Every finding on record at Beachside Center for Rehabilitation and Nursing

Based on observations, interviews and record review, the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan for two (Residents #96 and #154) of three residents reviewed for oxygen therapy. Neither resident was receiving oxygen at the flow rate ordered by their physicians.The findings include: 1.On 02/03/26 at 9:40 AM, Resident #96 was observed wearing a nasal cannula (NC) that was connected to an oxygen concentrator. The concentrator was set at a flow rate of 2.5 liters/minute. The resident stated he had been receiving a flow rate of 2 liters per minute and that he did not manipulate the oxygen flow rate. On 02/03/26 at 12:07 PM, another observation was made of Resident #96 wearing his NC attached to an oxygen concentrator with a flow rate set at 2.5 liters/minute. A review of Resident #96's medical record revealed that the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), mood disorder, depression, cognitive/communication deficit and shortness of breath. A review of Resident #96's physician's orders revealed an order for oxygen via nasal cannula at 2 liters continuously. (Started on 11/4/22) A review of Resident #96's active care plan revealed a focus area noting the resident was at risk for ineffective breathing pattern related to: Cough, Chronic Obstructive Pulmonary Disease (COPD). The care plan focus was created on 05/09/24. The resident's care plan goals noted that the resident would demonstrate an effective respiratory rate, depth and pattern, increase activity tolerance and no stated discomfort through the next review. The care plan goal was created 05/09/24. The care plan interventions included: Administer medication/oxygen as ordered, which was started 05/09/24. A review of Resident #96's minimum data set (MDS) assessment, dated 1/1/26, revealed that the resident had a brief interview for mental status (BIMS) score of 15 out of 15 possible points, indicating intact cognition. On 02/03/26 at 3:32 PM, an interview was conducted with Licensed Practical Nurse (LPN) A, who reported that she had been employed by the facility for 1 1/2 months. She explained her process for ensuring residents received oxygen at the correct flow rate was to review the resident's oxygen order prior to entering the resident's room. After she entered the resident's room, she checked the oxygen flow rate on the concentrator and measured the resident's oxygen saturation level. After leaving the resident's room, she signed off on the medication administration record (MAR) and treatment administration record (TAR) and signed off that the resident was receiving oxygen according to the physician's order and entered the resident's oxygen saturation level. On 02/03/26 at 3:35 PM, LPN A was accompanied to Resident #96's room. LPN A knelt, looked directly at the flow meter with her eyes level with the center of the indicator ball and reported that the oxygen flow rate was set at 2.5-3 liters/minute. The nurse reviewed the resident's oxygen order and reported that the physician's order, dated 11/04/22, was for a flow rate of 2 liters/minute. The nurse also reviewed the medication administration record (MAR) and treatment administration record (TAR) for January and February 2026 and reported that facility staff had signed off that the resident was receiving oxygen according to the physician's order at 2 Liters/minute. 2.A review of the medical record for Resident #154 revealed that the resident was admitted to the facility on [DATE] with diagnoses including mood disorder, solitary pulmonary nodule, tobacco use, shortness of breath, chronic systolic (congestive) heart failure and chronic obstructive pulmonary disease. On 02/02/26 at 12:01 PM, Resident #154 was observed wearing a nasal cannula attached to an oxygen concentrator with an oxygen flow rate set at 3.5 liters/minute. The resident stated she did not touch her oxygen concentrator. On 02/03/26 at 9:59 AM, another observation was made of Resident #154 wearing a nasal cannula attached to an oxygen concentrator with an oxygen flow rate set at 3 liters/minute. A review of Resident #154's active physician's orders revealed an order for oxygen with a flow rate of 2 liters per minute via nasal cannula. The order start date was 12/08/25. A review of Resident #154's care plan, initiated on 12/08/25, revealed a focus area noting that the resident was at risk for ineffective breathing pattern related to: Chronic obstructive pulmonary disease (COPD), patient has shortness of breath or trouble breathing when lying flat. Care plan focus started 12/8/25. The care plan goal noted that the resident would demonstrate an effective respiratory rate, depth and pattern, increase activity tolerance and no stated discomfort through the next review date. The care plan interventions documented: Administer medication/oxygen as ordered. A review of Resident #154's care plan, started 12/08/25 and revised 12/29/25, noted the resident required the use of oxygen therapy. The care plan goal noted that the resident would have no signs/symptoms of poor oxygen absorption through the review date. Care plan interventions included directions to administer oxygen via nasal cannula at 2 liters/minute. A review of Resident #154's minimum data set (MDS) assessment, dated 12/17/25, revealed that the resident had a brief interview for mental status (BIMS) score of 07/15, indicating severe cognitive impairment. On 02/03/26 at 3:32 PM, an interview was conducted with LPN A. She explained that her process for ensuring residents receiving oxygen were getting oxygen at the appropriate flow rate was to review the resident's oxygen order prior to entering the resident's room. After she entered the resident's room, she checked the oxygen flow rate on the concentrator and measured the resident's oxygen saturation level. After leaving the resident's room, she signed off on the medication administration record (MAR) and treatment administration record (TAR), then signed off that the resident was receiving oxygen according to the physician's order and entered the resident's oxygen saturation level. On 02/03/26 at 3:33 PM, LPN A was accompanied to Resident #154's room. She knelt, looked directly at the flow meter with her eyes level with the center of the indicator ball and reported that the oxygen flow rate was set at 3.5 liters/minute. The nurse reviewed the resident's physician orders and explained that an order dated 12/08/25 noted the flow rate should be 2 liters/minute. The nurse also reviewed the medication administration record (MAR) and treatment administration record (TAR) for January and February 2026 and reported that facility staff signed off that the resident was receiving oxygen according to the physician's order (2 Liters/minute). A review of the facility's policy and procedure titled SG Respiratory Care and Oxygen Administration (issued 03/20/20), revealed: It is the standard of this facility to provide guidelines for respirator care and safe oxygen administration. Policy guidelines included . 1. Verify that there is a physician's order for respiratory procedures or oxygen use. Review the physician's order for oxygen administration . 2. Review the resident's care plan to assess for any special needs of the resident.

Based on observations, staff interviews, and facility policy and procedure review, the facility failed to ensure the residents' right to personal privacy and confidentiality of personal and medical records when facility forms and documents were left unsecured on the top of three (300 hall, 600 hall, and 700 hall) out of six medication carts and taped to the top of one (600 hall) of two nursing stations' counters where passersby could see them. The findings include: On 03/25/2024 at 8:40 AM, Licensed Practical Nurse (LPN) F left a paper form with names of residents on the top of the 300 hall medication cart not secured for privacy and confidentiality. (Photographic evidence obtained) On 03/25/2024 at 8:42 AM during an interview with LPN F, she confirmed the list of names should not have been left on top of the medication cart unsecured. She turned the paper over and stated, I was only gone a few minutes. On 03/25/2024 at 11:58 AM, a green-colored paper, dated 03/25/2024, was observed taped to the countertop at the nurses' station on the 600 hall listing 27 resident names with instructions to have the residents ready for their therapy appointments. The list was not secured for privacy and confidentiality. (Photographic evidence obtained) On 03/25/2024 at 11:59 AM, a form dated 03/22/2024, was observed taped to the countertop at the nurses' station on the 600 hall listing 11 resident names, attending physicians' names for each resident, their Advance Directive status, and a handwritten note with a medication dosage for one unsampled resident. The list was not secured for privacy and confidentiality. (Photographic evidence obtained) On 03/28/2024 at 9:22 AM, LPN G's medication cart on the 600 hallway was observed. A half sheet of notebook paper with residents' names was lying on top of the cart not secured for privacy and confidentiality. (Photographic evidence obtained) On 03/28/2024 at 9:23 AM during an interview with LPN G, she confirmed that the names on the paper were current residents. She stated the paper was tucked up under a container used to store applesauce and pudding to use for medication administration. She was not sure why it was lying unsecured on the top of the cart now. She stated she had just stepped away from her cart. On 03/28/2024 at 9:45 AM, LPN H's medication cart on the 700 hallway was observed. On top of the cart, an open binder with personal health information was not secured for privacy and confidentiality. (Photographic evidence obtained) On 03/28/2024 at 9:47 AM, an interview was conducted with LPN H. She stated she realized that she had left the binder open. I just a left a couple of minutes ago. A review of the facility's policy and procedure titled HIPAA Sanctions Policy (implemented 11/27/2019), revealed: 1. The facility, as a covered entity under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), will implement policies and procedures to prevent, detect, contain, and correct any HIPPA violations. 2. All employees are expected to comply with all policies and procedures regarding the protection of personal identifiable health information of our residents. 6. Examples of violations include, but are not limited to: d. the negligent mishandling of confidential information. (Copy obtained)

Based on interviews and record reviews, the facility failed to ensure that one (Resident #26) of 50 residents in the total sample, was free from any physical restraints imposed for purposes other than the resident's medical condition. Inappropriate use of restraints could result in injury, skin breakdown, asphyxia, and/or strangulation among other things. The findings include: On 03/25/24 at 2:25 p.m., Resident #26 was observed in bed with bruises on her chest and the left side of her face. Her bed was in low position with floor mats on both sides of the bed. She also had a scoop mattress and half siderails that were padded. She had crossed her left leg over her right leg and was resting it on the right siderail. A bandage was observed on the resident's left shin, dated 3/24/24. An attempt to speak with the resident was unsuccessful due to confusion. A review of the resident's medical record revealed she was admitted to the facility on [DATE] with a re-entry on 03/21/2024. Her diagnoses included, but were not limited to: unspecified dementia with unspecified severity and anxiety; vascular dementia, severe with anxiety; severe protein-calorie malnutrition; adult failure to thrive; generalized anxiety disorder; dependence on a wheelchair; cognitive/communication deficit with restlessness and agitation; atrial fibrillation; weakness; hypertension; pain; major depressive disorder; constipation and insomnia. Her physician's orders included the following: 01/27/2023 - Half side rails x2 may be be up for enhanced independence and mobility. Monitor behavior for anxiety. 04/03/2023 - Sertraline 50 mg (milligrams) one time a day for depression 11/22/2023 - Trazadone 150 mg, give 0.5 tablet two times a day for major depressive disorder and insomnia 08/30/2023 - Lorazepam 1 mg two times a day for anxiety 03/20/2024 - Lorazepam 0.5 mg every 8 hours as needed for anxiety 03/21/2024 - Safety equipment: padded side rails related to poor safety awareness. 03/21/2024 - Safety check to be conducted every hour related to recent fall, every hour x 7 days. A Health Status note, dated 03/20/24 and authored by Licensed Practical Nurse (LPN) A, revealed: Resident noted to have discoloration to forehead, left side of face/neck this shift. No sign of pain/grimacing. Advanced Practice Registered Nurse (APRN) made aware of facial discoloration and order received to send resident out to emergency room (ER) for evaluation. Director of Nursing (DON) made aware. A facility report, dated 03/21/24 and authored by Registered Nurse (RN) B, read: CNA (certified nursing assistant) informed writer of bruising to resident's forehead around 5:00 p.m. Resident was restless at the start of shift. Not able to determine the cause of the bruising. Physician was notified and no new orders. A review of the resident's care plan, last revised on 02/27/24, noted that the resident had an Activities of Daily Living (ADL) Self-Care Performance Deficit related to weakness, poor endurance, activity intolerance, and impaired balance. Interventions included: Two half siderails may be up for enhanced mobility. Geri chair as needed for positioning and comfort. Requires assistance x2 for turning and repositioning and transfers. The care plan also indicated that the resident had impaired cognition and decision-making skills related to a diagnosis of dementia, and had a Determination of Incapacity (DOI) on file. A review of the Annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 02/09/24, revealed that Resident #26 had a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. The assessment also noted that the resident had no falls or wounds/skin tears, and bed rails were not used. In a joint interview on 03/27/24 at 12:44 PM with the Director of Nursing (DON) and Social Services Director (SSD), they stated LPN A informed the DON of the resident's forehead bruise on 03/20/24. The DON stated LPN A said she was not able to determine the origin of the injury but it appeared to have resulted from a fall. The DON stated she instructed LPN A to contact the resident's physician and have her sent to the emergency room for an evaluation. The DON also contacted the SSD and notified her of the concern. Staff involved were asked to write witness statements and none indicated knowledge of the origin of the injury. During the investigation on 03/21/23, RN B was interviewed by a representative from the Department of Children and Families and the SSD. RN B confirmed that she draped a sheet across the resident's siderails to keep the resident in bed. She reported the resident was restless but was still able to move all of her extremities freely and the sheet was not touching her body. The SSD and DON stated the facility did not use restraints. A review of the resident's Medication Administration Record (MAR) for March 2024 revealed that there were no behaviors noted. (Copy obtained) On 03/27/24 at 2:48 PM, LPN A/Evening Supervisor, was interviewed. She stated on 03/20/24 around 5:00 p.m., RN B, who was assigned to Resident #26, contacted her and stated the resident had a bruise on her head, the Advance Practice Registered Nurse (APRN) was notified, and no new orders were given. She told RN B that she would assess the resident as soon as she had an opportunity. She was assisting with an admission at the time. At around 9:00 p.m., CNA C approached her and stated she was concerned about the bruises on Resident #26's face. CNA C also stated there was a sheet tied across the resident's siderails. LPN A said she immediately went to the resident's room and found a bed sheet tied across the resident's siderails over the resident's abdomenal area. She stated RN B had followed her to the resident's room. Both CNA C and RN B stated they were not sure who put the sheet on the siderails. LPN A and RN B took the sheet off the siderails. LPN A conducted a skin assessment, which revealed skin tears to the left elbow, left jaw line and lateral neck and bruising/discoloration to the resident's forehead, left side of her face, left neck, left chest area, and left arm. She stated as soon as she contacted the DON, the DON instructed her to complete a body audit and notify the APRN. When asked if she notified the DON that the resident was found with a sheet tied to her siderails, she said, Yes. When asked if she notified the APRN of the sheet tied to the siderails, LPN A stated she could not recall. She confirmed that she completed the transfer form and indicated that the resident had fallen. She said, I thought it was an unwitnessed fall. She was then asked if the resident was able to get herself up after the fall, and she replied, No. She added, The sheet was not touching the resident's body; therefore, I did not think the bruises could have resulted from it. In a telephone interview on 03/27/24 at 3:47 p.m., CNA C stated she had been employed by the facility since 2020. She added that the facility protocol, upon reporting on duty, was to check the schedule for the assignment. Once the assignment was identified, she was to conduct rounds with the off-going staff, then obtain resident vital signs. She confirmed that she worked on 03/20/24 on the 3-11 shift and was assigned to Resident #26. When she reported on shift, she obtained vital signs. Resident #26 was restless and no bruises or skin tears were observed. She returned to the resident's room at approximately 4:45 p.m. to provide incontinence care. When she entered the room, she found the resident with bruises on her face, the side of her neck, her chest and a skin tear on her shin. She notified her assigned nurse (RN B) that the resident had a new bruise on her face. She also called her co-worker, CNA D, to assist with ADL care. When the nurse came to the room around 5:00 pm while CNA C and CNA D were providing incontinence care, CNA C asked Resident #26 what happened. Resident #26 pointed to RN B and said, You know what happened. RN B stroked the resident's face in a calming manner and stated she would notify the supervisor. At 9:00 p.m., CNA C and CNA D went to assist Resident #26 with ADL care. At that time they found a bed sheet tied across the resident's siderails over her abdomen. They also noted bruises to the resident's chest. CNA C stated she went directly to the supervisor. The supervisor and RN B returned to the resident's room and they untied the bed sheet from the siderails. On 03/28/24 at 1:07 p.m., an interview was conducted with the Medical Director. He stated he was notified that the resident had bruises on her face. He added that after evaluating the resident, he thought the resident had a fall and someone did not report it. He added that the resident's family was in the facility and was able to speak with the resident in French, but the resident could not recall what happened. When asked if he was notified about the sheet found tied across the resident's siderails, he said, Yes, and that was not acceptable. The facility does not allow restraints. A review of the facility's policy and procedure titled Siderails and Restraints (06/04/2020), revealed: It is the intention of the facility for each resident to attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience, and limit restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. Restraints will not be used for staff convenience. Procedures: Upon admission, the admitting nurse will complete the evaluation. The initial assessment included: Observation of the resident's movement in bed and resident's ability to independently use partial siderails to assist with turning, positioning, moving up and down, exiting and entering the bed. Assess the resident's ability to follow directions for use of siderails. Interview of alert resident to identify their performance for use of partial siderails to assist with need for mobility. After evaluation of the resident, if it is determined that the use of the siderails or restraint is appropriate, the least restrictive restraint will be deemed appropriate for individual resident to attain or maintain his or her highest practicable physical and psychological well-being. If the resident/resident representative request, or the facility deems the use of siderails is appropriate for the resident, the admitting nurse or nurse responsible for the resident at the time the determination is made, will compete the siderail evaluation and obtain informed consent for use. Whenever restraint use is considered, the facility will explain to the resident and or legal representative how the use of the restraint would treat the resident's medical symptoms and assist the resident in attaining or maintaining his/her highest practicable level of physical or psychological well-being. The nurse responsible for the resident at the time of the determination is made for the restraint use will complete the Restraint Evaluation within the resident's electronic medical record. The facility will also explain the potential negative outcomes of restraint use which include, but are not limited to, decline in the resident's physical functioning (e.g. ability to ambulate) and muscle condition, delirium, agitation and incontinence, and obtaine a consent for device use. Before using a device for mobility or transfer, an evaluation should include a review of the resident's bed mobility and ability to transfer between positions and from bed or chair to stand and toilet. The resident will be re-evaluated for appropriate use of the least restrictive device in conjunction with the Resident Assessment Instrument. A review of the Admission Packet - Restraint Section revealed that the facility believed in the resident's right to remain free from physical and chemical restraints whenever possible, therefore strived to maintain a restraint-free facility. If any type of restraint becomes necessary, it shall be used only upon a physician's order, a thorough assessment, and permission from the resident's legal designated representative.

