Coordination with PASARR Program, date reviewed, 9/18/2023, read, Policy: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidelines: 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or related condition will be referred promptly to the state mental health and intellectual disability authority for level 2 resident review. Examples include: a. A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder (where dementia is not the primary diagnosis) b. A resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR.

Based on interview and record review, the facility failed to ensure each resident was screened for a mental disorder or intellectual disability prior to admission to ensure those individual identified with mental disorders or intellectual disabilities are evaluated and receive care and services in the most appropriate setting for one (Resident #4) out of 37 residents sampled for Preadmission Screening and Resident Review (PASARR). The findings include: Review of the admission record for Resident #4 documented an initial admitted [DATE] with readmitted s following hospital stays on 12/28/23 and 3/29/24. Diagnoses included cerebral palsy unspecified (onset date 1/2/2018), generalized anxiety disorder (onset date 10/26/2020), bipolar disorder unspecified (onset date 1/2/2018), and major depressive disorder (onset date 5/20/2022). Review of the PASARR Level 1 screening for Resident #4 dated 12/28/2023 did not document anxiety disorder, bipolar disorder, depressive disorder or a related condition of cerebral palsy. The Level I screening for Resident #4 documented on page 5: No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASARR evaluation not required. Review of the Minimum Data Set Annual Assessment for Resident #4 dated 6/17/2023, Section I documented the resident has cerebral palsy, anxiety disorder, depression and bipolar disorder. It further documented the resident is taking antipsychotic and antidepressant medication, the antipsychotic is received on a routine basis, and a gradual dose reduction (GDR) has not been attempted. During an interview on 9/24/2024 at 3:10 PM, the Director of Nursing stated that the Level 1 Preadmission Screening and Resident Review (PASARR) for [Resident #4's Name] was not accurate. Review of the policy titled Resident Assessment - Coordination with PASARR Program, date reviewed, 9/18/2023, read, Policy: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs.

Based on observation, interview, and record review, the facility staff failed to provide central venous catheter dressing changes as ordered in accordance with professional standards of practice for one (Resident # 237) out of one resident reviewed with a peripherally inserted central catheter, out of a total sample of 37 residents. The findings include: During an observation on 9/23/2024 at 10:25 AM, Resident #237 was sitting in bed with a right arm single lumen peripherally inserted central catheter (PICC) line. The transparent dressing was lifting up at the edges, exposing the insertion site. The date on the dressing was 9/10/2024. During an interview on 9/23/2024 at 10:30 AM, Resident #237 stated, They have not changed this (the PICC line dressing) since I was admitted , I get antibiotics for a blood infection. I have not been offered a dressing change. During an observation on 9/23/2024 at 2:30 PM, Resident # 237 was observed sitting up in bed with a right upper arm single lumen PICC line with date of 9/10/2024 on the transparent dressing, with the edges of dressing lifting up exposing the insertion site. Review of the admission record documented that Resident #237 was admitted to the facility on [DATE] with the following diagnoses: Sepsis due to enterococcus (a life-threatening condition that occurs when the body's immune system has an extreme response to an infection or injury), Type 2 diabetes mellitus with hyperglycemia (high blood glucose), and essential (primary) hypertension. Review of Resident #237's physician orders dated 9/20/2024 reads, Change central line catheter site dressing every week with only transparent dressing. Change needleless access device every day shift every fri (Friday). Review of Resident #237's physician orders from 9/12/2024 through 9/24/2024 revealed there were no orders for central line catheter site dressings changes prior to 9/20/2024. During an observation of medication administration for Resident #237 on 9/24/2024 at 1:27 PM, Staff E, Licensed Practical Nurse (LPN) flushed the right upper arm PICC Line with 5 milliliters of normal saline. Staff E, LPN did not verify PICC line placement by aspirating to check for blood return prior to administering the normal saline and did not use a push-pause motion when administering the normal saline flush. During an interview on 9/24/2024 at 1:38 PM with Staff E, LPN, she stated, I did take care of him (Resident #237) after the 17th, I did not change his dressing or check it, I should have, all PICC lines get changed every 7 days, so his dressing should have been changed on September 17th. He has not refused to have his dressing changed, because I didn't ask to change it when I took care of him. I should have checked for placement by verifying whether it had a blood return. I did not use a push pause when I flushed his line. We should check whether a dressing is current every day when we flush the line or give the antibiotic. During an interview on 9/24/2024 at 2:04 PM, the Director of Nursing (DON) stated, All midline or PICC line dressings get changed every week. We should have changed his (Resident #237) dressing on the 17th. I 'm not sure why it was not completed. We don't need an order to change the dressing, it would be a standard of care to change it every 7 days at least, more often if it needs it. Review of the policy and procedure titled Central Venous Catheter Dressing Changes last review date of 1/25/2024 reads, Policy: Central venous catheter dressings will be changed at specific intervals, or when needed, to prevent catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings, Preparation: 2. A physicians order is not needed for the procedure, General guidelines: 1. Apply and maintain sterile dressing on intravenous access devices. Dressings must stay clean, dry, and intact. 5. Change transparent semi-permeable membrane (TSM) dressings every 5 to 7 days and PRN (when wet, soiled, or not intact). Review of the policy and procedure titled Flushing Midline and Central line IV catheters last review date of 1/25/2024 reads, Policy: Midline and central line IV catheters (CVAD's) will be flushed to maintain patency; to prevent mixing of incompatible medications and solutions; and to ensure entire dose of medication is administered into the venous system. Flushing Technique: 2. Use a push-pause motion or pulsing motion for flushing technique. 3. Aspirate the CVAD catheter for blood return to confirm patency prior to administration of medication and solutions. Procedure: Flushing to maintain patency of catheter: 4. Aspirate slowly for blood return to ensure patency of catheter.

