Every finding on record at Bennington Health & Rehab

Based on interview and record review, the facility failed to ensure that an allegation of staff to resident physical abuse for 1 of 3 residents in the applicable sample (Resident #1), and staff to resident sexual abuse for 1 of 3 residents in the applicable sample (Resident #2) was reported to the Administrator of the facility and the state agency within the required timeframe.Findings include:1.) Per review of the facility abuse reporting form that was submitted to the state agency on 6/16/2026 an alleged incident of staff to resident abuse occurred on 6/16/2026 at 3:00 AM. Facility administration had not been made aware of the allegation until 6/16/2026 at 5:15 PM, after Resident #1 reported to the facility Scheduler at 5:00 PM that a Licensed Nursing Assistant (LNA) had hit [him/her] on the side of the head at the nurse's station, when asked when [s/he] stated early this morning. Per interview on 8/31/2026 at 1:15 PM, with LNA #2 she stated that she had witnessed LNA #1 hit Resident #1 on the left side of his/her head. LNA #2 stated that the Nurse who was there quickly defused the situation. She did not know if the nurse reported it, but LNA #1 continued to work that shift. Per facility policy titled Abuse-VT effective date 3/1/2024, page 3 of 5 Reporting Mechanisms:Facility In-House Reporting: Whenever there is a witnessed, suspected, or alleged abusive action involving a resident, as defined above, the following is initiated: The staff member who hears an allegation of abuse, or suspects or witnesses abuse will report immediately to their supervisor. [NOTE: If the allegation involves the employee's immediate Supervisor, then the employee shall take the allegation to the next higher Supervisory level.]The Administrator or on-call designee and Director of Nursing Services [DNS] are to be notified immediately. Per interview with the facility Administrator on 8/31/2026 at 11:15 AM she confirmed that LNA #2 had stated she witnessed LNA #1 hit Resident #1 at the nurse's station on 6/16/2026 and that she had not immediately reported it, per facility policy and regulatory requirements. 2. Per review of the facility Abuse Reporting form submitted to the state agency on 8/3/2026, an LNA reported that she witnessed a Nursing Supervisor engaged in a sexual act with Resident #2. The form states that the LNA stated it happened on the night shift, but she was not sure of the time. The reporting form also states that the Administrator was notified at 10:30 AM. Per interview with the facility Administrator on 8/31/2026 at approximately 3:00 PM the LNA who witnessed the alleged sexual abuse had stated that she had not reported the incident because the alleged abuser was her immediate Supervisor. She waited until another Supervisor arrived and informed them. The Administrator confirmed that the alleged abuse had not been reported per regulatory requirements and facility policy. Based on corrective actions completed on 8/11/2026 prior to the onsite, this citation is designated as past non-compliance with the compliance date of 8/11/2026. The following actions were completed by the facility:Once aware, the Administrator reported both incidents to the Licensing Agency, local law enforcement, and the Office of Professional Regulation.All staff were educated on the facility abuse policy with a focus on immediate reporting abuse allegations to the Administrator or Director of Nursing.An audit of facility incident reports, 24-hour reports, and nurses notes was conducted and will continue to be conducted at designated intervals.The results of the audits are reported and evaluated during the quality assurance, performance improvement quarterly meetings.

Based on interviews, and record reviews, the facility failed to ensure that each resident receives adequate supervision to maintain safety and prevent elopement for 1 or 1 sampled residents (Resident #1). Findings Include:A progress note dated 4/30/26 stated that Resident #1 left the faciity on an unauthorized leave of absence. A document completed by the facility titled: Elopement Drill Documentation form stated Resident #1 was identified missing at 9:42 PM. Resident #1 was located by [NAME] Police Department at their partners apartment and returned to facility at 10:12PM.Per record review, Resident #1 has a Brief Interview for Mental Status (BIMS) score of 14. (BIMS is a standardized cognitive screening tool used primarily in long-term care and skilled nursing facilities to assess a resident's memory, thinking, and orientation skills. A score of 14 indicates intact cognitive function). Resident #1's care plan indicates that they can ambulate independently with a walker or wheelchair and are at risk for falls.Per interview with Resident #1 on 6/30/26 at 8:32 AM, s/he stated they left the facility in a hurry because they were concerned about their spouse when they learned their spouse was in hospital. Resident #1 confirmed they did not utilize the facility's protocol for a leave of absence because they did not have a ride and they were not thinking clearly. Resident #1 confirmed they walked with their walker to the apartment complex where their spouse lives approximately 0.7 miles from the facility. Resident #1 stated it took a very long time to get there. [NAME] Police Department arrived and brought Resident # 1 back to the facility. Per interview with Physical Therapist #1 on 6/30/26 1:45 PM, they stated that Resident #1 does have balance issues, poor safety awareness, and frequently becomes short of breath with ambulation.Per interview with the Communications Specialist at [NAME] Police Department on the morning of 6/30/26, they read from a police report of the elopement that a call came in at 9:30 PM on 4/30/26. It was reported that Resident #1 had eloped from the facility. The facility reported they had last seen Resident #1 30 minutes prior to the call. The resident had gone to the spouse's house. Between 10:02PM and 10:07 PM [NAME] Police found Resident #1 and returned them to the facility.Per interview with the Administrator on 6/30/26 at approximately 11:15 AM, the facility was unaware that Resident #1 had left facility grounds at the time of their departure. Resident #1 is their own person who on occasion uses the facility's leave of absence pass to go out with a friend or family. The Administrator confirmed they reviewed the camera footage from 4/30/26 and Resident #1 exited through the front door as a visitor was entering and went to the right of the building. The Administrator confirmed the footage did not show Resident #1 entering a vehicle. The Administrator confirmed Resident #1 should not have been able to exit the facility without staff knowing. The facility has a 24 hour 7 days a week receptionist at the front door and the front door locks at 8:00PM. Some family members have the code to enter the building. At approximately 12:35 PM she confirmed they may not have remembered the exact time the resident departed when reviewing the facility's camera footage.