Based on observations, staff interviews, record review, and facility policy review, the facility failed to ensure that residents who required respiratory care received such care consistent with professional standards of practice for three (Residents #110, #146, and #150) of 25 residents who required oxygen therapy from a total sample of 50 residents. failed to ensure that physicians' orders for respiratory care were followed as prescribed, and when not followed, the reasons were recorded in the residents' medical record during that shift for three (Residents #110, #146, and #150) of 25 residents requiring oxygen therapy, from a total sample of 50 residents. The findings include: 1. On 3/25/2024 at 10:18 am, Resident #110 was observed lying in bed wearing a nasal cannula. Resident #110's oxygen concentrator was observed with a flow rate set at 2.5 L/min (liters per minute). On 3/25/2024 at 1:46 pm, another observation was made of Resident #110 lying in bed wearing a nasal cannula with the oxygen flow rate set at 2.5 L/min. (Photographic evidence obtained) On 3/28/2024 at 9:20 am, a third observation was made of Resident #110's oxygen concentrator with a flow rate set at 2.5 L/min. (Photographic evidence obtained) A review of the resident's medical record revealed active physician's orders for oxygen at 2 L/min via nasal cannula every shift, dated: 11/9/2023. A review of the resident's Quarterly Minimum Data Set (MDS) assessment, dated 2/16/2023, revealed he had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 possible points, indicating intact cognition. A review of the resident's active care plan, initiated on 11/23/2023, revealed: oxygen therapy related to chronic obstructive pulmonary disease (COPD). Interventions included administering oxygen via __(specify) L/min and administering medications as ordered by the physician. Monitor/document side effects and effectiveness. The resident's Medication Administration Record (MAR) for March 2024 indicated no oxygen had been documented as administered for 3/18/2024 on the evening shift. All other oxygen was documented as having been provided at 2 L/min via nasal cannula as ordered by the physician, as opposed to 2.5 L/min as observed twice on 3/25/24 and once on 3/28/24. On 3/28/2024 at 9:31 am, Registered Nurse (RN) I stated Resident #110 would change his oxygen settings and sometimes unplug the machine. When asked how staff addressed this behavior with the resident, she stated, Staff reiterate to the resident the importance of his oxygen therapy. The nurse is responsible for providing ongoing monitoring of the resident'a oxygen therapy. Nurses are also responsible for ensuring that residents receive correct oxygen orders. Correct oxygen settings are identified in the order and the MAR. Central supply or nursing staff change residents' oxygen tubing every seven days or as needed. Correct oxygen settings are communicated from one staff person to another in report. RN I stated Resident #110 changed his own oxygen flow rate setting. He did not refuse oxygen therapy; he was not noncompliant but would forget. No documentation was noted in the resident's progress notes related to the resident changing his own oxygen setting or education provided to the resident regarding changes to oxygen settings. On 3/28/2024 at 1:27 pm, the Assistant Director of Nursing (ADON) confirmed that the correct oxygen settings were identified in the orders and MAR. 2. On 3/24/2024 at 3:10 PM, Resident #146 was observed with oxygen therapy in progress and a flow rate of 2 L/min via nasal cannula. (Photographic evidence obtained) On 3/25/2024 at 10:08 AM, the resident was observed with oxygen therapy in progress. The flow rate was set at 2 L/min via nasal cannula. (Photographic evidence obtained) A review of the resident's MDS assessment, dated 2/12/2024, revealed he had a Brief Interview for Mental Status (BIMS) score of 14/15, indicating intact cognition. There were no behaviors noted. A review of the resident's physician's orders revealed a 2/6/24 order for oxygen at 3 L/min via nasal cannula every shift. 3. On 3/24/24 at 3:57 PM, Resident #150 was observed receiving oxygen infusing at 3.5 L/min via nasal cannula. (Photographic evidence obtained) On 3/25/24 at 10:55 AM, the resident was observed receiving oxygen infusing at 2.5 L/min via nasal cannula. (Photographic evidence obtained) A review of the Admission MDS assessment, dated 2/8/24, revealed a BIMS score of 15/15, indicating intact cognition. The MDS further revealed no psychosis or behaviors indicated. A review of resident's physician's orders revealed an order dated 2/1/24 for oxygen at 4 L/min via nasal cannula every shift. A review of the facility's Nursing Manual: Standards and Guidelines: SG Respiratory Care and Oxygen Administration, Section Respiratory, Issued 3/2020, pages 1-2. Standard: It is the standard of this facility for respiratory guidelines for respiratory care and safe oxygen administration. Guidelines: 1. Verify that there is a physician's order for respiratory procedures or oxygen use. Review the physician's order for oxygen administration. 4. Oxygen therapy is administered by way of oxygen mask, nasal cannula, and/or nasal catheter as is ordered by the physician or required to provide for the needs of the resident. 48947

Based on observations, interviews, and record review, the facility failed to 1) Use appropriate alternatives prior to installing a siderail. 2) Review the risks and benefits of siderails with the resident or resident representative and obtain informed consent prior to installation, and 3) Re-assess the resident for risk of entrapment from siderails for one (Resident #26) of a total of 50 residents sampled. The findings include: On 03/25/24 at 2:25 p.m., Resident #26 was observed in bed. Her bed was in low position with floor mats on both sides of the bed. She also had a scoop mattress and half siderails that were padded. She had crossed her left leg over her right leg and was resting it on the right siderail. An attempt to speak with the resident was unsuccessful due to confusion. In an interview with Licensed Practical Nurse (LPN) G on 03/25/24 at 2: 30 pm in Resident #26's room, LPN G stated the resident understood minimal English. She added that the resident spoke French, but at times the family stated even her French did not make sense. LPN G was asked if the resident was at risk for falls and she replied, yes. She added that the resident had climbed over the siderail and had multiple falls. On 03/26/24 at 9:44 am, Resident #26 was observed in bed, lying on her back with her eyes closed. Her bed was in low position with padded half siderails and fall mats on both sides of the bed. On 03/27/24 at 11:19 am, the resident was observed in bed, lying on her back with her eyes closed. Her bed was in low position with padded half siderails and fall mats on both sides of the bed. A review of the resident's medical record revealed that Resident #26 was admitted to the facility on [DATE] with a re-entry on 03/21/2024. Her diagnoses included dementia with anxiety; vascular dementia, severe with anxiety; severe protein-calorie malnutrition; adult failure to thrive; generalized anxiety disorder; dependence on a wheelchair; cognitive/communication deficit; restlessness and agitation, atrial fibrillation; weakness, hypertension, pain, major depressive disorder, and insomnia. Her physician's orders included the following: 01/27/2023 - Half side rails x2 may be be up for enhanced independence and mobility. Monitor behavior for anxiety. 04/03/2023 - Sertraline 50 mg (milligrams) one time a day for depression 11/22/2023 - Trazadone 150 mg, give 0.5 tablet two times a day for major depressive disorder and insomnia 08/30/2023 - Lorazepam 1 mg two times a day for anxiety 03/20/2024 - Lorazepam 0.5 mg every 8 hours as needed for anxiety 03/21/2024 - Safety equipment: padded side rails related to poor safety awareness. 03/21/2024 - Safety check to be conducted every hour related to recent fall, every hour x 7 days. A facility note dated 02/26/24 read, Further investigation on discolored area, resident was noted with anticoagulants in place and recent incidents noted of resident grabbing side rails and pulling on them , scooting self closer to them. A review of the resident's care plan, last revised on 03/21/24, revealed that the resident was at Risk for Falls related to requiring assistance with transfers and toileting, impaired balance, cognitive deficit, restlessness, and resident climbs out of bed. The resident had an Activities of daily Living (ADL) Self-Care Performance Deficit related to weakness, poor endurance, activity intolerance and impaired balance. Interventions included Two half siderails may be up for enhanced mobility. Geri chair as needed for positioning and comfort. Requires assistance x 2 for turning and repositioning and transfers. Resident has impaired cognition and decision-making skills related to a diagnosis of dementia and has a Determination of Incapacity (DOI) on file. A review of the Annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 02/09/24, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 00 out of a possible 15 points, indicating severe cognitive impairment. In an interview on 03/27/24 at 12:50 pm, the Director of Nursing (DON) stated siderail assessments were done on admission and as needed. Staff should obtain consent from residents' families for residents who were unable to give consent. In an interview on 03/27/24 at 1:31 pm, the Director of Rehabilitation (DOR) stated physical Therapy (PT) as well as Nursing could conduct siderail assessments and make recommendations. When asked about Resident #26's functional status, the DOR stated the resident required maximum assistance for bed mobility and transfers. He added that the resident was on caseload for PT, occupational therapy (OT) and speech therapy (ST). When asked if his department had made any siderail recommendations for this resident, he said, As far as I can recall, my department has not made any recommendation for siderails. The resident is totally dependent with bed mobility and I don't think she can use the siderails for positioning. A review of the PT evaluation notes, dated 03/20/24, revealed that the resident was totally dependent with bed mobility and transfers without attempts to initiate. (Copy obtained) A review of the available Siderail/Entrapment Screenings, dated 01/27/23 and 05/16/23 revealed that the resident was confused, safety impaired, could not retain safety precautions or state her preference about siderails. The assessment noted that the resident representative requested the siderails. (Copies obtained) There was no consent obtained for siderail use. In an interview on 03/28/24 at 12:30 pm, LPN E/Unit Manager confirmed that Resident #26 used half siderails for safety. She also confirmed that the resident could not release the siderails if needed. She stated she padded the siderails because the resident was climbing over the rails and was getting skin tears. When asked if the resident was assessed for the siderails, LPN E stated the DON and Assistant Director of Nursing (ADON) should have those assessments. On 03/28/24 at 1:07 pm, an interview was conducted with the Medical Director. When he was asked about the resident's siderails, he stated initially the siderails were used as enablers for positioning, but he was made aware that the resident had a functional decline and therefore, the siderail use should have been reassessed. He added, Siderails do not prevent falls and per the Centers for Medicare and Medicaid services (CMS), siderails have been found to cause injuries. He also stated the facility should not use siderails unless they are assessed for reasonable use. A review of the facility's policy and procedure titled Siderails and Restraint Reduction (6/4/2020) revealed that It is the intention of the facility for each resident to attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limit restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. Restraints will not be used for staff convenience. Procedures: Upon admission the admitting nurse will complete the evaluation. The initial assessment include: Observation of the resident's movement in bed and resident's ability to independently use partial siderails to assist with turning, positioning, moving up and down, exiting and entering the bed. Assess the resident's ability to follow directions for use of siderails. Interview of alert resident to identify their performance for use of partial siderails to assist with bed mobility. After evaluation of the resident, if it is determined that the use of the siderails or restraints are appropriate, the least restrictive restraint will be deemed appropriate for the individual resident to attain or maintain his or her highest practicable physical and psychological well-being. If the resident/resident representative request or the facility deems the use of siderails is appropriate for the resident, the admitting nurse or nurse responsible for the resident at the time of the determination is made will competed the siderail evaluation and obtain informed consent for use. Whenever restraint use is considered, the facility will explain to the resident and/or legal representative how the use of the restraint would treat the resident's medical symptoms and assist the resident in attaining or maintaining his/her highest practicable level of physical or psychological well-being. The nurse responsible for the resident at the time of the determination is made for the restraint use will complete the Restraint Evaluation within the resident's electronic medical record. The facility will also explain the potential negative outcomes of restraint use which include, but are not limited to declines in resident's physical functioning (e.g. ability to ambulate) and muscle condition, delirium, agitation, and incontinence, and obtain a consent for device use. Before using a device for mobility or transfer, evaluation should include a review of the resident's bed mobility and ability to transfer between positions from bed or chair to stand and toilet. The resident will be re-evaluated for appropriate use of the least restrictive device on conjunction with the Resident Assessment Instrument. .

Based on observations, staff interviews, and review of facility records, the facility failed to maintain kitchen food distribution carts in a clean, safe, and sanitary manner for 3 of 5 food carts observed during lunch service to resident rooms. Failure to provide food services that meet standards of professional food service safety place residents at risk for possible illness. The findings include: On 9/8/23 at 12:10 pm, a tour of the facility was conducted during the lunch hour. Dietary staff were observed delivering beverages and meal trays to resident rooms on rolling food carts. On the 200 hallway, a two-tiered plastic rolling cart used to deliver lunch trays to that hall was observed to be stained and soiled. There were drips and splatters resembling food and beverage, and dark smudges, across the side of the cart's vertical surfaces. The four plastic legs were pitted, stained, soiled and scratched. The hydration cart on the 200 hallway was observed to have trash from opened straws and exposed/uncovered cup lids on the shelves, which were stained and soiled. The bottom shelf had an unknown black substance. The top shelf of the cart was also stained and soiled around the edges. The metal cart legs were covered with a substance resembling rust. (Photographic evidence was obtained) During observations on the 600 hallway, meals were delivered on a tall (approximately 5 feet) metal cart. Drips and splatters of what resembled dried-on food and/or beverages were observed on the sides of the carts. (Photographic evidence was obtained) During an interview with the Registered Dietician (RD) at 2:25 pm on 9/8/23, she was asked to provide a kitchen Cleaning Assignment Schedule. The document read September 2023 across the top of the form. One of the tasks listed on the form was Meal Carts and another was Coffee Carts. Most of the tasks were signed off by staff but there no tasks dated past 8/30/23. The meal and coffee carts were signed off as completed but there was no date indicating the last time they were cleaned. (Photographic evidence was obtained) The RD stated she was not aware of how often the carts were to be cleaned but had seen staff wipe them down between meals. When shown the photographic evidence, she said, That's not good. They should at least wipe them before distributing the meals. On 9/8/23 at 2:35 pm, Dietary Aid (DA) A was interviewed. When asked about the lunch carts, she stated they used to have a porter who would take the coffee and food carts outside and power wash them daily. Since there was currently no porter, staff just wipe them down after meals with soapy water and a rag. The DA was shown the pictures. Upon seeing the condition of the carts, she said, Oh God, that's not good! She confirmed the carts were not clean and they needed daily and deep cleaning.