Based on observation, interview, and record review, the facility staff failed to ensure that oxygen was administered consistent with professional standards of practice for two (Residents #80 and #187) out of four residents reviewed for respiratory care, from a total of 37 residents sampled. The findings include: 1. Review of Resident #80's admission record revealed the following diagnoses: cerebral infarction, unspecified (a stroke), acute respiratory failure with hypoxia (low levels of oxygen in the blood), acute pulmonary edema (fluid in the lungs), essential (primary) hypertension (high blood pressure), major depressive disorder, hypothyroidism, unspecified, and hemiplegia (paralysis of one side of the body), unspecified affecting right dominant side. Review of Resident #80's physician orders dated 4/8/24 reads, Oxygen at 2 liters/ min (minute) via nasal cannula with Humidification PRN (pro re nata) [as needed]-to keep O2 (oxygen) sat (saturation) above 90% as needed for SOB (shortness of breath). Review of Resident #80's nursing progress notes from 9/16/2024 through 9/24/24 revealed there was no documentation related to change of condition or need to increase oxygen. During an observation on 9/23/24 at 11:34 AM, Resident #80 was observed sitting at bedside in a wheelchair with oxygen being administered via nasal cannula. The oxygen concentrator was administering oxygen at 3.5 liters with no humidification. The oxygen concentrator was across the room from the resident and out of the reach of the resident. During an observation on 9/24/24 at 7:23 AM, Resident #80 was observed in bed, with the oxygen concentrator at the head of the bed outside of the reach of the resident. The oxygen concentrator was administering oxygen at 3 liters nasal cannula with no humidification. During an interview on 9/24/24 at 7:25 AM, Resident #80 stated, I cannot reach that (the oxygen concentrator), I don't try to change the oxygen, the nurses do that. During an interview on 9/24/24 at 8:00 AM, Staff A, LPN stated, The oxygen should be at 2 liters, I'm not sure how it's at 3 liters. I will need to change that. No, there is no humidification, I have to see the order to see if she needs that. We should be checking what the rate of oxygen at least once a shift. We do walking rounds; I did not check the oxygen when I did them today. During an interview on 9/24/24 at 12:19 PM, the Director of Nursing (DON) stated, I expect staff to assess residents on oxygen at a minimum daily and make sure that we are following the orders for correct oxygen administration. 34769 2. During an observation on 9/23/24 at 12:31 PM, Resident #187 was receiving oxygen from a concentrator via a nasal cannula. The concentrator was set at 4 liters and the humidification bottle was wrapped in plastic, empty, and was not hooked up to the concentrator. During an interview on 9/23/24 at 12:41 PM, Resident #187 confirmed that 4 liters of oxygen was correct. Review of the admission record for Resident #187 revealed the resident was admitted on [DATE] with diagnosis that included: Chronic Obstructive Pulmonary Disease With (Acute) Exacerbation, Acute Respiratory Failure With Hypoxia and Acute Respiratory Failure With Hypercapnia (elevated level of carbon dioxide in the blood). Review of the physician orders for Resident #187 dated 9/3/24 read Oxygen at 2 liters/min (minute) via nasal cannula, humidification: Yes. During an observation on 9/24/24 at 8:38 AM, Resident #187 was receiving oxygen from a concentrator via a nasal cannula. The concentrator was set at 2.5 liters and the humidification bottle was wrapped in plastic, empty, and was not hooked up to the concentrator. During an interview on 9/24/24 at 3:14 PM, with Staff D, Registered Nurse regarding his observation of Resident #4's concentrator, he stated, The humidification is not connected. The liters are currently slightly above 2 liters. [Resident #187's name] had previously told the therapist that his oxygen was to be set on 4 but she stated that she corrected him. When asked what the physician orders were for Resident #187, he stated, The order is for 2 liters with humidification. Review of the policy and procedure titled Oxygen Administration last date revised 5/4/2022, last approval date of 1/25/2024 reads, Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Policy explanations and compliance guidelines: 1. Oxygen is administered under orders of a physician. Except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in a secured manner to limit unauthorized access to medications for three (Residents #78, #74, and #6) out of six residents reviewed for medication storage. The findings include: 1. During an observation on 9/23/2024 at 12:24 PM of Resident #78's room, one bottle of Tylenol PM (acetaminophen 500 milligrams (mg)) and diphenhydramine HCL 25 mg was sitting on dressing table unsecured. During an interview on 9/23/2024 at 12:24 PM Resident #78 stated I take one tablet every night and they know that I have it and take it. During an observation on 9/23/2024 at 2:50 PM of Resident #78's room, one bottle of Tylenol PM (acetaminophen 500 milligrams (mg)) and diphenhydramine HCL 25 mg was sitting on dressing table unsecured. During an observation on 9/24/2024 at 07:55 AM of Resident #78's room one bottle of Tylenol PM (acetaminophen 500 milligrams (mg)) and diphenhydramine HCL 25 mg was sitting on dressing table unsecured. During an observation in Resident #78's room on 9/24/2024 at 1:38 PM with Staff A, License Practical Nurse (LPN), one bottle of Tylenol PM (acetaminophen 500 milligrams (mg)) and diphenhydramine HCL 25 mg was sitting on dressing table unsecured. During an observation in Resident #78's room on 9/24/2024 at 1:42 PM with Staff C, LPN, one bottle of Tylenol PM (acetaminophen 500 milligrams (mg)) and diphenhydramine HCL 25 mg was sitting on dressing table unsecured. 2. During an observation on 9/23/2024 at 12:41 PM of Resident #74's room, one tube of Zinc ointment 20% was lying on the dresser. During an interview on 9/23/2024 at 12:41 PM with Resident #74, the resident stated, I don't know what that is or what it's for. During an observation on 9/24/2024 at 8:58 AM of Resident #74's room, one tube of Zinc ointment 20% was lying on the dresser unsecured. During an observation on 9/24/2024 at 1:38 PM of Resident #74's room, one tube of Zinc ointment 20% was lying on the dresser unsecured. During an observation in Resident #74's room on 9/24/20924 at 01:38 PM with Staff A, LPN, one tube of Zinc ointment 20% was lying on the dresser unsecured. During an observation on 9/24/2024 at 01:42 PM with Staff C, LPN of Resident #74's room, one tube of Zinc ointment 20% lying on the dresser unsecured 3. During an observation on 9/23/2024 at 12:58 PM of Resident #6's room, one tube of Muscle rub menthol 2% ointment was on the bedside table unsecured. During an interview on 9/23/2024 at 12:58 PM with Resident #6, the resident stated, My friend comes in and will rub the cream anywhere that I hurt. During an observation on 9/24/2024 at 8:58 PM of Resident #6's room, one tube of Muscle rub menthol 2% was lying on the dresser unsecured. During an observation in Resident # 6's room on 9/24/20924 at 1:38 PM with Staff A, LPN, one tube of Muscle rub menthol 2% was on bedside table unsecured. During an observation in Resident # 6's room on 9/24/2024 at 1:42 PM with Staff C, LPN, one tube of Muscle rub menthol 2% on bedside table unsecured. During an interview on 9/24/2024 at 1:38 PM with Staff A, LPN, she stated, Medication cannot be at the bedside or the residents rooms. All medications has to be locked in the medication cart and a physician must write an order for self-administration. During an interview on 9/24/2024 at 1:45 PM with Staff C, LPN, she stated, Medication cannot be in the room unsecured. All medication must be secured in the medication cart. During an interview on 9/24/2024 at 1:58 PM with the Director of Nursing (DON), the DON stated, Medications are to be secured. No medications are to be in the residents rooms unsecured. All medications are to be locked in the medication cart. Review of facilities policy and procedure titled Medication Storage dated 01/25/2024 read It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and or medications=rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security .a. All drugs and biologicals will be stored in locked compartments (i.e. medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls . c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. (Photographic evidence obtained)