Based on staff interviews and record review, the facility failed to ensure the timely acquisition and availability of ordered medications to meet resident needs, resulting in omission or delay of physician ordered drugs for 3 of 5 sampled residents (Resident #1, #2, and #3) and, per facility audit, for 35 of 81 residents facility wide. As a result, Resident #1 did not receive venlafaxine XR for 4 days and pregabalin for 8 days and suffered an unwitnessed fall, headache, elevated blood pressure, and seizure like activity that required them to be evaluated and treated at the hospital. Findings include: 1. Per record review, Resident #1 had a Physician's Order dated 10/22/2025 for Effexor XR [Anti-Depressant] Oral Capsule Extended Release 24 Hour 150 MG (Venlafaxine HCl) Give 300 mg by mouth one time a day for Depression.Review of Resident # 1's Progress Notes and December 2025 and January 2026 medication administration records (MARs) revealed that the Resident did not receive the prescribed Effexor for 4 days, from 12/31/2025- 1/6/2026 as it was not available. Further record review reveals that Resident #1 also had a Physician's Order dated 10/21/2025 for Pregabalin (Lyrica, an anticonvulsant [anti-seizure] and gabapentinoid [used to treat nerve pain]) 25 mg per day for pain. Review of the Resident's Progress notes and December 2025 and January 2026 MARs reveals that the prescribed Lyrica was not available and not administered from 12/29/2025 - 1/5/2026.A progress note dated 1/3/2026 reads Walked into residents room and found resident lying on the floor on [her/his] left side. Resident crying stating [her/his] head was pounding and [her/his] left hand was hurting. [blood pressure] 206/104- [according to the American Heart Association could signal severe hypertension or hypertensive emergency] [pulse] 98- [Oxygen Saturation] 97% Resident noted to have seizure activity x 2. The Resident was sent to the emergency department .Review of the hospital Discharge Summary revealed that there was a suspicion for organic seizure [events that look like epileptic seizures but are caused by a direct physical issue in the brain] and a recommendation for Keppra 500 mg twice daily was made. Discharge diagnoses of seizure-like activity with known history of nonepileptic shaking, resolved elevated troponin and elevated lactic acid [diagnostic tests used to confirm heart damage]. The assessment and plan states Possibly nonepileptic seizure, but elevated troponin and lactic somewhat concerning. Review of laboratory results revealed that Resident #1's Troponin T level on 1/3/2026 was 38.90 at 6:23 PM (the normal range is less than 14.00). The Discharge Summary also stated, The Patient be going back on all [her/his] standard meds there was some question if she missed a couple of [her/his] meds at Mission care by [her/his] friend. The note does not address which medications may have been missed or whether the Resident had been evaluated for rapid withdrawal contributing to her/his condition. While being evaluated at the hospital Resident #1 experienced behavior changes and it was determined that it was best for her/his overall emotional wellbeing s/he would discharge back to the facility with orders to continue previous medications. A communication note dated 1/5/2026 states This nurse was made aware that both Effexor and Lyrica had still not arrived from pharmacy despite multiple contacts made with the pharmacy. Spoke with [name omitted] (Pharmacy Rep), states she will have medication sent STAT [without delay]. Spoke with [Medical Director] ordered to continue with medication as scheduled. Resident was made aware. Further review of Resident #1's progress notes revealed that on 1/11/2026 nursing staff were again unable to administer the ordered Effexor due to unavailability. Further record review revealed that on 1/6/2026 Resident #1 had laser iridotomy (an outpatient procedure that uses a focused laser beam to create a tiny hole in the iris, allowing fluid to drain and reducing eye pressure in patients with or at high risk of, narrow-angle glaucoma) to both eyes. S/he returned to the facility with an order to continue to use Prednisolone 1% one drop in each eye daily for a total of 7 days to start on 1/7/2026.Review of Resident #1's January MAR revealed that the order for the Prednisolone 1% was not implemented until 1/9/2026.Per interview on 1/21/2026 at 11:04 AM, the Director of Nursing (DON) confirmed the above medication errors occurred. 