Based on observation, staff and resident interviews, medical record review, and facility policy review, the facility failed to implement their abuse investigation and reporting policy related to an injury of unknown origin, and failed to file a federal report within the required timeframe to the State Survey Agency for one (Resident #3) of three sampled residents reviewed for abuse. The findings include: On 10/07/22 at 12:50 pm, Resident #3 was observed to have a bluish/purple color under his right eye. He stated, I woke up a week or two ago and had this bruise. I don't know how it happened. I don't know if someone hit me while I was sleeping or what happened, but I woke up and had a bruise. They said maybe I had a [CONDITION(S)] and hit the siderail, but I don't know. When asked if he made the facility aware of the bruised area. He stated, Yeah, I told the nurse, but they didn't know how it happened, either. I filed a report with the ombudsman, and she came to see me. A review of the medical record for Resident #3 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #3's 5-day minimum data set (MDS) assessment dated [DATE] revealed he had a brief interview for mental status (BIMS) score of 15 out of 15 points, indicating intact cognition. A review of Resident #3's progress notes created by Employee A, Registered Nurse (RN) revealed the following: 9/20/22 13:47: Resident approached this writer in office to discuss health related issues and this writer noticed a teardrop shape discolored area under right eye. Upon further inquiry, resident stated I don't know what happened. I woke up yesterday morning and it was like this. APRN and friend made aware. 9/21/22 12:16: Resident came to this writer stating Someone hit me. I didn't see who it was, but I know someone hit me. When inquiring if he would have woke up if struck, resident stated, No, I wouldn't of. Discolored area appearing larger today then yesterday. Measuring at 1.5cm x 2cm currently. MD and family made aware. (Photographic evidence obtained) A review of Resident #3's progress notes dated 9/21/22, made by his nurse practitioner revealed, Patient is seen for bruise. Pt asked to be seen today for bruise to his right eye. Pt does not know how he got the bruise but states he does toss and turn at night due to inability to lay on his back due to chronic back pain. (Photographic evidence obtained) During an interview with the Administrator on 10/7/22 at 1:10 pm, she was asked if she had any knowledge of a bruise under Resident #3's right eye. She stated, Yes, I'll get the investigation for you. A review of the facility investigation with Administrator revealed a DCF (Department of Children and Families) contact form, nurse practitioner notes from 9/21/22, and Resident #3s physician orders. The administrator stated, The bruise was reported to DCF and (DCF worker) came in to see the patient, but she closed the case without findings. He was seen by his nurse practitioner for the bruise. When the administrator was asked if any report for abuse, neglect or injury of unknown origin was filed. She stated, No. When she was asked if a report should have been filed, she stated, Yes, probably. We're going to do that today. During an interview with the Social Services Director on 10/7/22 at 1:20 pm, she was asked about the above-mentioned incident regarding Resident #3 and if any reports were filed. She stated, The Director of Nursing/Risk Manager would normally file the 1-day report for an injury of unknown origin. I believe this wasn't considered an injury of unknown origin because he told the nurse practitioner that he hit his eye on his bed rail. We're going to file a one-day report now. The resident called DCF and (DCF worker) came out, but she closed the case and didn't accept it after speaking with him. He fabricates issues and he is care planned for that. The staff follow his care plan for his behaviors, but he has a traumatic brain injury and that affects him and causes him to act out and fabricate stories. During an interview with Employee A on 10/7/22 at 3:20 pm, she was asked if she was familiar with Resident #3. She stated, Yes, he is on my unit. When asked if she could recall her interaction with him on 9/20/22. She stated, Yes, he usually sees me at least 2, 3, 4 times a day. We talk throughout the day, sometimes he tells the same stories, or he just wants to talk. He came into the office that day; I think he was talking about his cough and that was already a resolved issue, but we were just discussing it. I noticed a mark under his right eye, and I asked him about it. He said he didn't know what happened, he said he was asleep, and when he woke up, it was like this. I notified his practitioner and left a voice mail for his friend, his emergency contact. I told him if he had any pain or changes to let me know. When asked to describe the area she observed. She stated, It was tear drop in shape, under and to the side of his right eye. It was slightly green around the edges with a light blue and dark purple hue center. She then stated, The next day he came to me and changed his whole story. He told me, Someone had to hit me, I didn't see it, but I know someone had to hit me. I noticed the area looked a little larger. It appeared there may have been some re-injury to the area, like it had been spreading. I measured the area then. Since then, the area has been decreasing. She was asked if she reported what she observed to anyone. She stated, Yes, to his nurse practitioner and to his emergency contact on the 20th. I reported it on the 21st to social services. When asked if she reported the observation to anyone else. She stated, No. During an interview with Employee B on 10/7/22 at 3:45 pm, she was asked if she had worked with Resident #3. She stated, He's not been assigned to me, but I have assisted other CNAs (certified nursing aides) by answering his call light. When asked if she had noticed a bruise under his right eye. She stated, Yes, I saw that a couple weeks ago. When asked if she let anyone know about the bruised area she observed. She stated, No because it was already known by staff that the bruise was there. Record review of the facility's policy titled, Abuse Investigation and Reporting, revised July 2017, revealed: Policy statement: All reports of resident abuse, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown origin (abuse) shall be promptly reported to local, state and federal agencies (as defined in current regulations) and thoroughly investigated by facility management. Reporting: 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown origin and misappropriation of property will be reported to the facility Administrator or his/her designee, to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; c. The resident's representative of record; d. Adult protective services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's attending physician; g. The facility Medical Director. 2. An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately but no later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. (Photographic evidence obtained)

Based on observations, interviews, record review, and review of the facility's policy, the facility failed to provide appropriate and timely assistance with toileting for one (Resident #3) of three residents reviewed for activities of daily living (ADLs), who required extensive assistance with toileting. The findings include: On 07/22/2022 at 9:12 AM, a call light was observed illuminated over the doorway to Resident #3's room. After knocking on the door and asking whether she was alright, the resident stated, she put the call light on because she thought she had a bowel movement and needed her brief changed. During this time, Employee A, Certified Nursing Assistant (CNA) entered the room and spoke with the Resident in A bed. The Resident in A bed told Employee A, CNA that she wanted her head up. The CNA told the Resident in A bed, your position looks fine. The resident in A bed repeated she wanted her head up and Employee A, CNA assisted the resident with raising the head of bed. Employee A, CNA then went to Resident #3 in B Bed. Resident #3 told Employee A, CNA, I need to have my brief changed. Employee A, CNA told her, she was passing meal trays now, and would come back. Employee A, CNA turned off the call light and left the room on 07/22/2022 at 9:15 AM. An interview was conducted with Employee C, CNA on 07/22/2022 at 9:16 AM. When she was asked about answering call lights, she said, When I respond to a call light, I turn off the light and meet the resident needs. If I cannot meet their need at that time, then I would leave the call light on. On 07/22/2022 at 9:17 AM, Employee A, CNA was observed entering Resident #3's room with a breakfast meal tray. Employee A, CNA explained to Resident #3, that she could eat her breakfast while it was hot, and she would be changed after her breakfast. An interview was conducted on 07/22/2022 at 9:21 AM with Employee B, RN-Unit Manager (UM). She was told about the interaction between Employee, A CNA and Resident #3 as mentioned above. The UM stated that this was not an acceptable practice if Resident #3 needed to have her brief changed, and that she would take care of that right away. During an interview with Resident #3 on 7/22/2022 at 11:30 AM, she confirmed that Employee A, CNA came in her room, placed her meal on the over the bed table and told her that she could eat, and they would be back to change her after she ate. Resident #3 added that Employee A, CNA told her she had to find her CNA. An interview was conducted with the Director of Nursing (DON) on 07/22/2022 at 2:49 PM. The DON confirmed that Employee A, CNA should not have put off Resident #3 who needed a brief change. It was not acceptable to leave a resident in a soiled brief until after breakfast. A medical record review was conducted for Resident #3. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of possible 15 points, indicating she was cognitively intact. Section G, Functional Status of the MDS indicated the resident required extensive assistance with toilet use with one-person physical assist. (Copy obtained) A review of the care plan for Resident #3 with revision date of 06/16/2022 revealed a focus of ADL self-care performance deficit related to [CONDITION(S)], seizures, [CONDITION(S)], and impaired mobility. Resident #3 requires total assist of one to two persons for ADLs. Interventions included total assist one for toileting, does not utilize commode. The care plan also revealed a focus of incontinent of bowel related to impaired mobility and [CONDITION(S)]. Interventions included check resident every two hours and assist with toileting as needed and provide pericare after each incontinent episode. (Copy obtained) A review of the facility's policy, Answering the Call Light indicated the steps in the procedure at line 4. Do what the resident asks of you, if permitted. If you are uncertain as to whether or not a request can be fulfilled or if you cannot fulfill the resident's request, ask the nurse supervisor for assistance. (Copy obtained)

Based on record reviews, observations, and interviews, the facility failed to ensure the medical records were accurately documented in accordance with acceptable standards of practice for one (Resident #81) of two residents reviewed for respiratory care; and for one (Resident #91) of one resident reviewed for skin care, from a total of 23 residents in the sample. The findings include: 1. A record review for Resident #81 revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 15 out of 15 points, indicating she was cognitively intact and able to independently make decisions. A review of Resident #81's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the care plan for Resident #81 revealed she was care planned on 2/16/22 for her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included [CONDITION(S)] as ordered; Assure it is working correctly; Assess frequently for tolerance to treatment; and encourage to wear as ordered. Instruct resident on the benefits and risks related to treatment. If resident refuses to use the [CONDITION(S)], document the refusal, inform the physician and if needed, get a risk/benefit form signed. (Photographic evidence was obtained) During an inspection of Resident #81's room on 3/28/22 at 11:31 AM, a [CONDITION(S)] machine was observed on the resident's bedside table. During a follow up inspection of Resident #81's room on 3/30/22 at 10:15 AM, the [CONDITION(S)] machine was observed in the same location with two bed pillows sitting on top of the machine. An interview was conducted with Resident #81 on 3/30/22 at 1:21 PM. She stated, she was doing well. When she was asked about her use of the [CONDITION(S)] machine. She said, she used the device at home, but had never used it since her admission to the facility. She no longer needed it. Resident #81 stated if she did need to use it, she was sure all she had to do was to notify the nurse; however, there was no reason for her to use it. A record review of Resident #81's electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A Key Code at the bottom of the eMAR revealed the number 2 was to be used for any medication/treatment refused. The code had not been used all month. (Photographic evidence was obtained) During an interview with Employee B, Certified Nursing Assistant (CNA) on 3/30/22 at 1:41 PM, she confirmed that she had never seen Resident #81 use the [CONDITION(S)] machine. During an interview with Employee C, Registered Nurse (RN) on 3/30/22 at 2:34 PM, she thought Resident #81 used her [CONDITION(S)], but had never seen her using it. She explained that if the resident refused to use the machine, staff would code the electronic medication or treatment administration record to indicate resident refusal. Employee C, RN reported that Resident #81 was alert and oriented. A second interview was conducted with Resident #81 on 3/31/22 at 9:50 AM. During the conversation, she again denied ever using the [CONDITION(S)] while a resident of the facility. She only used it at home. Observation at this time found the [CONDITION(S)] in same location on the bedside table, and the snorkel (nosepiece) had not moved since the first observation. (Photographic evidence was obtained) A review of Resident #81's nursing progress notes during the month of March 2022 revealed no refusals or explanations that the device was not used. On 3/31/22 at 10:17 AM, an interview was conducted with Employee A, Licensed Practical Nurse (LPN) regarding Resident #81. She stated that she did not know if Resident #81 used her [CONDITION(S)] machine. She was asked to review the resident's March eMAR. After reviewing the eMAR, she confirmed that the nurses had signed off that the machine was being used during the day, evening, and night shift from 3/1-3/29/22. She explained that Resident #81 was alert and oriented and, to her knowledge, had never refused any medications or treatments. Employee A, LPN added that if she had refused any treatment, the nurse should enter a 2 in the corresponding signature box to indicate refusal. Employee A, LPN confirmed that Resident #81 was an accurate enough historian to self-report not using the device. An interview was conducted with Employee D, Registered Nurse/Unit Manager on 3/31/22 at 10:40 AM. She stated, she reviewed Resident #81's March eMAR for the [CONDITION(S)], and confirmed it was signed off as used on every shift. She explained that it was not her expectation that it would be signed off as being used when it was not. In addition, she expressed certainty that the device would not be used on every shift. 2. A record review for Resident #91 revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the annual MDS assessment dated [DATE], assessed her as rarely/never able to make herself-understood and rarely/never able to understand others. The resident required assistance with all activities of daily living (ADLs) and was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #91's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Photographic evidence was obtained) On 3/28/22 at 10:58 AM, Resident #91 was observed in her room with a laceration approximately 2.5 inches on her right forearm which was surrounded by a large bruise. An oversized rectangle foam bandage was falling off and the wound was exposed. The left elbow had a bruise which was approximately 3 x 2 inches. There was also a bandage on Resident #91's left wrist. An interview was attempted with Resident #91 at this time; however, she was unable to explain her injuries. Both of Resident #91's arms were exposed during the observation. A review of care plan for Resident #91 revealed she was care planned on 2/16/22 for self-care performance deficit related to her requiring limited to total assistance with ADLs. The goal was to maintain her current level of function through the next review. Interventions included to encourage resident with daily clothing choices, and Geri sleeves (protective sleeves worn on the arms) on all extremities. (Photographic evidence was obtained) Additional observations of Resident #91 revealed her arms were bare, and she did not have Geri sleeves on her arms during the following dates. 3/28/22 at 12:37 PM 3/29/22 at 12:05 PM 3/29/22 at 9:17 AM 3/29/22 at 12:08 PM 3/29/22 at 4:00 PM 3/30/22 at 9:25 AM 3/30/22 at 9:50 AM 3/30/22 at 12:44 PM 3/31/22 at 10:00 AM A record review of Resident #91's electronic Treatment Administration Record (eTAR) for March 2022 revealed the sleeves were signed off as applied on the day, evening, and night shifts. Further record review revealed the eTAR was documented that Resident #91 had her sleeves on for the past four days (3/28-3/31/22). (Photographic evidence was obtained) A review of Resident #91's nursing progress notes for March 2022 revealed there were no refusals noted and no explanation that the Geri sleeves were removed by the resident. On 3/30/22 at 1:37 PM, an interview was conducted with Employee B, CNA. She reported Resident #91 seemed to bruise easily and had Geri sleeves, but when staff put them on, the resident took them right off. On 3/30/22 at 2:30 PM, an interview was conducted Employee C, RN. She reported Resident #91 had Geri sleeves which she removed. She explained that the resident kept them on if she had on long sleeves, because then, she didn't know they were on. She stated that when the resident removed her bandages it should be documented. She explained there was a code on the eTAR that would be used for removing/refusing them. She could not recall if it was a 2 or a 3, but that it was supposed to be used to indicate refusal. The CNAs applied the Geri sleeves and staff try to reapply if she removes them. She confirmed that any removal should be documented. On 03/31/22 at 10:06 AM, an interview was conducted with Employee A, LPN. She reported, Resident #91's skin was very fragile. She said, the CNAs normally applied her Geri sleeves, and the resident would remove them. Sometimes the night shift got her up and applied them, or the day shift would do it if they were not on when they came in. When Employee A, LPN was told that Resident #91 Geri sleeves had not been observed on her since 3/28/22, she reviewed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the Unit Manager on 3/31/22 at 11:45 AM, she reported that the nurse on duty had corrected the situation for Resident #91 by applying the Geri sleeves. She confirmed her expectation was that nurses documented all refusals on the eTAR or eMAR using the codes for Refused or See nurses note.