Based on observation, resident and staff interviews, clinical record reviews and facility policy and procedure review, the facility failed to ensure that it accurately documented interventions for wound care for one (Resident #3) of three residents reviewed for wound care. Failure to document accurately in the clinical record can result in inaccurate assessment of needs, and medical complications, thereby increasing the potential for delays and errors in medical treatment and putting the resident at risk for not receiving proper treatment. The findings include: A review of Resident #3's clinical record revealed she was admitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Copy obtained) On 02/25/22 at 8:32 AM, Resident #3 was observed wearing a pink sock on her left foot that was stained with a yellowish hue. When she was asked if she had a wound on the foot, she replied, Yes. When she was asked if the dressing was changed yesterday, she replied, No, they do not come unless I ask. As Resident #3 removed her sock, a wound dressing appeared with gauze and tape that was marked 02/20/22. During this observation, Employee B, Licensed Practical Nurse (LPN)/Wound Care (WC) entered the resident's room. Employee B, LPN/WC was asked to read the date on the wound dressing. After looking at the date on the wound dressing, she said, 02/20/22. She confirmed that if the dressing change was ordered to be changed daily, then there was a problem. A review of the Quarterly Minimum Data Set (MDS) assessment, dated 01/19/22, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. A review of the care plan for Resident #3 revealed the resident has potential for pressure ulcer development related to limited/impaired mobility. Goal: will have intact skin, free of redness, blisters, or discoloration through review date. Interventions included: administer treatments as ordered and monitor for effectiveness. Follow facility policies/protocols for prevention of skin breakdown. A review of the February 2022 Treatment Administration Record (TAR) for Resident #3 revealed an order to wash arch of left foot with normal saline pat dry apply [MEDICATION(S)]-soaked gauze skin prep to peri wound wrap with stretch gauze every day, every night. Further review of the TAR revealed Resident #3 was documented as receiving her wound care as follows: 02/21/22 - documented as resident refused 02/22/22 - documented as completed 02/23/22 - documented as completed 02/24/22 - documented as completed During an interview with the Director of Nursing (DON) on 02/25/22 at 12:00 PM, she confirmed that Employee A, LPN initials were documented on the TAR on 02/24/22 indicating that Resident #3's wound dressing change was completed to her left heel. The DON also confirmed that Employee C, RN/LPN initials were documented on the TAR on 02/22 and 02/23/22, that she had completed the wound intervention for Resident #3. An attempt to interview Employee C, RN/LPN by telephone was made on 02/25/22 at 12:15 PM. Employee C, RN/LPN did not answer the phone, the employee was requested to return a call as part of the survey process. Employee C, RN/LPN did not return a call at the time of the survey completed date. The DON did confirm that it was Employee C, LPN who documented two wound dressing changes completed on 02/22 and 02/23/22 by reviewing the TAR. A telephone interview was conducted with Employee A, LPN on 02/25/22 at 12:19 PM. She confirmed she worked with Resident #3 on 02/24/22 and documented that she completed the physician ordered intervention Wash arch of left foot with normal saline pat dry apply [MEDICATION(S)]-soaked gauze skin prep to peri wound wrap with stretch gauze every day-every evening shift. She confirmed that she did not complete the intervention but was told by another nurse that the wound dressing was changed. She understood that she documented an intervention that she did not complete. A review of the facility's policy and procedure titled, Pressure Injury Prevention and Management read: Policy: To minimize the risk of the formation of pressure injuries and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions. 2. Interventions for Prevention and to promote healing indicated at line B) (i) Evidence-based interventions for prevention will be implemented for residents who are assessed at risk or who have pressure injury present. (Copy obtained) A review of the facility's policy and procedure titled, Documentation of Wound Treatments read: Policy: The facility completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition, and changes in treatment. Line 3. Wound treatments are documented at the time of each treatment. (Copy obtained)

Based on observation, interviews, record review and facility policy review, the facility failed to ensure residents received care and treatment in accordance with professional standards of practice, by failing to ensure physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Review of Resident #1's medical record revealed the resident was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's annual minimum data set (MDS) with an assessment date of 8/2/21 revealed a brief interview for mental status (BIMS) score of 15, indicating cognitively intact. Review of the resident's care plan indicated he had Diabetes Mellitus (DM). Interventions included administer diabetes medication/insulin as ordered/if ordered by doctor and monitor/document for side effects and effectiveness if appropriate. During an interview with Resident #1 on 10/19/21 at 10:11 AM, he stated that ever since he had Ketoacidosis (a serious complication of diabetes that occurs when your body produces high levels of blood acids called ketones) in March and was hospitalized , he's been managing his diabetes better. Further review of Resident #1's clinical record, including his Medication Administration Records (MARs) for August, September, and October 2021 revealed the following current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] Kwik Pen 100 Unit/ML Solution pen-injector inject as per sliding scale: if 0-70 = 0 <70 give OJ if alert, if not alert give [MEDICATION(S)] per order. retest BS notify MD; 71-150 = 0; 151-200 = 3; 201-250 = 5; 251-300 = 8; 301-400 =10; 401-999 = 12 if >350 five 12 units, retest BS, if <350 call MD, subcutaneously before meals and at bedtime for DM. Upon further review, the facility failed to follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] August 2021: missing documentation on 8/28/21 at 2100. September 2021: missing documentation on 9/17/21 at 0630 & 9/29/21 at 0630. October 2021: missing documentation on 10/3/21 at 0630, 10/8/21 at 0630, 10/13/21 at 0630 and 10/19/21 at 1130. (Copy obtained) During a second interview with Resident #1 on 10/19/21 at 12:50 PM, he indicated that he did not receive his blood glucose check prior to eating his lunch. When he was asked if he refused his blood glucose check before getting his lunch today, he said, No, I did not refuse it. An interview was conducted with Employee A, Licensed Practical Nurse (LPN) on 10/19/21 at 1:36 PM, who was the nurse assigned to Resident #1. She confirmed that she did not check Resident #1's blood sugar level prior to his lunch today. She said she was one of two nurses working on the North Unit at the time and had to go to both sides to provide medication administration. An interview was conducted with the Assistant Registered Nurse Practitioner (ARNP) on 10/19/21 at 2:12 PM. After reviewing the MAR for Resident #1, she confirmed that his insulin orders revealed that his blood glucose levels should be assessed prior to his meals. She also confirmed that the staff were not following the order because they were checking it after the meal was served. During an interview with the Director of Nursing (DON) and Administrator on 10/19/21 at 3:25 PM, they confirmed that the blank spaces on Resident #1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the facility's Medication Administration policy (not dated) revealed, #14. Administer medication as ordered in accordance with manufacturer specifications. #17. Sign MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . (Copy obtained)

Based on observations and interviews, the facility failed to keep the kitchen safe from potential food contamination due to a ceiling area under which food was being prepared and distributed, having gaps and hanging tape on it. The findings include: On 4/13/21 at 1:40 pm, the kitchen's ceiling was observed with open areas and gaps. Some piping was visible. There was tape hanging from an area between ceiling tiles. One ceiling tile had a plastic, sheet-like covering that was hanging loose and had opening on one side where it had been taped up. On 4/15/21 at 11:30 am, the same observations were made of the kitchen's ceiling with no changes. Staff were observed working under open areas of the ceiling while preparing food. The areas of ceiling where gaps were observed have the potential to contaminate foods with dust/debris. On 4/16/21 at 11:50 am, the same observations were made of the kitchen's ceiling with no changes made. The residents' food was being prepared under open areas of ceiling that had gaps in it where dirt/dust or debris could fall into resident's food or food tray. The hanging tape had the potential to break off and fall into food. (photographic evidence obtained) The District Kitchen Manager was interviewed on 4/16/21 at 11:50 am about the condition of ceiling. He stated it was in terrible condition, it had been like that for a while, and the Administrator was aware. On 4/16/21 at 12:00 pm, the Administrator was asked about the condition of the kitchen ceiling. He reported it was like this when he came on board and he was working on it. The administrator has been at this facility for nine months.