Based on a review of facility records and an interview with the Administrator, the facility failed to report neglect that resulted in serious bodily injury for one (Resident #1) of one residents reviewed for neglect, from a total of four sampled residents. The findings include: A record review for Resident #1 found she was [AGE] years old. She had a Discharge Return Anticipated Minimum Data Set (MDS) assessment with an assessment reference date of 6/28/20. Resident #1 was noted with an unplanned discharge to an acute hospital. She had severely impaired cognition for daily decision making, required extensive assistance with bed mobility, and was totally dependent on staff for toileting. She was noted as always incontinent of bowel and bladder. Her [DIAGNOSES REDACTED]. She had one fall with injury since her prior assessment. The quarterly MDS assessment, dated 4/24/20, noted Resident #1 had a brief interview for mental status (BIMS) score of 5 out of a possible 15 points, indicating severe cognitive impairment, and she required extensive assistance of two or more staff for bed mobility and toileting. Resident #1 was care planned for activities of daily living (ADL)/self-care performance deficit related to her weakness, cognitive impairment, and impaired mobility. The care plan noted Resident #1 was non-ambulatory and required total assistance of two to three staff members for repositioning and turning in bed. She also required total assistance of two staff members for dressing and toilet use. Hospital records dated 6/28/20, noted Resident #1 had an unwitnessed fall resulting in right ankle deformity. X-ray results showed distal tibia-fibula fractures (the two lower leg bones above the ankle), distal femoral fracture (the large bone in the upper leg) and a possible [MEDICAL CONDITION] (knee bone). A review of facility reports confirmed that on 6/28/2020, at approximately 3:00 pm, Employee D, the certified nursing assistant (CNA) assigned to Resident #1, went into the resident's room to provide incontinence care. As the resident was being assisted onto her side, the CNA turned to obtain a clean adult protective undergarment. Resident #1 slid out of the bed at that time and her legs landed awkwardly. She was sent to the emergency room and was diagnosed with [REDACTED]. An investigation revealed the resident had care plans instructing that two staff be present to provide care, and Employee D had acted alone. The facility's policy and procedure on Abuse (revised July 2017) noted under Role of the Administrator: 1. If an incident or suspected incident of resident abuse, mistreatment or neglect . is reported, the Administrator will assign an investigation to an appropriate individual . .5. The Administrator or designee will provide the appropriate agencies a written report of the findings of the investigation within five (5) working days of the occurrence of the incident . The policy did not incorporate the requirement for an immediate report to the State Survey Agency following serious bodily injury. Review of state federal immediate and 5 day reports found no report was filed after the facility investigation revealed the employee's negligence in adhering to Resident #1's care plan and the resulting fall with major injuries to this resident. An interview was conducted with the Administrator at 2:45 pm on 7/27/20. He confirmed he did not file and immediate or 5-day federal report, because he thought he only had to file a 15-day adverse incident report to fulfill the regulatory requirements. The regulation was read to him and he acknowledged the reporting requirements.

Based on interviews with the complainant, facility staff, public officials and family members and a review of resident and hospital clinical records, the facility failed to permit one (Resident #1) of one sampled resident reviewed for facility-initiated discharge, to remain in the facility and not be discharged while her discharge appeal was pending. Resident #1 had exercised her right to appeal a 30-day notice of discharge. She remained in the facility under appeals protection until she was transferred to the hospital under a Baker Act for behavioral and medical issues. The facility then refused the resident readmission and continued residency in her home (the facility) while the appeals decision was pending. As a result, Resident #1 was displaced from her home of two years and relocated three separate times in one month. This resulted in undue confusion for the resident and distress to the family. The findings include: A telephone interview was conducted with the Complainant on 9/26/19 at 4:05 PM as part of the pre-survey preparation and planning process. The Complainant stated Resident #1 had lived in the facility for two years. On 7/2/19, the facility issued a 30-day discharge notice to Resident #1. The effective discharge date was projected to be 8/2/19. The discharge was appealed on behalf of Resident #1, and appeals hearing results were still pending. The Complainant explained while waiting for the results of the hearing, Resident #1 developed an infectious urinary tract infection and was not able to be maintained on isolation due to her wandering behavior. In addition, Resident #1 was alleged to have made suicidal statements. This resulted in a transfer out under a Baker Act on 8/5/19. Resident #1 was then dumped at a receiving hospital at 10:00 PM at night. She was then refused readmission by the facility Administrator. The hospital's psychiatric ward did not know what to do with Resident #1 after she was refused readmission to the long-term care facility. The hospital tried for two weeks to find an alternate placement. The facility staff had suggested two possible nursing homes for placement, each having a locked or secured unit. Resident #1 had no valid Power of Attorney designation, therefore there was no choice but for family to agree to alternate placement in one of those two nursing homes. The conditions in the first home were found to be unacceptable after placement, so Resident #1 was moved to the second nursing home. The Complainant said she recently visited with Resident #1 in one of the two alternate facilities. The resident told the Complainant, I am so glad I ran into you. I am so confused, I don't know where I am. The Complainant explained that Resident #1 just wanted to go home, that the discharging facility had been her home. A telephone interview was conducted with the clerk at the Office of Appeals on 9/27/19 at 10:20 AM. He reviewed the case number and confirmed the appeals hearing had already occurred. There was still no final order or ruling at this time, as it was pending review by a supervisor. A telephone interview was conducted with the hospital Case Worker on 9/27/19 at 10:34 AM. She confirmed Resident #1 was transferred to her unit under a Baker Act and was then refused readmission to the long-term care facility. A closed record review revealed Resident #1 was admitted to the facility on [DATE], with a readmission on 4/10/18 and a discharge on 8/5/19 (under the Baker Act). She was [AGE] years old. A Discharge Return Not Anticipated Minimum Data Set (MDS) assessment with an assessment reference date of 8/5/19, found Resident #1 had an unplanned discharge to an acute hospital with no return anticipated. She was assessed with [REDACTED]. Wandering behavior occurred on one to three days over the 7-day look back period. She required supervision with walking and eating, and limited assistance with personal care and toileting. Resident #1 was occasionally incontinent of bladder and bowel. [DIAGNOSES REDACTED]. Active discharge planning was occurring for her to return to the community. Resident #1 was care planned for no longer residing on the facility's secured unit due to the unit closing on 5/23/19. The goal was for Resident #1 to remain safe and secure and adjust to the new environment of the facility by the next review. Interventions included: Assist to activities and placement of a Wanderguard (personal alarm). She was care planned for activities of daily living (ADL) self-care performance deficit related to impaired cognition, and as an elopement risk with aimless wandering, aggression, and resistance to care. Resident #1 also had a care plan for behavior problems related to her [DIAGNOSES REDACTED].? or Why am I here? or How long do I have to stay here? and Where is my daughter? Where is she? I want to go home. Resident #1 was placed on one to one (1:1) supervision for safety. Approaches included 1:1 staffing until a secure unit could be located. Resident #1 had physician's orders [REDACTED]. She had a physician's orders [REDACTED]. A Behavioral Health Visit dated 6/28/19, revealed the resident had anxiety related to confusion/dementia. She was oriented only to herself, had brief attention/concentration and a pleasant affect. Mood was euthymic (tranquil). There was no apparent risk to herself or others. Notes indicated she continued to wander with 1:1 supervision. The function of this behavior was sensory-seeking, as she had a history of [REDACTED]. She was seen by the Physician/Medical Director on 7/2/19 for confusion and wandering. The note read, Patient was noted to be walking in the hallway and very confused at the time of the visit. She did not follow commands. Nursing reported this patient needed to be redirected multiple times a day. The plan indicated confusion/wandering/restlessness, monitor, redirect, and implement fall precautions. The physician noted dementia with behavioral disturbance and recommended to continue the current regimen and monitor behaviors. The Physician/Medical Director wrote an order on 7/2/19 which read, OK to discharge to (name of nursing home) due to needing a secure unit due to advanced dementia and wandering for safety. Resident's need cannot be met in this facility, and patient will need a secure unit due to advanced dementia and (wondering). A Nursing Home Transfer Discharge Notice was completed on 7/2/19 for an effective discharge date of [DATE]. The discharge location was another nursing home. The Reason for Discharge or Transfer noted Resident #1's needs could not be met in this facility. The Brief Explanation to Support the Action stated Resident #1 would need a secure unit due to advanced dementia and wandering. The form was signed by the Administrator and the Physician/Medical Director on 7/2/19. A hand-written note dated 7/2/19 at 1:00 AM, explained that the Social Services Director (SSD) and a family member had reviewed the discharge and transfer notice, the appeal rights, and the number to call. A progress note authored by the SSD on 7/22/19 at 4:42 PM, indicated the facility had been advised that Resident #1 had appealed the discharge decision and would be notified of the date/time of an appeal hearing. On 8/4/19, laboratory test results showed Resident #1 had ESBL (extended spectrum beta-lactimase, an antibiotic-resistant bacteria) in her urine. [MEDICATION NAME] (antibiotic) 500 mg twice a day for 10 days was ordered on [DATE], and contact isolation was ordered on [DATE], to be implemented every shift. Resident #1's record also showed that on 8/5/19, the Physician/Medical Director wrote an order for [REDACTED]. A Nursing Home Transfer and Discharge Notice dated 8/5/19, effective same day, revealed Resident #1 was being transferred to a local hospital. The notice explained Resident #1's needs could not be met and the health and safety of others in the facility was endangered. The Physician noted Resident #1 was a risk to herself, trying to get out of the facility, and a risk to others due to ESBL in her urine and her inability to remain on isolation. A Certificate of Professional Initiating Involuntary Examination was executed and signed by the Physician/Medical Director on 8/5/19 at 6:15 PM. Mental illness [DIAGNOSES REDACTED]. Because of the mental illness, Resident #1 had refused or was unable to determine for herself whether voluntary examination was necessary. There was substantial likelihood that without care or treatment she would cause serious bodily harm to herself or others in the near future, as evidenced by her recent behavior. The Supporting Evidence noted a urinary tract infection [MEDICAL CONDITION] with resistant bacteria (ESBL) and the inability to keep the resident on isolation. She was walking in the hallway and trying to get out of facility. She pushed the staff and threatened to hurt them, stating to staff she was going to kill herself. Resident #1's record included a document titled Transportation to Receiving Facility which reported Resident #1 was taken into custody by law enforcement and delivered to the hospital on [DATE] at 9:35 PM. An electronic Recapitulation of Stay note dated 8/5/19, revealed Resident #1 was Baker Acted related to wandering, unable to maintain isolation, and for health threat to others and self. The Disposition of Belongings section of the form stated Resident #1's items had been packed and were being held until the family could claim them. There were no notes in Resident #1's closed records after 8/5/19. There was no documentation, either electronic or handwritten, regarding communication between the facility and the hospital following Resident #1's transfer related to her condition, treatment, progress or emotional state. In addition, there were no notes detailing any communication between the facility and Resident #1's family following the Baker Act. An interview was conducted with Registered Nurse (RN) A on 9/27/19 at 2:20 PM. She remembered Resident #1, explaining she would typically pace up and down the hallways of the locked unit where she resided before it was unlocked. Resident #1 would also cling to this RN whenever she was on duty and was always right behind her. The RN said she was not on duty the day of the Baker Act but had heard about it. She did not know why this resident did not come back, stating apparently someone made that decision. An interview was conducted with the SSD on 9/27/19 at 2:30 PM. She confirmed Resident #1's 30-day day discharge had been appealed, and that the appeal hearing had taken place in the facility. They were still waiting for the final decision. During Resident #1's hospital stay, staff called the facility wanting to make sure Resident #1 would be permitted to return. The hospital was told their records would have to be reviewed before making the decision to permit Resident #1 to return. During the hospital stay, Resident #1's family member decided she did not want Resident #1 to go to the nursing home originally listed on the 30-day discharge notice. She asked the SSD to call another nursing home, and Resident #1 was discharged from the hospital to that alternate location. The SSD insisted the family member made the decision not to return Resident #1 to the facility out of fear Resident #1 would lose her appeal. The SSD denied that the facility refused readmission. She explained the decision to permit Resident #1 to return to the facility depended on review by the Director of Nursing (DON), Medical Director and Administrator. She was asked if there was any documented correspondence with the hospital staff regarding the resident's status or pending discharge. She said no, explaining there was no way to document progress notes in the system past the day of discharge. The SSD again insisted that Resident #1's family member stated verbatim that she feared she would not win the appeal, therefore wanted to secure alternate placement for Resident #1. She insisted that at no time did (no one) say Resident #1 could not return. An interview was conducted with the Administrator on 9/27/19 at 2:45 PM. He said the situation with Resident #1 was complicated. During Resident #1's hospitalization , the facility was communicating with hospital staff and recommended Resident #1 go to a facility with a locked unit. The Long-Term Care Ombudsman informed the facility that Resident #1's family no longer wanted Resident #1 to discharge to the nursing home listed on the original 30-day discharge notice. He said, Our facility staff was still debating, or rather communicating to the hospital that (Resident #1) needed a locked unit. The appeals hearing got delayed. Resident #1's family had been in communication with the facility SSD. Said family member told the SSD that if (name of nursing home) would accept Resident #1, she would allow her to go there. So, the hospital discharged the resident there. He was later told during the appeals hearing that family was unhappy with the chosen placement, and now wanted Resident #1 to go to another nursing home. That was the last he had heard. He was not sure where Resident #1 was now. He stated he guessed if the appeal was upheld, he would have no choice but to take Resident #1 back. He said his Medical Director felt Resident #1 was unsafe to return to the facility, but the hospital Physician said she was. He asked, Who was right? The Administrator was asked if he ever told the hospital that Resident #1 could return to the facility. He said he told them the decision would be pending review by the Medical Director, DON and him. The DON, who was in the room at the time, was asked if the hospital or the family was ever told Resident #1 could return following her hospitalization . She also stated the hospital was told the facility team would have to review the chart first to make that determination. Readmission was also dependent on whether the hospital determined Resident #1 would need a locked unit. The requirements regarding permitting transferred residents to return to the facility while an appeals decision was pending was explained. The DON and Administrator both acknowledged the regulatory requirement. The Administrator admitted he had no written policy and procedure for permitting residents to return to the facility. Concern was expressed to the Administrator that neither the family nor the hospital was told Resident #1 could return to her home of two years in order to wait for the final ruling of the appeal, as required. As a result, Resident #1 had now been relocated three times in just over a month, first to the hospital, then to two subsequent nursing homes. The DON, Administrator and SSD (also in the room) acknowledged the level of confusion a resident with a [DIAGNOSES REDACTED]. On 9/27/19 at 3:45 PM, a telephone call was placed to Resident #1's family member. She was asked to verify she was never told that Resident #1 could not return to the facility. She was also asked if it was her decision to find another placement for Resident #1 after her hospitalization , rather than return her to the facility. The family member insisted the facility Administrator and SSD one hundred percent refused to take Resident #1 back. She stated the SSD said that unless the doctor, DON and Administrator had a meeting, they would not be able to readmit. That meeting apparently never occurred. When the hospital asked the facility what to do with Resident #1, the facility staff directed them to find her alternate placement; they could not take her back. She concluded by stating the decision to place Resident #1 somewhere else was not made by her. She felt her back was against the wall and she had no other choice at that point. A review of the hospital Psychiatric Discharge Summary dated 8/16/19 revealed Resident #1 was admitted on [DATE]. She was noted with initial agitation in the emergency room , but upon transfer to the unit there were no aggressive behaviors. Resident #1 was seen and examined by psychiatry and [MEDICAL CONDITION] medications were adjusted. There was no evidence of any suicidality of homicidality on the in-patient unit since her admission. Resident 1's mood remained stable with the benefit of psychopharmacological treatment, and there was no behavioral disturbance since admission. Resident #1 was noted to interact with staff adequately, and the Counselor had arranged a discharge plan. Resident #1 had been off of 1:1 observation for 24 hours prior to the discharge and there were no behavioral issues overnight. The resident's level of function was deemed adequate for outpatient care. The notes stated Resident #1 had maximized the benefit from the in-patient psychiatric hospital stay and would be discharged with a discharge plan. A case note authored by the hospital's Care Manager (CM) on 8/6/19 at 1:47 PM was included with the Discharge Summary. The CM wrote she had received a call from the facility's Admissions Director, who stated Resident #1 would not be able to return to them. Due to the Baker Act and the resident needing a locked facility, she would not be able to return.