Based on observation, and interviews, the facility failed to ensure a safe, functional, sanitary environment for 41 of 72 residents by not replacing missing tiles, and not repairing an area on the wall which was covered with gray substance on one of two nursing units. The findings include: Observation of the shower room on South wing on 4/13/21 at 11:00 AM revealed green tiles missing around the sink area with a large gray area on the wall near venting unit with multiple white tiles missing. (photographic evidence obtained) Additional observations of the shower room on South wing were conducted on 4/14/21, 4/15/21 and 4/16/21. The shower room continued to have missing tiles with a large gray area on the wall. An interview was conducted with Employee B, Maintenance Assistant, at 9:10 AM on 4/16/21 concerning the observations in the shower room on South wing. He reported the sink was replaced in the shower room at least 6 months ago due to a leak and the tile was not replaced. He reported there was a leak and the tiles were taken down in order to reach the pipes and the leak. Employee B was asked about the gray area on the wall with the tiles missing near the venting unit. He stated the gray area was a concrete spreader that must have been used to patch a hole. He confirmed the gray area on the wall with tiles missing and stated, I will have to replace the tiles and fix the area. An interview was conducted with the Unit Manager, Licensed Practical Nurse (LPN,) on 4/16/21 at 9:18 AM. The LPN reported a work order is located on both units in a maintenance book that is checked by Maintenance staff daily. She reported she was not aware of a previous work order for the areas of concern.

Based on record review and interview, the facility failed to issue proper notices to inform each resident of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility's per diem rate. This affected one of three residents reviewed. (Resident #22) The findings include: On 4/14/2021 at 3:03pm, the Business Office Manager provided the survey team with three incomplete Beneficiary Notice forms. She inquired about possible changes in the Skilled Nursing Care Advanced Beneficiary Notice (ABN), Centers for Medicare and Medicaid (CMS) form . She was advised to provide the documentation that was given to the residents selected for the beneficiary notice task. On 4/14/2021 at 3:21 pm, the Social Services Director provided the survey team with incomplete beneficiary notice forms. The ABNs, CMS forms , were incomplete and not signed by the residents, and there were no Notice of Medicare Non-Coverage (NOMNC), CMS forms found for the residents. The form for Resident #22 indicated the last day of coverage was 1/20/21 with days not exhausted and a facility initiated discharge,. On 4/15/2021 at 4:53 pm, the Business Office Manager confirmed that the NOMNC's were not given to any of the residents. She confirmed this with the Social Services Director. On 4/16/2021 at 12:53 pm, the Social Services Director confirmed that she is responsible for issuing the cut letters. She stated that she inherited the duty when the building was purchased by the current owners and the previous Business Office Manager retired. She had not received any training, but knew they needed to be done and so she began doing them to the best of her knowledge. She was not familiar with the NOMNC.

Based on record review and staff interview the facility failed to ensure an allowable diagnosis for the use of antipsychotic medication and to obtain new physician orders to extend duration beyond 14 days for an as needed [CONDITION(S)] medication for 1 of 5 residents sampled for unnecessary medications from a total sample of 38. (Resident #23) The findings include: Record review for Resident #23 revealed a [AGE] year old male admitted on [DATE] and readmitted from the hospital on 3/30/21. His diagnoses included acute and chronic [CONDITION(S)] with hypercapnia, diabetes, [CONDITION(S)], major depressive disorder and anxiety. He was alert and oriented and required extensive assistance with activities of daily living. Upon admission he was ordered the medication [MEDICATION(S)] (antipsychotic) 25 mg at bedtime for anxiety and [MEDICATION(S)] (antianxiety) 0.5 mg every eight hours, as needed for anxiety. Review of the Medication Administration Record (MAR) revealed [MEDICATION(S)] 0.5 mg was ordered 3/30/21 and had not been used as of 4/15/21. There was no 14 day stop date for [MEDICATION(S)] or no new order written to extend duration beyond the 14 days. Review of the consultant pharmacy report from April 2021 indicated that the diagnosis of anxiety for use of [MEDICATION(S)] was not an allowable diagnosis. The recommendation from the pharmacist had not been followed up. During an interview with the unit manager on 4/16/21 at 10:20 am she confirmed that there was no order no extend the use of [MEDICATION(S)] and she said she would notify the physician of the need for appropriate diagnosis for [MEDICATION(S)].

Based on observation and staff interview, the facility failed to ensure oral medications and external biological and topical treatments were kept in separate areas of the medication room for 1 of 2 medication rooms, medications were stored under proper temperature control, and expired medications were removed from one of four medication carts. The findings include: During an observation of the medication room on the the south wing on 4/16/21 at 12:15pm, the following was found: over the counter oral medications (milk of magnesia, Prostat, Promod) were commingled on the shelves with wound cleaners, [MEDICATION(S)] (antiseptic external solution), and [MEDICATION(S)] (solution for cleaning wounds). An interview with the unit manager at 12:20pm confirmed the oral medications were not separated from external solutions. Observation of the medication refrigerator on the north wing at 12:30pm with the unit manager (UM) found the temperature was at 38 degrees and the freezer section was totally engulfed with ice and the bottom shelf was very soiled. The UM confirmed the temperature and the refrigerator needed to be defrosted and cleaned. An observation was made of the medication cart on the north wing with Licensed Practical Nurse (Emp A) on 4/16/21 at 1:40pm. There were two insulin pens that were found to be expired. Flex-touch [MEDICATION(S)] Insulin pen for Resident #77 was opened on 3/19/21 and was dated to expire on 4/15/21. [MEDICATION(S)] insulin pen for Resident #23 was dated to expire on 4/5/21. Employee A verified the insulin pens were expired and removed them from the cart.