Based on interviews with the complainant, facility staff, public officials and family members, and review of resident and hospital clinical records, the facility failed to establish and follow a written policy for permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. The facility failed permit one (Resident #1) of one sampled resident reviewed for facility-initiated discharge to remain in the facility, and not be discharged while a discharge appeal was pending. Resident #1 had exercised her right to appeal a 30-day notice of discharge. She remained in the facility under appeals protection until transferred to the hospital under a Baker Act for behavioral and medical issues. The facility then refused the resident readmission and continued residency in her home (the facility) while the appeals decision was pending. As a result, Resident #1 was displaced from her home of two years and relocated three separate times in one month. This resulted in undue confusion for the resident and distress to the family. The findings include: A telephone interview was conducted with the Complainant on 9/26/19 at 4:05 PM as part of the pre-survey preparation and planning process. The Complainant stated Resident #1 had lived in the facility for two years. On 7/2/19, the facility issued a 30-day discharge notice to Resident #1. The effective discharge date was projected to be 8/2/19. The discharge was appealed on behalf of Resident #1, and appeals hearing results were still pending. The Complainant explained while waiting for the results of the hearing, Resident #1 developed an infectious urinary tract infection and was not able to be maintained on isolation due to her wandering behavior. In addition, Resident #1 was alleged to have made suicidal statements. This resulted in a transfer out under a Baker Act on 8/5/19. Resident #1 was then dumped at a receiving hospital at 10:00 PM at night. She was then refused readmission by the facility Administrator. The hospital's psychiatric ward did not know what to do with Resident #1 after she was refused readmission to the long-term care facility. The hospital tried for two weeks to find an alternate placement. The facility staff had suggested two possible nursing homes for placement, each having a locked or secured unit. Resident #1 had no valid Power of Attorney designation, therefore there was no choice but for family to agree to alternate placement in one of those two nursing homes. The conditions in the first home were found to be unacceptable after placement, so Resident #1 was moved to the second nursing home. The Complainant said she recently visited with Resident #1 in one of the two alternate facilities. The resident told the Complainant, I am so glad I ran into you. I am so confused, I don't know where I am. The Complainant explained that Resident #1 just wanted to go home, that the discharging facility had been her home. A telephone interview was conducted with the clerk at the Office of Appeals on 9/27/19 at 10:20 AM. He reviewed the case number and confirmed the appeals hearing had already occurred. There was still no final order or ruling at this time, as it was pending review by a supervisor. A telephone interview was conducted with the hospital Case Worker on 9/27/19 at 10:34 AM. She confirmed Resident #1 was transferred to her unit under a Baker Act and was then refused readmission to the long-term care facility. A closed record review revealed Resident #1 was admitted to the facility on [DATE], with a readmission on 4/10/18 and a discharge on 8/5/19 (under the Baker Act). She was [AGE] years old. A Discharge Return Not Anticipated Minimum Data Set (MDS) assessment with an assessment reference date of 8/5/19, found Resident #1 had an unplanned discharge to an acute hospital with no return anticipated. Resident #1 was care planned for no longer residing on the facility's secured unit due to the unit closing on 5/23/19. The goal was for Resident #1 to remain safe and secure and adjust to the new environment of the facility by the next review. Interventions included: Assist to activities and placement of a Wanderguard (personal alarm). She was care planned for activities of daily living (ADL) self-care performance deficit related to impaired cognition, and as an elopement risk with aimless wandering, aggression, and resistance to care. Resident #1 also had a care plan for behavior problems related to her [DIAGNOSES REDACTED].? or Why am I here? or How long do I have to stay here? and Where is my daughter? Where is she? I want to go home. Resident #1 was placed on one to one (1:1) supervision for safety. Approaches included 1:1 staffing until a secure unit could be located. She was seen by the Physician/Medical Director on 7/2/19 for confusion and wandering. The note read, Patient was noted to be walking in the hallway and very confused at the time of the visit. She did not follow commands. Nursing reported this patient needed to be redirected multiple times a day. The plan indicated confusion/wandering/restlessness, monitor, redirect, and implement fall precautions. The physician noted dementia with behavioral disturbance and recommended to continue the current regimen and monitor behaviors. The Physician/Medical Director wrote an order on 7/2/19 which read, OK to discharge to (name of nursing home) due to needing a secure unit due to advanced dementia and wandering for safety. Resident's need cannot be met in this facility, and patient will need a secure unit due to advanced dementia and (wondering). A Nursing Home Transfer Discharge Notice was completed on 7/2/19 for an effective discharge date of [DATE]. The discharge location was another nursing home. The Reason for Discharge or Transfer noted Resident #1's needs could not be met in this facility. The Brief Explanation to Support the Action stated Resident #1 would need a secure unit due to advanced dementia and wandering. The form was signed by the Administrator and the Physician/Medical Director on 7/2/19. A hand-written note dated 7/2/19 at 1:00 AM, explained that the Social Services Director (SSD) and a family member had reviewed the discharge and transfer notice, the appeal rights, and the number to call. A progress note authored by the SSD on 7/22/19 at 4:42 PM, indicated the facility had been advised that Resident #1 had appealed the discharge decision and would be notified of the date/time of an appeal hearing. On 8/4/19, laboratory test results showed Resident #1 had ESBL (extended spectrum beta-lactimase, an antibiotic-resistant bacteria) in her urine. [MEDICATION NAME] (antibiotic) 500 mg twice a day for 10 days was ordered on [DATE], and contact isolation was ordered on [DATE], to be implemented every shift. Resident #1's record also showed that on 8/5/19, the Physician/Medical Director wrote an order for [REDACTED]. A Nursing Home Transfer and Discharge Notice dated 8/5/19, effective same day, revealed Resident #1 was being transferred to a local hospital. The notice explained Resident #1's needs could not be met and the health and safety of others in the facility was endangered. The Physician noted Resident #1 was a risk to herself, trying to get out of the facility, and a risk to others due to ESBL in her urine and her inability to remain on isolation. A Certificate of Professional Initiating Involuntary Examination was executed and signed by the Physician/Medical Director on 8/5/19 at 6:15 PM. Mental illness [DIAGNOSES REDACTED]. Because of the mental illness, Resident #1 had refused or was unable to determine for herself whether voluntary examination was necessary. There was substantial likelihood that without care or treatment she would cause serious bodily harm to herself or others in the near future, as evidenced by her recent behavior. The Supporting Evidence noted a urinary tract infection [MEDICAL CONDITION] with resistant bacteria (ESBL) and the inability to keep the resident on isolation. She was walking in the hallway and trying to get out of facility. She pushed the staff and threatened to hurt them, stating to staff she was going to kill herself. An electronic Recapitulation of Stay note dated 8/5/19, revealed Resident #1 was Baker Acted related to wandering, unable to maintain isolation, and for health threat to others and self. The Disposition of Belongings section of the form stated Resident #1's items had been packed and were being held until the family could claim them. There were no notes in Resident #1's closed records after 8/5/19. There was no documentation, either electronic or handwritten, regarding communication between the facility and the hospital following Resident #1's transfer related to her condition, treatment, progress or emotional state. In addition, there were no notes detailing any communication between the facility and Resident #1's family following the Baker Act. An interview was conducted with Registered Nurse (RN) A on 9/27/19 at 2:20 PM. She remembered Resident #1, explaining she would typically pace up and down the hallways of the locked unit where she resided before it was unlocked. Resident #1 would also cling to this RN whenever she was on duty and was always right behind her. The RN said she was not on duty the day of the Baker Act but had heard about it. She did not know why this resident did not come back, stating apparently someone made that decision. An interview was conducted with the SSD on 9/27/19 at 2:30 PM. She confirmed Resident #1's 30-day day discharge had been appealed, and that the appeal hearing had taken place in the facility. They were still waiting for the final decision. During Resident #1's hospital stay, staff called the facility wanting to make sure Resident #1 would be permitted to return. The hospital was told their records would have to be reviewed before making the decision to permit Resident #1 to return. During the hospital stay, Resident #1's family member decided she did not want Resident #1 to go to the nursing home originally listed on the 30-day discharge notice. She asked the SSD to call another nursing home, and Resident #1 was discharged from the hospital to that alternate location. The SSD insisted the family member made the decision not to return Resident #1 to the facility out of fear Resident #1 would lose her appeal. The SSD denied that the facility refused readmission. She explained the decision to permit Resident #1 to return to the facility depended on review by the Director of Nursing (DON), Medical Director and Administrator. She was asked if there was any documented correspondence with the hospital staff regarding the resident's status or pending discharge. She said no, explaining there was no way to document progress notes in the system past the day of discharge. The SSD again insisted that Resident #1's family member stated verbatim that she feared she would not win the appeal, therefore wanted to secure alternate placement for Resident #1. She insisted that at no time did (no one) say Resident #1 could not return. An interview was conducted with the Administrator on 9/27/19 at 2:45 PM. He said the situation with Resident #1 was complicated. During Resident #1's hospitalization , the facility was communicating with hospital staff and recommended Resident #1 go to a facility with a locked unit. The Long-Term Care Ombudsman informed the facility that Resident #1's family no longer wanted Resident #1 to discharge to the nursing home listed on the original 30-day discharge notice. He said, Our facility staff was still debating, or rather communicating to the hospital that (Resident #1) needed a locked unit. The appeals hearing got delayed. Resident #1's family had been in communication with the facility SSD. Said family member told the SSD that if (name of nursing home) would accept Resident #1, she would allow her to go there. So, the hospital discharged the resident there. He was later told during the appeals hearing that family was unhappy with the chosen placement, and now wanted Resident #1 to go to another nursing home. That was the last he had heard. He was not sure where Resident #1 was now. He stated he guessed if the appeal was upheld, he would have no choice but to take Resident #1 back. He said his Medical Director felt Resident #1 was unsafe to return to the facility, but the hospital Physician said she was. He asked, Who was right? The Administrator was asked if he ever told the hospital that Resident #1 could return to the facility. He said he told them the decision would be pending review by the Medical Director, DON and him. The DON, who was in the room at the time, was asked if the hospital or the family was ever told Resident #1 could return following her hospitalization . She also stated the hospital was told the facility team would have to review the chart first to make that determination. Readmission was also dependent on whether the hospital determined Resident #1 would need a locked unit. The requirements regarding permitting transferred residents to return to the facility while an appeals decision was pending was explained. The DON and Administrator both acknowledged the regulatory requirement. The Administrator admitted he had no written policy and procedure for permitting residents to return to the facility. Concern was expressed to the Administrator that neither the family nor the hospital was told Resident #1 could return to her home of two years in order to wait for the final ruling of the appeal, as required. As a result, Resident #1 had now been relocated three times in just over a month, first to the hospital, then to two subsequent nursing homes. The DON, Administrator and SSD (also in the room) acknowledged the level of confusion a resident with a [DIAGNOSES REDACTED]. On 9/27/19 at 3:45 PM, a telephone call was placed to Resident #1's family member. She was asked to verify she was never told that Resident #1 could not return to the facility. She was also asked if it was her decision to find another placement for Resident #1 after her hospitalization , rather than return her to the facility. The family member insisted the facility Administrator and SSD one hundred percent refused to take Resident #1 back. She stated the SSD said that unless the doctor, DON and Administrator had a meeting, they would not be able to readmit. That meeting apparently never occurred. When the hospital asked the facility what to do with Resident #1, the facility staff directed them to find her alternate placement; they could not take her back. She concluded by stating the decision to place Resident #1 somewhere else was not made by her. She felt her back was against the wall and she had no other choice at that point. A review of the hospital Psychiatric Discharge Summary dated 8/16/19 revealed Resident #1 was admitted on [DATE]. She was noted with initial agitation in the emergency room , but upon transfer to the unit there were no aggressive behaviors. Resident #1 was seen and examined by psychiatry and [MEDICAL CONDITION] medications were adjusted. There was no evidence of any suicidality of homicidality on the in-patient unit since her admission. Resident 1's mood remained stable with the benefit of psychopharmacological treatment, and there was no behavioral disturbance since admission. Resident #1 was noted to interact with staff adequately, and the Counselor had arranged a discharge plan. Resident #1 had been off of 1:1 observation for 24 hours prior to the discharge and there were no behavioral issues overnight. The resident's level of function was deemed adequate for outpatient care. The notes stated Resident #1 had maximized the benefit from the in-patient psychiatric hospital stay and would be discharged with a discharge plan. A case note authored by the hospital's Care Manager (CM) on 8/6/19 at 1:47 PM was included with the Discharge Summary. The CM wrote she had received a call from the facility's Admissions Director, who stated Resident #1 would not be able to return to them. Due to the Baker Act and the resident needing a locked facility, she would not be able to return.

Based on observation and staff interview, the facility failed to secure all medications in a locked area or medication cart for one (Resident #150) of 34 sampled residents. The findings include: An observation was made of Resident #150 in her room on 8/8/19 at 8:20 AM. She was lying in bed with her eyes closed. A clear, plastic bag with a small dropper container inside was observed on her bed. Employee A, Certified Nursing Assistant (CNA), entered the room and was asked what the item was. Employee A inspected the item label and stated it was eye drop medication for the resident. She then took the item to the nurse, Employee B, who was standing at the medication cart in the hallway. An interview with Employee B on 8/8/19 at 8:25 AM, confirmed that the item was eye drop medication for Resident #150 and that it should not have been there at bedside. She stated all medications were to be kept secure in the locked medication cart per the facility policy. She stated she had assisted the resident this morning, repositioning her for the breakfast meal, and forgot to pick the medication back up upon exiting the resident's room. A review of Resident #150's quarterly Minimum Data Set (MDS) assessment, dated 7/10/19, revealed both her cognitive skills and vision were severely impaired. A review of Resident #150's physician's orders [REDACTED]. There was no order to keep the medication at bedside. A review of the facility's policy on Medication Storage found that except for those requiring refrigeration or freezing, medications were to be stored in a medication cart or other designated area. Medication rooms, carts, and medication supplies were to be locked when not attended by persons without authorized access.

Based on observation, staff interview and record review, the facility failed to document the administration of oxygen treatments for four consecutive days for one (Resident #50) of 34 sampled residents. The findings include: An observation was made of Resident #50 in her room on 8/5/19 at 2:15 PM. She was lying in bed with her eyes closed. Oxygen was observed running at 2 liters per minute. The tubing was placed on the resident, however the nasal canula was inverted and was not placed within the resident's nasal passages. Subsequent observations were made of the resident on 8/6/19 at 9:35 AM, on 8/7/19 at 9:05 AM, and on 8/8/19 at 8:40 AM. Each observation found the oxygen running at 2 liters per minute with the tubing properly placed on the resident for administration. A review of the Medication Administration Record [REDACTED]. A review of Resident #50's physician's orders revealed that oxygen administration was ordered at 2 liters per minute as needed (PRN) for comfort. An interview with the nurse, Employee B, on 8/8/19 at 12:55 PM, revealed that medications or treatments which were ordered as needed, were to be documented on the resident's MAR indicated [REDACTED]. Upon inspection of the MAR for the month of (MONTH) 2019, she confirmed that no documentation of oxygen administration was entered for Resident #50. A review of the facility policy on Oxygen Administration, found that after completing the oxygen setup or adjustment, documentation of the treatment was to be recorded in the resident's record. The following information should be included in the documentation: the date and time that the procedure was performed, the name and title of the individual who performed the procedure, the rate of oxygen flow, the route, the rationale for treatment, the frequency and duration of the treatment, the reason for PRN administration, and how the resident tolerated the procedure, etc. During an interview with the Director of Nursing (DON) on 8/8/19 at 2:10 PM, she confirmed that she would expect to see documentation of all medication or treatment administration, regardless of whether is was routinely scheduled or as needed. After reviewing the (MONTH) 2019 MAR, she confirmed that no documentation of oxygen administration was entered for Resident #50 during the month of (MONTH) 2019.

Based on observation, staff interview and record review, the facility failed to ensure cleanliness of an oral-pharyngeal suctioning device for one (Resident #50) of 34 sampled residents. The findings include: An observation was made of Resident #50 in her room on 8/5/19 at 2:15 PM. She was lying in bed with her eyes closed. A suctioning device was observed at her bedside. The suction catheter tubing was exposed to air and had a white-colored debris within the tubing. The suctioning collection canister contained approximately 50 milliliters (ml) of secretions. A subsequent observation of the resident was made on 8/6/19 at 9:35 AM. The suction catheter tubing was exposed to the air with white-colored debris inside the tubing. The suction collection canister contained approximately 75 ml of secretions. Another observation was made of the resident on 8/8/19 at 8:40 AM. The suction catheter tubing was exposed to air and contained white-colored debris. The suctioning collection canister had approximately 100 ml of milky-colored secretions which were beginning to separate within the canister. On 8/8/19 at 10:35 AM, a new suction catheter was observed in the resident's room. It was stored in a plastic bag at the resident's bedside, and the suctioning collection canister was now empty and clean. An interview with the nurse unit manager, Employee C, was conducted on 8/8/19 at 10:40 AM. She stated Resident #50 was suctioned twice per month. She stated she had suctioned her today because the resident was pocketing food in her mouth. When asked how often the suctioning equipment was changed or cleaned, she stated that if the suctioning catheter was opened from its plastic package, it should be disposed of daily. It may be rinsed and used more than once that day, but should be stored within the plastic packaging between uses and then disposed of at the end of the day. When asked about the suctioning collection canister and its contents, she stated that if any secretions were collected in the canister, it should be cleaned out each shift per facility policy. A photograph of the previously exposed suction catheter tubing was shown to her, and she confirmed that it should have been rinsed and contained in a plastic bag between uses. A photograph of the collection canister containing approximately 100 ml of debris was also shared with her, and she confirmed that the canister was soiled and should have been changed each shift. A review of the facility policy on Advance Care Procedures for Suctioning - Oral Pharyngeal revealed that after completion of suctioning, the suction catheter was to be wrapped around the gloved hand, the glove pulled over the coiled catheter, and both were to be discarded in the designated container. The suction collection canister was to be emptied as necessary (for repeated use on the same resident, usually at the end of each shift, but at least daily). The suction collection canister was then rinsed and cleaned, as necessary; if secretions were adhered to the canister, discard or disinfect, as appropriate.

Based on observations, interviews, record reviews, a review of the Assure Platinum Blood Glucose Monitoring System QA/QC (quality assurance/quality control) reference guidelines, and a review of the Centers for Disease Control and Prevention guidelines, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice by failing to provide safe blood glucose monitoring to residents to protect them from the spread of blood-borne pathogens. During observations of Blood Glucose Monitoring (BGM) via finger stick testing, one (1) of one (1) Licensed Practical Nurses (Employee A) failed to clean and disinfect the glucometer (a device used to measure blood glucose levels) between each resident's use for three of three residents observed (Residents #76, #123, and #52), out of a total of 31 residents who required blood glucose monitoring. This failure placed the residents at risk for transmission of potentially infectious blood-borne pathogens such as [MEDICAL CONDITION] (HBV), [MEDICAL CONDITION] (HCV), and human immunodeficiency virus ,[MEDICAL CONDITION]. On 1/15/19 at 11:06 AM, Immediate Jeopardy (IJ) started. On 1/15/19 at 2:30 PM, the Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy determination. On 1/16/19 at 5:10 PM, the facility provided an acceptable credible Allegation of Compliance (A[NAME]). After the A[NAME] was presented to the survey team, improper cleansing and disinfecting of the glucometer was observed again for Resident #4 on 1/17/2019 at 11:35 AM. On 1/17/19 at 7:00 PM, the Immediate Jeopardy was removed after validation of the implementation of the A[NAME] and the severity was lowered form a K to an E. Cross reference to F880 and F726. The findings include: On 1/15/19 at 11:06 AM, a medication observation was conducted with Employee A, Licensed Practical Nurse (LPN), to observe blood sugar checks. She was observed to remove the Assure Platinum Meter (glucometer), labeled #1 from her cart. She obtained a Styrofoam tray, two alcohol wipes, two lancets, and two blood test strips, and placed them on the tray. She then removed another alcohol wipe and cleaned the glucometer with the alcohol wipe. She went to Resident #76's room to obtain a blood sugar level. The nurse did not properly disinfect the glucometer. She placed the tray on the dresser and then washed her hands. She donned gloves and pulled the curtain for privacy. She then inserted a test strip into the glucometer. She cleansed the resident's middle finger on right hand with an alcohol wipe, and obtained the blood sample (result was 104 mg/dl). She wrapped tissue, testing strip, and alcohol wipe in her glove, and returned to her cart. She threw the glove in the trash can on the cart, and disposed of the lancets in the sharps container (also on the cart). She removed an alcohol wipe from her cart and cleansed the glucometer for 3 seconds, and then placed it on top of her medication cart. The nurse did not properly disinfect the glucometer. Photographic evidence was obtained. On 1/15/19 at 11:17 AM, Employee A, LPN, obtained a Styrofoam tray, placed the glucometer labeled #1 (same glucometer used for Resident #76) on the tray. She removed two lancets, two blood testing strips, and four alcohol wipes, and placed them on the Styrofoam tray. She went to obtain the blood sugar reading for Resident #123. She placed the tray on the bedside table and washed her hands. She then donned gloves, and obtained a piece of toilet tissue from the bathroom and laid it on the bedside table. She cleansed the resident's fourth finger on the right hand with an alcohol wipe and obtained a blood drop (result was 201 mg/dl). She then wrapped the tissue, strip, and alcohol wipe in her glove and returned to the cart. She placed the glove in the trash can on the cart and the lancets in the sharps box. She then cleansed the glucometer with an alcohol wipe for 3 seconds and placed it on top of her cart. The nurse did not properly disinfect the glucometer. On 1/15/19 at 11:34 AM, Employee A, LPN, obtained a Styrofoam tray and placed it on top of her cart. She removed an alcohol wipe from her cart and cleansed the glucometer machine labeled #1 (same machine used for Residents #76 and #123) that was sitting on top of her cart, with the alcohol wipe for about 3 seconds. She then placed the glucometer (labeled #1) on the tray, along with two lancets, two blood test strips, and four alcohol wipes. She picked up the tray and went to obtain the blood sugar for Resident #52. She entered the room and placed the tray on the bedside table and washed her hands. She then donned gloves, and cleansed Resident #52's finger with an alcohol wipe. She obtained a blood sample and got a result of 157mg/dl. She wrapped the alcohol wipe, strip, and tissue in her glove. She held the glove in her left hand and obtained sanitizer in her right hand on the way out of the room. She threw the glove away in the trash can on the cart, and rubbed the sanitizer on both hands. She then removed an alcohol wipe from the cart and cleansed the glucometer (labeled #1) with an alcohol wipe for 3 seconds, and placed it on top of her cart. The nurse did not properly disinfect the glucometer. On 1/15/19 at 11:42 AM, an interview was conducted with Employee A, LPN, regarding cleaning and disinfecting of the glucometer, and she confirmed alcohol wipes were acceptable. On 1/15/19 at 5:42 PM, an observation of an in-service regarding cleaning of the glucometer machine was observed by three Registered Nurse Surveyors. Employee F, Registered Nurse/Infection Control Nurse was providing training to Employee B, Registered Nurse (RN), at his medication cart on the 200 hallway. Employee F was following the guidelines that she had printed out from the Assure Platinum web site. As Employee B was cleaning the glucometer, he stated that he can usually find the purple disinfectant wipes. He was then asked what does he use if he cannot find the purple wipes, and he stated, Oh, I manage to find them. Employee F was asked what do they use if the purple wipes were not available, and she stated that they can just use the alcohol wipes. She was then asked if it was okay that the nurse observed earlier had only used alcohol wipes to clean and disinfect the machine during several residents' blood sugars, and she stated, Yes, it is in here that you can use the alcohol wipes. She stated the 70% alcohol wipes were okay to use. She was asked if the alcohol wipes disinfect as well as the purple wipes, and she stated, Well no, it does not kill as many bacteria and germs as the wipes. She was then asked where in the instructions does it state that you can clean the glucometer with alcohol wipes. She reviewed the instructions, and pointed to a paragraph. After reviewing the in-service she was following, it was determined that alcohol can be used to clean the machine; however, it does not disinfect it. She then confirmed that they needed to clean and disinfect the glucometer between each resident. A review of the Assure Platinum User Instruction Manual was conducted and revealed the following: Assure Platinum User Instruction Manual Page 47 Cleaning & Disinfecting Guidelines Healthcare professionals should wear gloves when cleaning the Assure Platinum meter. Wash hands after taking off gloves. Contact with blood presents a potential infection risk. We suggest cleaning and disinfecting the meter between patient use. Option 1: Cleaning and disinfecting can be completed by using a commercially available EPA-registered disinfectant detergent or germicide wipe. To use a wipe, remove from container and follow product label instructions to disinfect the meter. Take extreme care not to get liquid in the test strip and key code ports of the meter. Many wipes act as both a cleaner and disinfectant, though if blood is visibly present on the meter, two wipes must be used; use one wipe to clean and a second wipe to disinfect. Option 2: To clean the outside of the blood glucose meter, use a lint-free cloth dampened with soapy water or [MEDICATION NAME] alcohol (70-80%). To disinfect the meter, dilute 1 mL of household bleach (5-6% sodium hypochlorite solution) in 9 mL of water to achieve 1:10 dilution (final concentration of 0.5-0.6% sodium hypochlorite). The solution can then be used to dampen a paper towel (do not saturate the towel). Then use the dampened paper towel to thoroughly wipe down the meter. Please note that there are commercially available 1:10 bleach wipes from a variety of manufacturers. Take extreme care not to get liquid in the test strip and key code ports of the meter. With all the recommended meter cleaning and disinfecting methods, it is critical that the meter be completely dry before testing a resident's glucose level. Please follow the disinfectant product label instructions to ensure proper drying time. A review of the Centers for Disease Control and Prevention (CDC) guidelines for Infection Prevention during Blood Glucose Monitoring and Insulin Administration (6/8/2017) revealed the following, The Centers for Disease Control and Prevention (CDC) has become increasingly concerned about the risks for transmitting [MEDICAL CONDITION] virus (HBV) and other infectious diseases during assisted blood glucose (blood sugar) monitoring and insulin administration. Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected, then it should not be shared. Outbreaks of [MEDICAL CONDITION] virus (HBV) infection associated with blood glucose monitoring have been identified with increasing regularity, particularly in long-term care settings, such as nursing homes and assisted living facilities, where residents often require assistance with monitoring of blood glucose levels and/or insulin administration. The facility's policy and procedure for glucometer disinfection was reviewed and revealed the following: Glucometer Disinfection Date Implemented: 9/2014 Date Reviewed/Revised: Reviewed/Revised By: Policy: The purpose of this procedure is to provide guidelines for the disinfection of capillary-blood sampling devices to prevent transmission of blood borne diseases to residents and employees. Definitions: Cleaning is the removal of visible soil from objects and surfaces normally accomplished manually or mechanically using water with detergents or enzymatic products. Disinfection is a process that eliminates many or all pathogenic microorganisms, except bacterial spores, on inanimate objects. Policy Explanation and Compliance Guidelines 1. The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use. 2. If the manufacturers' are unable to provide information specifying how the glucometer should be cleaned and disinfected, then the meter should not be used for multiple patients. 3. The glucometers should be disinfected with a wipe pre-saturated with an EPA registered healthcare disinfectant that is effective [MEDICAL CONDITION].[MEDICAL CONDITION] and [MEDICAL CONDITION] virus. 4. Glucometers should be cleaned and disinfected after each use and according to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use. 5. Procedure: a. Obtain needed equipment and supplies: Gloves, glucometer, alcohol pads, gauze pads, single-use lancet, blood glucose testing strips, disinfecting wipes. b. Wash hands c. Explain the procedure to the resident. d. Provide privacy e. Put on gloves. f. Obtain capillary blood sampling according to facility policy. g. Remove and discard gloves, perform hand hygiene prior to exiting room. h. Reapply gloves if there is visible contamination of the device or if the resident [MEDICAL CONDITIONS] or C positive. i. Retrieve (2) disinfectant wipes from container. j. Using first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer. k. After cleaning, use second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, following the manufacture's instructions. l. Discard disinfectant in waste receptacle. m. Perform hand hygiene The revised facility's policy and procedure for glucometer disinfection was reviewed and revealed the following: Glucometer Disinfection Date Implemented: Date Reviewed/Revised: 1/16/19 Reviewed/Revised By: Director of Clinical Policy: The purpose of this procedure is to provide guidelines for the disinfection of capillary-blood sampling devices to prevent transmission of blood borne diseases to residents and employees. Definitions: Cleaning is the removal of visible soil from objects and surfaces normally accomplished manually or mechanically using water with detergents or enzymatic products. Disinfection is a process that eliminates many or all pathogenic microorganisms, except bacterial spores, on inanimate objects. Policy Explanation and Compliance Guidelines 1. The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use. 2. If the manufacturers' are unable to provide information specifying how the glucometer should be cleaned and disinfected, then the meter should not be used for multiple patients. 3. The glucometers should be disinfected with a wipe pre-saturated with an EPA registered healthcare disinfectant that is effective [MEDICAL CONDITION].[MEDICAL CONDITION] and [MEDICAL CONDITION] virus. 4. Glucometers should be cleaned and disinfected before and after each use and according to manufacture's instructions regardless of whether they are intended for single resident or multiple resident use. 5. Procedure: a. Obtain needed equipment and supplies: Gloves, glucometer, alcohol pads, gauze pads, single-use lancet, blood glucose testing strips, disinfecting wipes. b. Wash hands c. Explain the procedure to the resident. d. Provide privacy e. Put on gloves. f. Obtain capillary blood sampling according to facility policy. g. Remove and discard gloves, perform hand hygiene prior to exiting room. h. Reapply gloves if there is visible contamination of the device or if the resident [MEDICAL CONDITIONS] or C positive. i. Retrieve (2) disinfectant wipes from container. j. Using first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer. k. After cleaning, use second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, place on a second clean barrier and allow to dry for 2 minutes following the manufacturer's instructions. l. Discard disinfectant in waste receptacle. m. Perform hand hygiene The facility's Allegation of Compliance (A[NAME]) was received on 1/16/19 at 5:10 PM. The survey team verified implementation of the A[NAME] through multiple observations of staff providing blood glucose monitoring, interviews with nursing staff to determine their knowledge of the disinfection process, interviews with the DON and Administrator, review of re-education provided to staff, and review of the revised policies and procedures. These activities occurred throughout the day on 1/17/19 until the IJ was removed at 7:00 PM on 1/17/19.