Based on record reviews and resident and staff interviews, the facility failed to meet professional standards of quality during provision of care as evidenced by failure to obtain physician's orders for administration of sliding scale insulin for one (Resident #1) of 11 sampled residents, failure to notify the physician related to elevated blood sugar levels greater than 450 for one (Resident #2) of 11 sampled residents, failure to dispose of expired insulin and administration of expired insulin, which affected two (Residents #2 and #8) of 11 sampled residents, and for administration of oxygen by unlicensed staff for one (Resident #11) of 11 sampled residents, who had no order for supplemental oxygen. These practices placed residents at risk for a high likelihood or potential for harm. The Professional Standard of Care is defined in Chapter 766.102, as the prevailing professional standard of care for a given health care provider shall be that level of care, skill, and treatment which in light of all relevant surrounding circumstances is recognized as acceptable and appropriate by reasonably prudent similar health care providers. According to the Florida Nurse Practice Act, Chapter 464.003: (3)(a) Practice of professional nursing means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: 1. The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. 2. The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. (e) Nursing [DIAGNOSES REDACTED]. (f) Nursing treatment means the establishment and implementation of a nursing regimen for the care and comfort of individuals, the prevention of illness, and the education, restoration, and maintenance of health. The practice of practical nursing is defined as the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured or infirmed and the promotion of wellness, maintenance of health, and the prevention of illness of others under the direction of a registered nurse, or a licensed physician. The findings include: 1. A record review was conducted for Resident #1, which revealed a physician's order sheet dated [DATE] that stated Accu-check (blood sugar level check) before meals and at bedtime with sliding scale coverage (of insulin). A review of the June, July, and [DATE] Medication Administration Records (MARs) for Resident #1 revealed, Accu-check before meals and at bedtime with sliding scale coverage. A review of the MARs revealed no sliding scale orders. (Photographic evidence obtained) An interview was conducted with Employee A, Licensed Practical Nurse (LPN), on [DATE] at 11:06 AM, and she was asked to find the sliding scale for Resident #1. The employee reviewed the resident's record and stated, I don't see it for him, but I don't do his medications. Let me look. The employee was not able to find the sliding scale anywhere in Resident #1's record and stated, We have a facility sliding scale that we use, and I'm sure it's in the front of his Medication Administration Record (MAR) and the bottle of insulin we use. An observation was conducted of the MAR for Resident #1, and no sliding scale signed by the physician was found. On [DATE] at 11:10 AM, a review was conducted with Employee D, LPN, of the medication cart for the North Wing, which housed the medication for Resident #1. The observation revealed the resident had a [MEDICATION NAME] Insulin 100 units (u) / milliliter (ml) flex pen, inject five units (u) subcutaneously (Sub-Q) every evening. It did not list any sliding scale for this resident. Upon further observation of the medication cart, no other insulin was found. An interview was conducted with Employee D, LPN, on [DATE] at 11:10 AM, and she was asked if she administered sliding scale insulin to Resident #1. She stated, Yes, I didn't have to today, but I usually have to give it to him. She confirmed that she used his flex pen to administer the sliding scale insulin coverage. She was asked what she used for the sliding scale, as it was not listed on the MAR or in the resident's clinical record, and she referenced a piece of paper in the front of her MAR and stated, I use this. The nurse confirmed Resident #1 did not have signed physician order to administer the sliding scale that she was using. (Photographic evidence obtained) A review of the facility's Physician Order Sheets for Resident #1 for June and [DATE] revealed there was no sliding scale coverage listed for the resident. (Photographic evidence obtained) An interview with Employee A, LPN, on [DATE] at 11:45 AM confirmed the facility had no signed physician's order for sliding scale insulin for Resident #1, and the nursing staff should not be administering insulin without the signed physician's order. An interview with Resident #1 on [DATE] at 2:20 PM confirmed he received sliding scale insulin three to four times a day, and confirmed his last dose of sliding scale insulin was given to him last night on [DATE]. A phone interview with the Consultant Pharmacist on [DATE] at 4:40PM confirmed he reviewed Resident #1's record during his July visit. The pharmacist confirmed he was not aware the resident did not have sliding scale insulin listed or current physician orders. He stated, I looked at his orders when I did the record review and honestly, I didn't catch that. The pharmacist contacted the pharmacy and confirmed the [MEDICATION NAME] for sliding scale had not been filled since April of 2017, and had not received a signed order for sliding scale since [DATE]. 2. A record review was conducted for Resident #2, which revealed a readmission date of [DATE]. [DIAGNOSES REDACTED]. A review of the facility's care plan for Resident #2, dated [DATE], stated, (Resident) has Diabetes Mellitus. Interventions included but were not limited to diabetes medication as ordered; educate resident, family, caregivers as to the correct protocol for glucose monitoring and insulin injections, fasting serum blood glucose as ordered by the physician. A review of a signed Physician Order Sheet (POS) read Accu-check 3 times a day with sliding scale as follows: (100 -150 - 2u, 151 - 200+ - 4u, 201 - 250+ - 6u, 251 - 300 - 8u, 301 - 350 - 10u, 351 - 400 - 12u, 401 - 450 - 14u). The physician's orders did not address what the nursing staff should do for blood sugar readings greater than 450. (Photographic evidence obtained.) An interview with Employee A, LPN, on [DATE] at 2:30 PM confirmed the staff on [DATE] and [DATE] documented Resident #2 obtained a Hi reading, and documented, they administered 14 units of insulin to Resident #2, but had no orders that addressed a blood glucose reading greater than 450. Employee A confirmed the facility protocol was to call the physician to obtain orders for readings over 450, and then re-check the blood sugar in two hours. The employee was asked if she knew how high a blood glucose level had to be for the blood glucose monitor the facility used to give a Hi reading, and she said, I thinks it's for a reading over 500. A medication storage observation was conducted for the North Wing medication cart where the insulin for Resident #2 was stored. The observation revealed two bottles of [MEDICATION NAME] Insulin 100 units/ml currently in use with fill dates of [DATE] and [DATE]. Neither was dated to verify when it was opened, and each had to be discarded 28 days after opening. The resident received daily sliding scale coverage from these bottles of insulin, which should have been discarded by the time of this survey. (Photographic evidence obtained) A review of the MAR for Resident #2 revealed the resident received a total of six (6) doses of insulin since [DATE], during a period after the insulin should have been discarded. Four of the six readings were given a Hi, indicating his blood glucose level was 600 mg/dl (milligrams per deciliter). (Photographic evidence obtained) An interview with Employee D, LPN, on [DATE] at 11:13 AM confirmed the insulin for Resident #2 was expired, and he had been receiving sliding scale coverage from the undated, expired bottles. The employee was not able to verify the date the bottles were opened, and stated they should have been and would be discarded. A review of the facility's nurses' notes for July and [DATE] for Resident #2 revealed no documentation where the