Based on observations, interviews, and record reviews, the Infection Control Nurse and nurses performing blood glucose monitoring failed to have appropriate competencies and skills required for the Staff Development and Infection Control Coordinator's Job Description for maintaining a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents (facility census of 154). On 1/15/19 at 11:06 AM, Immediate Jeopardy (IJ) started. On 1/15/19 at 2:30 PM, the Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy determination. On 1/16/19 at 5:10 PM, the facility provided an acceptable credible Allegation of Compliance (A[NAME]). After the A[NAME] was presented to the survey team, improper cleansing and disinfecting of the glucometer was observed again for Resident #4 on 1/17/2019 at 11:35 AM. On 1/17/19 at 7:00 PM, the Immediate Jeopardy was removed after validation of the implementation of the A[NAME] and the severity was lowered form a K to an E. Cross reference to F880 and F684. The findings include: Reviewing the Assure Platinum Blood Glucose Monitoring System QA/QC (quality assurance/quality control) reference guidelines and the Centers for Disease Control and Prevention guidelines, the facility failed to ensure blood glucose meters were cleaned and disinfected between residents to prevent the spread of blood-borne pathogens. During observations of Blood Glucose Monitoring (BGM) via finger stick testing, one (1) of one (1) Licensed Practical Nurses (Employee A), failed to clean and disinfect the glucometer (a device used to measure blood glucose levels) between each resident's use for three (Residents #76, #123, and #52) of three residents observed, out of a total of 31 residents who required blood glucose monitoring, including 2 residents (Residents #355 & #51) who had [DIAGNOSES REDACTED]. The Infection Control Nurse failed to maintain a list of residents with communicable diseases. The Infection Control Nurse failed to properly train nursing staff how to clean and disinfect glucometers per manufacturer's instructions. This failure placed the residents at risk for transmission of potentially infectious blood-borne pathogens, such as [MEDICAL CONDITION] (HBV), [MEDICAL CONDITION] (HCV), and human immunodeficiency virus ,[MEDICAL CONDITION]. On 1/15/19 at 11:06 AM, Immediate Jeopardy (IJ) started. On 1/15/19 at 2:30 PM, the Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy determination. On 1/16/19 at 5:10 PM, the facility provided an acceptable credible Allegation of Compliance (A[NAME]). After the A[NAME] was presented to the survey team, improper cleansing and disinfecting of the glucometer was observed again for Resident #4 on 1/17/2019 at 11:35 AM. The survey team verified implementation of the A[NAME] through multiple observations of staff providing blood glucose monitoring including additional observations after 1/17/19 at 11:35 AM, interviews with nursing staff to determine their knowledge of the disinfection process, interviews with the DON and Administrator, review of re-education provided to staff, and review of the revised policies and procedures. These activities occurred throughout the day on 1/17/19 until the IJ was removed at 7:00 PM on 1/17/19. The facility also failed to ensure that 12 residents (residing in Rooms 613, 614, 615, 616, 617, and 619) out of a facility census of 154 residents had a clean and sanitary environment provided. Review of the Infection Control Nurse's personnel record revealed she was hired on 5/27/15. The facility's Staff Development and Infection Control Coordinator Job Description revealed: 1. Monitor Infection Control Practices and Procedures to ensure that all personnel are implementing universal precautions standard operating procedures for tasks involving exposure to blood/body fluids. 2. Report all reportable diseases to the county and state health departments. 3. Ensure that the facility is in compliance with current CDC, OSHA, and local regulations concerning infection control or universal precautions. 4. Report occupational exposures to blood, body fluids, infectious materials, hazardous chemical in accordance with the facility's policies and procedures governing accidents and incidents.