physician was called to notify him of the 'Hi' blood glucose readings or that further observation was conducted of the resident to ensure his safety and well-being. An interview with the Director of Nursing (DON) on [DATE] at 2:40 PM confirmed the facility used the EvenCare G2 blood glucose-monitoring unit by Medline, and a 'Hi' reading meant the blood sugar level was greater than 600 mg/dl. A review of the manufacturer's user guide for the Medline Evencare G2 blood glucose monitoring system revealed a 'Hi' reading indicated a blood glucose level that was higher than 600 mg/dl. (Photographic evidence obtained) An interview with Resident #2 on [DATE] at 2:45 PM confirmed he received blood glucose testing from the facility 3 - 4 times a day. The resident was asked whether he was aware of what his blood sugar results were, and he said 'yes'. He was asked if he knew that his blood sugars ran high, and he replied, Yes, they get a Hi reading all the time. My sugar is frequently over 500. An interview with Employee D, LPN, on [DATE] at 2:55 PM confirmed she gave Resident #2 14 units of insulin for any blood sugar result over 450 mg/dl. She was asked why since his blood sugars were higher than 450, and there were no specific orders to address his sugar. She said because it was greater than 450, and that's the order that we have. The employee confirmed she had not called the resident's physician to make him aware of the 'high' readings, or when the resident's blood sugar level was over 450 in order to obtain new orders. An interview on [DATE] at 3:42 PM confirmed the physician should be called and close monitoring of the resident should be done for a blood sugar reading greater than 600. An interview was conducted with the DON on [DATE] at 4:38 PM, and was asked what was expected of the staff if they received a blood sugar reading of 'Hi'. She said they should call the physician and obtain orders. She was asked how the facility's nursing staff was trained on proper blood glucose monitoring. She replied, We don't have a specific policy and procedure for blood glucose monitoring, but it should be common sense and you shouldn't have to be told to do something that basic nursing 101. A phone interview with Resident #2's physician on [DATE] at 1:16 PM confirmed he would expect the facility to contact him with any Hi reading, as the resident was a brittle diabetic. The physician confirmed the facility staff had not called him and made him aware of the high glucose readings for the resident. A review of the Mayo Clinic Website (http://www.mayoclinic.org/ diseases-conditions/diabetic-coma/basics/causes/CON- 691) revealed the following risk for blood sugar levels greater than 600: Prolonged blood sugar extremes or blood sugar that is too high may cause various conditions, all of which can lead to a diabetic coma. Diabetic ketoacidosis. If your muscle cells become starved for energy, your body may respond by breaking down fat stores. This process forms toxic acids known as [MEDICATION NAME]. Left untreated, diabetic ketoacidosis can lead to a diabetic coma. Diabetic hyperosmolar syndrome. If your blood sugar level tops 600 milligrams per deciliter (mg/dL), the condition is known as diabetic hyperosmolar syndrome. When your blood sugar gets this high, your blood becomes thick and syrupy. The excess sugar passes from your blood into your urine, which triggers a filtering process that draws tremendous amounts of fluid from your body. Left untreated, diabetic hyperosmolar syndrome can cause life-threatening dehydration and a diabetic coma. Diabetic hyperosmolar syndrome is most common in middle-aged and older adults who have type 2 diabetes. 3. An observation was conducted of the North Wing medication cart on [DATE] at 11:10 AM, with Employee D, LPN. A bottle of [MEDICATION NAME] 100 u/ml was discovered for Resident #8, with a fill date of [DATE] and an open date of [DATE]. The bottle had a labeled affixed which read, Discard 28 days after opening [DATE]. A review of the MAR for Resident #8 revealed the resident received [MEDICATION NAME] 10 units every evening from [DATE] - [DATE] from the expired bottle of insulin, which should have been discarded on [DATE]. (Photographic evidence obtained) An interview was conducted with Employee D on [DATE] at 11:13 AM, who confirmed the insulin for Resident #8 should have been discarded in July and that the resident had been receiving it nightly. 4. An observation was conducted on [DATE] at 12:05 PM of Resident #11 being escorted via wheelchair to the North Wing beside the medication cart of Employee C, LPN. The aide could be overheard telling the nurse that the resident was coughing at lunch. On [DATE] at 12:15 PM, Resident #11 could be heard coughing, and at times, would cough to the point of gagging. This surveyor walked over the Resident #11 where she was sitting in her wheelchair next to Employee C, LPN's medication cart. Employee C was asked what was going on with the resident and she replied, The aide brought her back from the dining room because she started coughing a lot, and I'm watching her since her nurse is on lunch. I don't know a lot about her since she's not on my assignment, but I will go and review her record. A record review for Resident #11 revealed a date of admission of [DATE], with [DIAGNOSES REDACTED]. An observation was made on [DATE] at 12:17 PM of Employee B, Certified Nursing Assistant (CNA), escorting Resident #11 in the wheelchair back to her room while the nurse was in the nurse's station reviewing the record. An observation was made of Resident #11 on [DATE] at 12:25 PM sitting in her wheelchair beside her bed with her eyes closed and oxygen applied via nasal cannula at 1-,[DATE] liters per minute. A record review for Resident #11 revealed no physician's order to administer oxygen for the resident. An interview was conducted with the Director of Nursing on [DATE] at 12:27 PM. She was asked if the facility had orders to administer oxygen for Resident #11. The DON confirmed she did not see orders in the resident's record, but the facility had standing orders to apply oxygen in an emergency if the nurse felt the resident needed it. The DON confirmed only nurses were able to assess and determine whether a resident needed oxygen applied. An observation was made with the DON and Employee A, LPN, on [DATE] at 12:27 PM of Resident #11 with oxygen applied via nasal cannula at 1-,[DATE] liters per minute. Employee A stated the oxygen that Resident #11 had on was her roommate's (B bed) oxygen. She had a new oxygen concentrator delivered, and the staff placed it by Resident #11's bed instead of switching it out with the resident in B bed's old one, as they should have. The staff must have thought it should be used for Resident #11. An interview with Employee C, LPN, on [DATE] at 12:34 PM confirmed she did not apply the oxygen to Resident #11, but that it was applied by the CNA. An interview with Employee A, LPN, on [DATE] at 12:36 PM confirmed the oxygen level for Resident #11 was 97 % on room air, and that she did not need supplemental oxygen. She was asked who could apply oxygen to a resident. She replied, Only a nurse can make the decision to apply oxygen. A CNA can come to the nurse and let her know that the resident is having a hard time breathing, but it's up to the nurse to apply it. An interview conducted with Employee B, CNA, on [DATE] at 12:42 PM confirmed she placed Resident #11 on oxygen when she took her back to her room. She was asked why she put the oxygen on the resident, and she replied, The resident was coughing and seemed short of breath when I took her back to her room and I thought she needed it. The employee confirmed she did not receive instructions from the LPN. She stated, I couldn't find her, and I thought it would help. Employee B confirmed she was not aware that the oxygen concentrator she used for Resident #11 was for the resident in the B bed. A review of the facility's Policy and Procedure for administering oxygen delivery via nasal cannula revised on [DATE] read, Oxygen should only be administered when ordered by a physician; however, it can be applied in emergency situations by a licensed nurse and the physician notified after the application.

Based on observations, record reviews and resident and staff interviews, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being consistent with professional standards of practice by failing to obtain physician's orders for administration of sliding scale insulin for one (Resident #1) of 11 sampled residents, failure to notify the physician related to elevated blood sugar levels greater than 450 for one (Resident #2) of 11 sampled residents, failure to dispose of expired insulin and administration of expired insulin, which affected two (Residents #2 and #8) of 11 sampled residents, and for administration of oxygen by unlicensed staff for one (Resident #1) of 11 sampled residents, who had no order for supplemental oxygen. These practices placed residents at risk for a high likelihood or potential for harm. The findings include: 1. A record review was conducted for Resident #1, which revealed a physician's order sheet dated [DATE] that stated Accu-check (blood sugar level check) before meals and at bedtime with sliding scale coverage (of insulin). A review of the June, July, and [DATE] Medication Administration Records (MARs) for Resident #1 revealed, Accu-check before meals and at bedtime with sliding scale coverage. A review of the MARs revealed no sliding scale orders. (Photographic evidence obtained) An interview was conducted with Employee A, Licensed Practical Nurse (LPN), on [DATE] at 11:06 AM, and she was asked to find the sliding scale for Resident #1. The employee reviewed the resident's record and stated, I don't see it for him, but I don't do his medications. Let me look. The employee was not able to find the sliding scale anywhere in Resident #1's record and stated, We have a facility sliding scale that we use, and I'm sure it's in the front of his Medication Administration Record (MAR) and the bottle of insulin we use. An observation was conducted of the MAR for Resident #1, and no sliding scale signed by the physician was found. On [DATE] at 11:10 AM, a review was conducted with Employee D, LPN, of the medication cart for the North Wing, which housed the medication for Resident #1. The observation revealed the resident had a [MEDICATION NAME] Insulin 100 units (u) / milliliter (ml) flex pen, inject five units (u) subcutaneously (Sub-Q) every evening. It did not list any sliding scale for this resident. Upon further observation of the medication cart, no other insulin was found. An interview was conducted with Employee D, LPN, on [DATE] at 11:10 AM, and she was asked if she administered sliding scale insulin to Resident #1. She stated, Yes, I didn't have to today, but I usually have to give it to him. She confirmed that she used his flex pen to administer the sliding scale insulin coverage. She was asked what she used for the sliding scale, as it was not listed on the MAR or in the resident's clinical record, and she referenced a piece of paper in the front of her MAR and stated, I use this. The nurse confirmed Resident #1 did not have signed physician order to administer the sliding scale that she was using. (Photographic evidence obtained) A review of the facility's Physician Order Sheets for Resident #1 for June and [DATE] revealed there was no sliding scale coverage listed for the resident. (Photographic evidence obtained) An interview with Employee A, LPN, on [DATE] at 11:45 AM confirmed the facility had no signed physician's order for sliding scale insulin for Resident #1, and the nursing staff should not be administering insulin without the signed physician's order. An interview with Resident #1 on [DATE] at 2:20 PM confirmed he received sliding scale insulin three to four times a day, and confirmed his last dose of sliding scale insulin was given to him last night on [DATE]. A phone interview with the Consultant Pharmacist on [DATE] at 4:40PM confirmed he reviewed Resident #1's record during his July visit. The pharmacist confirmed he was not aware the resident did not have sliding scale insulin listed or current physician orders. He stated, I looked at his orders when I did the record review and honestly, I didn't catch that. The pharmacist contacted the pharmacy and confirmed the [MEDICATION NAME] for sliding scale had not been filled since April of 2017, and had not received a signed order for sliding scale since [DATE]. 2. A record review was conducted for Resident #2, which revealed a readmission date of [DATE]. [DIAGNOSES REDACTED]. A review of the facility's care plan for Resident #2, dated [DATE], stated, (Resident) has Diabetes Mellitus. Interventions included but were not limited to diabetes medication as ordered; educate resident, family, caregivers as to the correct protocol for glucose monitoring and insulin injections, fasting serum blood glucose as ordered by the physician. A review of a signed Physician Order Sheet (POS) read Accu-check 3 times a day with sliding scale as follows: (100 -150 - 2u, 151 - 200+ - 4u, 201 - 250+ - 6u, 251 - 300 - 8u, 301 - 350 - 10u, 351 - 400 - 12u, 401 - 450 - 14u). The physician's orders did not address what the nursing staff should do for blood sugar readings greater than 450. (Photographic evidence obtained.) An interview with Employee A, LPN, on [DATE] at 2:30 PM confirmed the staff on [DATE] and [DATE] documented Resident #2 obtained a Hi reading, and documented, they administered 14 units of insulin to Resident #2, but had no orders that addressed a blood glucose reading greater than 450. Employee A confirmed the facility protocol was to call the physician to obtain orders for readings over 450, and then re-check the blood sugar in two hours. The employee was asked if she knew how high a blood glucose level had to be for the blood glucose monitor the facility used to give a Hi reading, and she said, I thinks it's for a reading over 500. A medication storage observation was conducted for the North Wing medication cart where the insulin for Resident #2 was stored. The observation revealed two bottles of [MEDICATION NAME] Insulin 100 units/ml currently in use with fill dates of [DATE] and [DATE]. Neither was dated to verify when it was opened, and each had to be discarded 28 days after opening. The resident received daily sliding scale coverage from these bottles of insulin, which should have been discarded by the time of this survey. (Photographic evidence obtained) A review of the MAR for Resident #2 revealed the resident received a total of six (6) doses of insulin since [DATE], during a period after the insulin should have been discarded. Four of the six readings were given a Hi, indicating his blood glucose level was 600 mg/dl (milligrams per deciliter). (Photographic evidence obtained) An interview with Employee D, LPN, on [DATE] at 11:13 AM confirmed the insulin for Resident #2 was expired, and he had been receiving sliding scale coverage from the undated, expired bottles. The employee was not able to verify the date the bottles were opened, and stated they should have been and would be discarded. A review of the facility's nurses' notes for July and [DATE] for Resident #2 revealed no documentation where the physician was called to notify him of the 'Hi' blood glucose readings or that further observation was conducted of the resident to ensure his safety and well-being. An interview with the Director of Nursing (DON) on [DATE] at 2:40 PM confirmed the facility used the EvenCare G2 blood glucose-monitoring unit by Medline, and a 'Hi' reading meant the blood sugar level was greater than 600 mg/dl. A review of the manufacturer's user guide for the Medline Evencare G2 blood glucose monitoring system revealed a 'Hi' reading indicated a blood glucose level that was higher than 