Based on observations, interviews, record reviews, a review of the Assure Platinum Blood Glucose Monitoring System QA/QC (quality assurance/quality control) reference guidelines, and a review of the Centers for Disease Control and Prevention guidelines, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections by failing to provide safe blood glucose monitoring to residents to protect them from the spread of bloodborne pathogens. During observations of Blood Glucose Monitoring (BGM) via finger stick testing, one (1) of one (1) Licensed Practical Nurses (Employee A), failed to clean and disinfect the glucometer (a device used to measure blood glucose levels) between each resident's use for three (Resident #76, #123, and #52) of three residents observed, out of a total of 31 residents who required blood glucose monitoring, including two residents (Residents #355 & #51) who had [DIAGNOSES REDACTED]. This failure placed the residents at risk for transmission of potentially infectious blood-borne pathogens such as [MEDICAL CONDITION] (HBV), [MEDICAL CONDITION] (HCV), and human immunodeficiency virus ,[MEDICAL CONDITION]. On 1/15/19 at 11:06 AM, Immediate Jeopardy (IJ) started. On 1/15/19 at 2:30 PM, the Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy determination. On 1/16/19 at 5:10 PM, the facility provided an acceptable credible Allegation of Compliance (A[NAME]). After the A[NAME] was presented to the survey team, improper cleansing and disinfecting of the glucometer was observed again for Resident #4 on 1/17/2019 at 11:35 AM. On 1/17/19 at 7:00 PM, the Immediate Jeopardy was removed after validation of the implementation of the A[NAME] and the severity was lowered for a K to an E. The facility also failed to ensure that 12 residents (residing in Rooms 613, 614, 615, 616, 617, and 619) out of a facility census of 154 residents had a clean and sanitary environment provided. Cross reference to F684 and F726 The findings include: 1. On 1/15/19 at 11:06 AM, a medication observation was conducted with Employee A, Licensed Practical Nurse (LPN), to observe blood sugar checks. She was observed to remove the Assure Platinum Meter (glucometer), labeled #1 out of her cart. She obtained a Styrofoam tray, two alcohol wipes, two lancets, and two blood test strips, and placed them on the tray. She then removed another alcohol wipe and cleaned the glucometer with the alcohol wipe. The nurse did not properly disinfect the glucometer. She went to Resident #76's room to obtain a blood sugar level. She placed the tray on the dresser, and then washed her hands. She donned gloves and pulled the curtain for privacy. She then inserted a test strip into the glucometer. She cleansed the resident's middle finger on right hand with the alcohol wipe, and obtained a blood sample (result was 104 mg/dl). She then wrapped tissue, testing strip, and alcohol wipe in her glove, and returned to her cart. She threw the glove in the trash can on the cart, and disposed of the lancets in the sharps container (also on the cart). She removed an alcohol wipe from her cart and cleansed the glucometer for 3 seconds, and then placed it on top of her medication cart. The nurse did not properly disinfect the glucometer. (Photographic evidence was obtained). On 1/15/19 at 11:17 AM, Employee A, LPN obtained a Styrofoam tray, and placed the glucometer labeled #1 (same glucometer used for Resident #76) on the tray. She removed two lancets, two blood testing strips, and four alcohol wipes, and placed them on the Styrofoam tray. She then went to obtain the blood sugar reading for Resident #123. She placed the tray on the bedside table and washed her hands. She donned gloves and obtained a piece of toilet tissue from the bathroom and laid it on the bedside table. She then cleansed the resident's fourth finger on the right hand with an alcohol wipe, and obtained a blood drop (result was 201 mg/dl). She wrapped the tissue, strip, and alcohol wipe in her glove. She then returned to the cart and placed the glove in the trash can on the cart and the lancets in the sharps box. She then cleansed the glucometer with an alcohol wipe for 3 seconds and placed it on top of her cart. The nurse did not properly disinfect the glucometer. On 1/15/19 at 11:34 AM, Employee A, LPN, obtained a Styrofoam tray and placed it on top of her cart. She removed an alcohol wipe from her cart and cleansed the glucometer machine labeled #1 (same machine that she had used for Resident's #76 and #123) that was sitting on top of her cart, with the alcohol wipe for about 3 seconds. She then placed the glucometer (labeled #1) on the tray, along with two lancets, two blood test strips, and four alcohol wipes. She picked up the tray and went to obtain the blood sugar for Resident #52. She entered the room and placed the tray on the bedside table, and washed her hands. She donned gloves and cleansed Resident #52's finger with an alcohol wipe. She obtained a blood sample and got a result of 157 mg/dl. She then wrapped the alcohol wipe, strip, and tissue up in her glove. She held the glove in her left hand and obtained sanitizer in her right hand on the way out of the room. She threw the glove away in the trashcan on the cart, and rubbed the sanitizer on both hands. She then removed an alcohol wipe from the cart and cleansed the glucometer labeled #1 with an alcohol wipe for 3 seconds, and placed it on top of her cart. The nurse did not properly disinfect the glucometer. On 1/15/19 at 11:42 AM, an interview was conducted with Employee A, Licensed Practical Nurse (LPN), regarding cleaning and disinfecting of the glucometer, and she confirmed alcohol wipes were acceptable. On 1/15/19 at 3:43 PM, an observation was conducted of the glucometers on the medication cart of Employee E, Licensed Practical Nurse, (LPN), and one of two glucometers on the cart (#1) was noted to have a red colored substance resembling blood present on the end of the glucometer where the test strip is inserted. Photographic evidence was obtained. On 1/15/19 at 4:30 PM, an interview was conducted with Employee E, Licensed Practical Nurse, (LPN) regarding the new glucometers observed on top of his medication cart. He stated that Employee C, Licensed Practical Nurse (LPN)/Unit Manager (UM), came to him and told him that they were to replace the glucometers on the cart. She then provided him with two new glucometer machines. He was then shown the earlier photographic evidence of the soiled glucometer that was on his cart, and was asked if that is why they threw the machines away, and he stated, Yes, that would be why. On 1/15/19 at 4:32 PM, an interview was conducted with Employee D, Licensed Practical Nurse (LPN), regarding if Employee C, LPN/UM, had provided her with new glucometers that day. She stated that she had not received any new machines for her cart today, and removed the two she had from her drawer (they were both lying in top drawer/uncovered). The two glucometers observed were both noted to have a small spot of a red substance present on them. Photographic evidence was obtained. She then confirmed that they should be cleaned with a purple wipe prior to placing in the cart. There were two surveyors present at her cart during the observation of the glucometers and interviews. On 1/15/2019 at 4:35 PM, an observation was made of the Assure Platinum Glucometers that were in the 200/600 medication cart. Employee B, Registered Nurse, stated that one of the glucometers was brand new. The supervisor came around and replaced it. The glucometers were observed in the medication drawer without a barrier/cover or in any type of bag. The #2 glucometer had a dark red spot under the release button (photographic evidence obtained). Employee B stated the glucometers in the drawer should not be soiled. They should be cleaned and disinfected before putting them in the drawer. On 1/15/19 at 4:37 PM, an interview was conducted with the Employee C, Unit Manager (UM) who stated that she reviewed the glucometers on each cart on her unit because the nurse had told her that the surveyor was coming back to watch a blood sugar test, so she reviewed the machines and noted that they were stained, so she replaced them. During the interview, Employee D, Licensed Practical Nurse, (LPN) approached with the two glucometers that were on her cart and asked Employee C for new ones. She then took the glucometers and stated that she would have to go get her some new ones. Employee C was asked where the machines were that she removed from the other nurse's cart, and she stated that she had thrown them away in the trash on the cart. She was then shown the photographic evidence of the glucometers, and she confirmed that they were soiled with something, but she was unable to say exactly what. She was then asked if the machines should be cleaned and sanitized prior to placing in the cart, and she stated, Yes. On 1/15/19 at 5:42 PM, an observation of an in-service regarding cleaning of the glucometer machine was observed by three Registered Nurse Surveyors. Employee F, Registered Nurse/Infection Control Nurse, was providing training to Employee B, Registered Nurse (RN), at his medication cart on the 200 hallway. She was following the guidelines that she had printed out from the Assure Platinum website. As Employee B was cleaning the glucometer, he stated that he can usually find the purple disinfectant wipes. He was then asked what does he use if he cannot find the purple wipes, and he stated, Oh, I manage to find them. Employee F was then asked what do they use if the purple wipes are not available, and she stated that they can just use the alcohol wipes. She was then asked if it was okay that the nurse observed earlier had only used alcohol wipes to clean and disinfect the machine during several residents blood sugars, and she stated, Yes, it is in here that you can use the alcohol wipes. She stated the 70% alcohol wipes were okay to use. She was asked if the alcohol wipes disinfect as well as the purple wipes, and she stated, Well no, it does not kill as many bacteria and germs as the wipes. She was then asked where in the instructions does it state that you can clean the glucometer with alcohol wipes only, and she reviewed the instructions and pointed to a paragraph. After reviewing the in-service she was following, it was determined that alcohol can be used to clean the machine; however, it does not disinfect it. She then confirmed that they needed to clean and disinfect the glucometer between each resident. A review of the Assure Platinum User Instruction Manual was conducted and revealed the following: Assure Platinum User Instruction Manual Page 47 Cleaning & Disinfecting Guidelines Healthcare professionals should wear gloves when cleaning the Assure Platinum meter. Wash hands after taking off gloves. Contact with blood presents a potential infection risk. We suggest cleaning and disinfecting the meter between patient use. Option 1: Cleaning and disinfecting can be completed by using a commercially available EPA-registered disinfectant detergent or germicide wipe. To use a wipe, remove from container and follow product label instructions to disinfect the meter. Take extreme care not to get liquid in the test strip and key code ports of the meter. Many wipes act as both a cleaner and disinfectant, though if blood is visibly present on the meter, two wipes must be used; use one wipe to clean and a second wipe to disinfect. Option 2: To clean the outside of the blood glucose meter, use a lint-free cloth dampened with soapy water or [MEDICATION NAME] alcohol (70-80%). To disinfect the meter, dilute 1 mL of household bleach (5-6% sodium hypochlorite solution) in 9 mL of water to achieve 1:10 dilution (final concentration of 0.5-0.6% sodium hypochlorite). The solution can then be used to dampen a paper towel (do not saturate the towel). Then use the dampened paper towel to thoroughly wipe down the meter. Please note that there are commercially available 1:10 bleach wipes from a variety of manufacturers. Take extreme care not to get liquid in the test strip and key code ports of the meter. With all the recommended meter cleaning and disinfecting methods, it is critical that the meter be completely dry before testing a resident's glucose level. Please follow the disinfectant product label instructions to ensure proper drying time. A review of the Centers for Disease Control and Prevention (CDC) guidelines for Infection Prevention during Blood Glucose Monitoring and Insulin Administration (6/8/2017) revealed the following, The Centers for Disease Control and Prevention (CDC) has become increasingly concerned about the risks for transmitting [MEDICAL CONDITION] virus (HBV) and other infectious diseases during assisted blood glucose (blood sugar) monitoring and insulin administration. Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected, then it should not be shared. Outbreaks of [MEDICAL CONDITION] virus (HBV) infection associated with blood glucose monitoring have been identified with increasing regularity, particularly in long-term care settings, such as nursing homes and assisted living facilities, where residents often require assistance with monitoring of blood glucose levels and/or insulin administration. On 1/16/2019 at 9:15 AM, Employee F (Infection Control Nurse) stated that she has not made any plans to notify any of the residents that may have been exposed to blood borne pathogens due to not properly disinfecting the glucometers in the building. She has not notified any of their physicians or the Medical Director of this concern. She stated she has not initiated any glucometer audits to ensure that they were properly being cleaned. She was asked if any residents who were receiving glucometer checks had known [DIAGNOSES REDACTED]. She was asked what blood-borne pathogens/infections had to be reported to the Department of Health. She was not quite sure. She had a list of reportable infections, but could not locate it at this time. The Director of Nurses was interviewed on 1/16/2019 at 10:12 AM. She was not aware that one of the nurses only used alcohol wipes to disinfect glucometers between several residents. The Infection Control Nurse did not inform of her of this. On 1/16/2019 at 10:35 AM, Employee R, LPN, was interviewed. She had training this morning on cleaning and disinfecting the glucometers after use. She was working in the 300 hallway (secure unit). The glucometers in the drawer were inspected. The glucometers were lying in the cart without a barrier. On one of the glucometers, there was a dried liquid spot (photographic evidence obtained). Employee R stated if they were in the drawer, they should be clean and disinfected. The surveyor asked her to wipe the glucometer with a disinfectant wipe and the spot disappeared. On 1/16/2019 at 10:52 AM, Employee H, LPN, was interviewed. She received training that morning on cleaning and disinfecting the glucometer. She used Glucometer #2 (on 600 South Cart) that morning and cleaned it afterwards with a disinfectant wipe. Glucometer #2 was observed to have a dark red spot on the side of the meter where the test strip was inserted. Employee H took a germicidal wipe and wiped the side of the machine and the red spot came off. Employee H stated she cleaned it so she did not know how it got there. On 1/16/19 at 11:40 AM, an observation was conducted for a blood glucometer check with Employee H, for Resident #76. Employee H removed a Styrofoam tray and placed it on top of her cart. She then placed gloves, glucometer machine labeled #1 (Glucometer was lying in the top drawer and was not covered), two alcohol wipes, two test strips, and one lancet on the tray. She entered the room, washed her hands, and obtained the blood sugar. She went to the bathroom and washed her hands. After she washed her hands, she returned to the cart with the glucometer, one used lancet, one new lancet, and a paper towel from the bathroom. She stated the paper towel was her barrier. She then donned gloves and removed two wipes from the cart and wiped the glucometer for 20-25 seconds. She then placed it back down on the paper towel barrier and waited 30 seconds for it to dry. She then removed two more wipes and wiped the machine again for 15 seconds, then placed it back down on the same paper towel barrier for the third time. She stated that she was going to let it dry for 2 minutes. The wet surface contact time using the disinfectant wipes is 2 minutes; threfore, the nurse did not properly disinfect during this process. On 1/16/19 at 11:48 AM, an interview was conducted with Employee H regarding the infection control practice of cleaning her machine. She confirmed that she had placed the cleaned glucometer machine on the dirty paper towel barrier, and stated that she would have to clean it again. She was then asked about not cleaning the machine prior to entering the room and obtaining the blood sugar. She stated that she did not clean it, because she only had her cart parked down at the nurses station for 15-20 minutes, so she did not need to clean it. She then stated according to the training that she had received this morning, she should have cleaned it before as well. The facility's policy and procedure for glucometer disinfection was reviewed and revealed the following: Glucometer Disinfection Date Implemented: 9/2014 Date Reviewed/Revised: Reviewed/Revised By: Policy: The purpose of this procedure is to provide guidelines for the disinfection of capillary-blood sampling devices to prevent transmission of blood borne diseases to residents and employees. Definitions: Cleaning is the removal of visible soil from objects and surfaces normally accomplished manually or mechanically using water with detergents or enzymatic products. Disinfection is a process that eliminates many or all pathogenic microorganisms, except bacterial spores, on inanimate objects. Policy Explanation and Compliance Guidelines 1. The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use. 2. If the manufacturers are unable to provide information specifying how the glucometer should be cleaned and disinfected, then the meter should not be used for multiple patients. 3. The glucometers should be disinfected with a wipe pre-saturated with an EPA registered healthcare disinfectant that is effective [MEDICAL CONDITION].[MEDICAL CONDITION] and [MEDICAL CONDITION] virus. 4. Glucometers should be cleaned and disinfected after each use and according to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use. 5. Procedure: a. Obtain needed equipment and supplies: Gloves, glucometer, alcohol pads, gauze pads, single-use lancet, blood glucose testing strips, disinfecting wipes. b. Wash hands c. Explain the procedure to the resident. d. Provide privacy e. Put on gloves. f. Obtain capillary blood sampling according to facility policy. g. Remove and discard gloves, perform hand hygiene prior to exiting room. h. Reapply gloves if there is visible contamination of the device or if the resident [MEDICAL CONDITIONS] or C positive. i. Retrieve (2) disinfectant wipes from container. j. Using first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer. k. After cleaning, use second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, following the manufacture's instructions. l. Discard disinfectant in waste receptacle. m. Perform hand hygiene The Director of Nursing was interviewed on 1/16/2019 at 1:55 PM. She was made aware of the nurse using alcohol wipes to disinfect the glucometers and that was not appropriate. She has notified the Medical Director. She stated that there were three residents with [DIAGNOSES REDACTED].#355 and #51 had [DIAGNOSES REDACTED]. They will notify residents of possible exposure to blood borne pathogens. She stated they revised the facility's policy and procedure for glucometer disinfection. The revised facility's policy and procedure for glucometer disinfection was reviewed and revealed the following: Glucometer Disinfection Date Implemented: Date Reviewed/Revised: 1/16/19 Reviewed/Revised By: Director of Clinical Policy: The purpose of this procedure is to provide guidelines for the disinfection of capillary-blood sampling devices to prevent transmission of blood borne diseases to residents and employees. Definitions: Cleaning is the removal of visible soil from objects and surfaces normally accomplished manually or mechanically using water with detergents or enzymatic products. Disinfection is a process that eliminates many or all pathogenic microorganisms, except bacterial spores, on inanimate objects. Policy Explanation and Compliance Guidelines 1. The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use. 2. If the manufacturers are unable to provide information specifying how the glucometer should be cleaned and disinfected then the meter should not be used for multiple patients. 3. The glucometers should be disinfected with a wipe pre-saturated with an EPA registered healthcare disinfectant that is effective [MEDICAL CONDITION].[MEDICAL CONDITION] and [MEDICAL CONDITION] virus. 4. Glucometers should be cleaned and disinfected before and after each use and according to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use. 5. Procedure: a. Obtain needed equipment and supplies: Gloves, glucometer, alcohol pads, gauze pads, single-use lancet, blood glucose testing strips, disinfecting wipes. b. Wash hands c. Explain the procedure to the resident. d. Provide privacy e. Put on gloves. f. Obtain capillary blood sampling according to facility policy. g. Remove and discard gloves, perform hand hygiene prior to exiting room. h. Reapply gloves if there is visible contamination of the device or if the resident [MEDICAL CONDITIONS] or C positive. i. Retrieve (2) disinfectant wipes from container. j. Using first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer. k. After cleaning, use second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, place on a second clean barrier and allow to dry for 2 minutes following the manufacture's instructions. l. Discard disinfectant in waste receptacle. m. Perform hand hygiene. Employee F, RN, was interviewed on 1/16/2019 at 3:15 PM. She stated that residents with [MEDICAL CONDITION] should be reported to the Department of Health (DOH) within 24 hours of admission. She did not report Residents #355 and #51 as having [MEDICAL CONDITION]. She stated maybe the Director of Nursing reported them. Reporting to the DOH is not required for residents who were admitted with previously diagnosed [MEDICAL CONDITION]. If the residents acquired [MEDICAL CONDITION] in the facility, then they are required to report to the DOH the next business day. The Medical Director was interviewed on 1/16/2019 at 3:47 PM. He stated that disinfecting a glucometer with an alcohol wipe between residents posed a minuscule risk for transmitting blood borne pathogens. He did state there was a risk though. On 1/16/2019 at 5:10 PM, the Administrator presented an Immediate Plan of Action which revealed the facility's policy and procedure was revised and updated to include cleaning and disinfecting the glucometer before and after use. The glucometer will be stored in a clean plastic bag before being placed in the medication cart. On 1/17/2019 at 11:35 AM, an observation was made of Employee K, LPN, performing a glucometer test for Resident #4. The glucometer was in a clear plastic bag in the 500 medication cart. Employee K removed the glucometer and gathered the other supplies, placed them on a Styrofoam tray and took it into the resident's room. She removed the glucometer from the plastic bag and performed the glucometer check. She did not disinfect the glucometer before using it. After the glucometer test, she brought the glucometer back to the medication cart and used two germicidal wipes to clean and disinfect the meter. However, she did not fully wipe all surface areas. She only partially cleaned the left side and back of the machine. This observation resulted in the survey team continuing the process for validating the full implementation of the A[NAME] for the remainder of the survey. On 1/17/2019 at 11:40 AM, Employee K stated they do not have to clean and disinfect before doing the test because it was already clean in the bag. She stated she had the training yesterday and did not believe they told her that it had to be done both before and after use. Another interview was conducted with Employee F on 1/17/2018 at 5:25pm. She stated that she did call the Department of Health yesterday and they told her that residents with [MEDICAL CONDITION] have to be reported. She stated the previous DON used to do it. She did not realize that the present DON was not doing it. The facility's Allegation of Compliance (A[NAME]) was received on 1/16/19 at 5:10 PM. The survey team verified implementation of the A[NAME] through multiple observations of staff providing blood glucose monitoring including additional observations after 1/17/19 at 11:35 AM, interviews with nursing staff to determine their knowledge of the disinfection process, interviews with the DON and Administrator, review of re-education provided to staff, and review of the revised policies and procedures. These activities occurred throughout the day on 1/17/19 until the IJ was removed at 7:00 PM on 1/17/19. 2. Observations were conducted of Rooms 613, 614, 615, 616, 617, and 619 on 1/14/19 during tour observations that were conducted between 10:45 am and 3:30 pm. The rooms were noted to have unbagged and unlabeled basins in the bathrooms of shared rooms. A second observation was conducted of the rooms on 1/15/19 and the basins remained unbagged and unlabeled. On 1/15/19 at 2:37 pm, an interview and observation was conducted with Employee C, Licensed Practical Nurse/Unit Manager, and she confirmed that the basins should have been bagged and labeled, or disposed of after using.

Based on record review and staff interview, the facility failed to complete Minimum Data Set (MDS) assessments within 7 days of assessment reference date and transmit them within 14 days after completion for 25 out of 154 residents, Residents #1, #11, #144, #15, #16, #106, #122, #8, #4, #12, #131, #38, #19, #17, # 20, #14, #123, #5, #7, #6, #9, #25, #3, #10, and #105. The findings include: Review of the facility's MDS scheduler revealed that numerous MDS assessments (Residents # 1, #11, #144, #15, #16, #106, #122, #8, #4, #12, #131, #38, #19, #17, # 20, #14, #123, #5, #7, #6, #9, #25, #3, #10, and #105) were over 120 days late. One of the MDS nurses (Employee Q) was interviewed on 1/15/2019 at 1:08 PM. She confirmed the above residents had late MDS assessments. She looked each resident up in the computer and stated many of them had incomplete sections (Social Services) and some were completed, but just not locked and transmitted. The Social Service Director was interviewed on 1/15/2019 at 2:10 PM. She stated that one of the previous Social Service assistants quit and left her as the only person to do all of the assessments, and she concentrated on the 'upstairs' ones. She does get a report from the MDS Director of assessments that are late. She realized she had incomplete assessments for about a month now. The MDS Director was interviewed on 1/15/2019 at 3:12 PM. She stated they were behind in MDS assessments and transmittals. She stated they should be locked within 14 days of Assessment Reference Date and submitted within 7 days after that.

Based on interview and record review, the facility failed to ensure one of 3 residents (Resident #137) reviewed for activities of daily living care (ADL), received services to maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan did not address the resident's dentures not being removed or the resident not allowing dentures to be removed. The findings include: During an interview on 1/14/2019 at 12:20 PM with Resident #137 and local representative, the representative stated Resident #137 was not getting the care needed for her teeth. He stated Resident #137 had informed him that the dentures were grown in and could not come out. Resident #137 agreed. Resident #137 stated that she does not take her dentures out and wipe them with a towel. Record review for Resident #137 found she was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of the most recent Minimum Data Set (MDS) found Resident #137 was assessed as having a Brief Interview Mental Status score (BIMS) of 13 out of 15. Personal hygiene was coded for extensive one person assist. Section L L0200 was coded No to mouth or facial pain, discomfort or difficulty chewing, and No to broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose). Further record review for Resident #137 found she was care planned for having upper dentures and some missing teeth on bottom, and has partial on bottom but does not always wear. Intervention of monitor/document/report as needed any sign or symptoms needing attention. The care plan for ADL self-care deficit had the approach of limited to extensive assist with personal hygiene and oral care. The resident's care plan did not address the resident's refusal to remove her dentures at night. Record review found Resident #137 was last seen for a dental consult on 12/18/2018. The consult advised the daily removal of the denture for proper cleaning. During an interview with Resident #137's nurse, Employee I, on 1/16/19 at 10:21 AM, she stated she started working with the resident in (MONTH) of (YEAR). She could not answer about her teeth without checking the record. She was not aware of the dentures stuck in her mouth. The 600 Hall Unit Manager was at the nursing station at the time and added that sometimes Resident #137 will not want to take her dentures out. During a second interview on 1/16/2019 at 1:53 PM with Resident #137's nurse, Employee I, she stated she went in to see the resident around 10:50 AM. She asked the resident if she could remove the dentures to clean them and the resident refused. During an interview on 1/16/19 at 2:12 PM with Resident #137's Certified Nursing Assistant (CNA) (Employee J), she stated she has worked with the resident for 4-5 months. She does the morning ADLs with the resident. She stated Resident #137 will not let you take the dentures out of her mouth and will not take them out herself. She has uppers only. She has tried in the past and she tried this morning. She tries every morning and she refuses. During a follow-up interview with Resident #137's nurse, Employee I, on 1/16/2019 at 2:24 PM, she stated the CNA had not informed her of the refusal to take her dentures out. She stated she was not aware until this morning.