600 mg/dl. (Photographic evidence obtained) An interview with Resident #2 on [DATE] at 2:45 PM confirmed he received blood glucose testing from the facility 3 - 4 times a day. The resident was asked whether he was aware of what his blood sugar results were, and he said 'yes'. He was asked if he knew that his blood sugars ran high, and he replied, Yes, they get a Hi reading all the time. My sugar is frequently over 500. An interview with Employee D, LPN, on [DATE] at 2:55 PM confirmed she gave Resident #2 14 units of insulin for any blood sugar result over 450 mg/dl. She was asked why since his blood sugars were higher than 450, and there were no specific orders to address his sugar. She said because it was greater than 450, and that's the order that we have. The employee confirmed she had not called the resident's physician to make him aware of the 'high' readings, or when the resident's blood sugar level was over 450 in order to obtain new orders. An interview on [DATE] at 3:42 PM confirmed the physician should be called and close monitoring of the resident should be done for a blood sugar reading greater than 600. An interview was conducted with the DON on [DATE] at 4:38 PM, and was asked what was expected of the staff if they received a blood sugar reading of 'Hi'. She said they should call the physician and obtain orders. She was asked how the facility's nursing staff was trained on proper blood glucose monitoring. She replied, We don't have a specific policy and procedure for blood glucose monitoring, but it should be common sense and you shouldn't have to be told to do something that basic nursing 101. A phone interview with Resident #2's physician on [DATE] at 1:16 PM confirmed he would expect the facility to contact him with any Hi reading, as the resident was a brittle diabetic. The physician confirmed the facility staff had not called him and made him aware of the high glucose readings for the resident. A review of the Mayo Clinic Website (http://www.mayoclinic.org/ diseases-conditions/diabetic-coma/basics/causes/CON- 691) revealed the following risk for blood sugar levels greater than 600: Prolonged blood sugar extremes or blood sugar that is too high may cause various conditions, all of which can lead to a diabetic coma. Diabetic ketoacidosis. If your muscle cells become starved for energy, your body may respond by breaking down fat stores. This process forms toxic acids known as [MEDICATION NAME]. Left untreated, diabetic ketoacidosis can lead to a diabetic coma. Diabetic hyperosmolar syndrome. If your blood sugar level tops 600 milligrams per deciliter (mg/dL), the condition is known as diabetic hyperosmolar syndrome. When your blood sugar gets this high, your blood becomes thick and syrupy. The excess sugar passes from your blood into your urine, which triggers a filtering process that draws tremendous amounts of fluid from your body. Left untreated, diabetic hyperosmolar syndrome can cause life-threatening dehydration and a diabetic coma. Diabetic hyperosmolar syndrome is most common in middle-aged and older adults who have type 2 diabetes. 3. An observation was conducted of the North Wing medication cart on [DATE] at 11:10 AM, with Employee D, LPN. A bottle of [MEDICATION NAME] 100 u/ml was discovered for Resident #8, with a fill date of [DATE] and an open date of [DATE]. The bottle had a labeled affixed which read, Discard 28 days after opening [DATE]. A review of the MAR for Resident #8 revealed the resident received [MEDICATION NAME] 10 units every evening from [DATE] - [DATE] from the expired bottle of insulin, which should have been discarded on [DATE]. (Photographic evidence obtained) An interview was conducted with Employee D on [DATE] at 11:13 AM, who confirmed the insulin for Resident #8 should have been discarded in July and that the resident had been receiving it nightly. 4. An observation was conducted on [DATE] at 12:05 PM of Resident #11 being escorted via wheelchair to the North Wing beside the medication cart of Employee C, LPN. The aide could be overheard telling the nurse that the resident was coughing at lunch. On [DATE] at 12:15 PM, Resident #11 could be heard coughing, and at times, would cough to the point of gagging. This surveyor walked over the Resident #11 where she was sitting in her wheelchair next to Employee C, LPN's medication cart. Employee C was asked what was going on with the resident and she replied, The aide brought her back from the dining room because she started coughing a lot, and I'm watching her since her nurse is on lunch. I don't know a lot about her since she's not on my assignment, but I will go and review her record. A record review for Resident #11 revealed a date of admission of [DATE], with [DIAGNOSES REDACTED]. An observation was made on [DATE] at 12:17 PM of Employee B, Certified Nursing Assistant (CNA), escorting Resident #11 in the wheelchair back to her room while the nurse was in the nurse's station reviewing the record. An observation was made of Resident #11 on [DATE] at 12:25 PM sitting in her wheelchair beside her bed with her eyes closed and oxygen applied via nasal cannula at 1-,[DATE] liters per minute. A record review for Resident #11 revealed no physician's order to administer oxygen for the resident. An interview was conducted with the Director of Nursing on [DATE] at 12:27 PM. She was asked if the facility had orders to administer oxygen for Resident #11. The DON confirmed she did not see orders in the resident's record, but the facility had standing orders to apply oxygen in an emergency if the nurse felt the resident needed it. The DON confirmed only nurses were able to assess and determine whether a resident needed oxygen applied. An observation was made with the DON and Employee A, LPN, on [DATE] at 12:27 PM of Resident #11 with oxygen applied via nasal cannula at 1-,[DATE] liters per minute. Employee A stated the oxygen that Resident #11 had on was her roommate's (B bed) oxygen. She had a new oxygen concentrator delivered, and the staff placed it by Resident #11's bed instead of switching it out with the resident in B bed's old one, as they should have. The staff must have thought it should be used for Resident #11. An interview with Employee C, LPN, on [DATE] at 12:34 PM confirmed she did not apply the oxygen to Resident #11, but that it was applied by the CNA. An interview with Employee A, LPN, on [DATE] at 12:36 PM confirmed the oxygen level for Resident #11 was 97 % on room air, and that she did not need supplemental oxygen. She was asked who could apply oxygen to a resident. She replied, Only a nurse can make the decision to apply oxygen. A CNA can come to the nurse and let her know that the resident is having a hard time breathing, but it's up to the nurse to apply it. An interview conducted with Employee B, CNA, on [DATE] at 12:42 PM confirmed she placed Resident #11 on oxygen when she took her back to her room. She was asked why she put the oxygen on the resident, and she replied, The resident was coughing and seemed short of breath when I took her back to her room and I thought she needed it. The employee confirmed she did not receive instructions from the LPN. She stated, I couldn't find her, and I thought it would help. Employee B confirmed she was not aware that the oxygen concentrator she used for Resident #11 was for the resident in the B bed. A review of the facility's Policy and Procedure for administering oxygen delivery via nasal cannula revised on [DATE] read, Oxygen should only be administered when ordered by a physician; however, it can be applied in emergency situations by a licensed nurse and the physician notified after the application.