2. Per record review, Resident #2 had a physician's order with a start date of 5/27/2025 for Depakote Delayed Release (DR) 1000 mg by mouth one time a day and 500 mg at bedtime for mood disorder for a total of 1500mg daily.Per review of a Health Note written by an on-call provider dated 7/6/2025 [Resident's] diet changed to pureed, [Resident]not able to swallow Depakote due to the size/coating. Nurse requests liquid or crushable formulation. Only comes in sprinkles or extended release formulation. Changing to sprinkles will necessitate dosing modification, so will defer to Pharmacy for their expertise. Orders: Notify a clinician of any change in condition. change depakote DR 500 mg 2 tabs daily and 1 tab at bedtime to depakote sprinkles, dosing as per Pharmacy recommendations. Per review of an Administration Order Summary, the Depakote order from admission on [DATE] was placed on hold because there was a new order for Depakote sprinkles.Review of Resident #2's July 2025 Medication Administration Record (MAR) reveals that the Depakote order was placed on hold on 7/6/2025 and the new order for Depakote sprinkles was not implemented for 20 days, until 7/25/2025. Per interview on 1/21/2026 at 2:47 PM, the Director of Nursing stated the Depakote order had been placed on hold until the order for the Depakote sprinkles could be obtained from the pharmacy. The DON confirmed that Resident #2 did not receive Depakote from 7/6/2025 to 7/25/2025.3. Per record review Resident #3 had a Physician's Order for Pregabalin (Lyrica) 50 mg three times daily. Progress notes dated 12/30/25 - 1/2/26 state that the medication was not available. Further record review revealed a SBAR (Situation, Background, Assessment, Request, used to communicate a change in condition to the provider) dated 1/4/2026 revealed that Resident #3 was experiencing painful urination. Provider feedback was CBC, CMP, UAR with C&S (urinalysis and urine culture & sensitivity), 1 liter IV Fluid @75ml/hr, Pyridium 100mg BID x 3 days, Keflex 500mg BID for 5 days. A physician's order dated 1/4/2026 read start on keflex 500 mg [twice daily] for 5 days . start on pyridium 100 mg [twice daily] for 3 days Notify a clinician of any change in condition. Per review of the Resident's January Medication Administration Record the order for Keflex was not implemented until 1/6/2026 and the Pyridium was documented on 1/6/26 as awaiting pharmacy.Per interview with the Director of Nursing (DON) on 1/21/2026 at 11:04 AM, she confirmed that the above some medications have not been available for administration per physician's orders. The DON stated that the facility has had ongoing issues with the Pharmacy. This began before Christmas to just recently and the issue is that the Pharmacy is not getting the medications to the facility, on time. The DON stated that she has reviewed the patterns of what medications have not been delivered and they are trying to address the issues by having the medications added to their backup medications. The main medications identified as not being filled timely were Effexor, Lyrica, and Hydroxyzine but there are others (See F760).Review of the facility audit dated 1/9/2026 revealed 35 out of 81 residents had been identified to have missing medications. Drugs@FDA: FDA-Approved Drugs

Based on interview and record review the facility failed to ensure that residents were free from significant medication errors caused by frequent omissions of medications related to availability and/or transcription practices for 3 of 5 residents in the sample (Residents #1. #2. and #3). Due to this deficient practice Resident #1 experienced an unwitnessed fall, headache, elevated blood pressure, and seizure like activity that required them to be evaluated and treated at the hospital. Findings include:1. Per record review, Resident #1 has diagnoses that include panic disorder, anxiety disorder, dissociative identity disorder, major depressive disorder, tremor, and hypertension. A Physician's Order dated 10/22/2025 states Effexor XR [Anti-Depressant] Oral Capsule Extended Release 24 Hour 150 MG (Venlafaxine HCl) Give 300 mg by mouth one time a day for Depression.Review of Resident # 1's Progress Notes and December 2025 and January 2026 medication administration records (MARs) revealed that the Resident did not receive the prescribed Effexor for 4 days, from 12/31/2025- 1/6/2026. Per Black Box Warning (alerts healthcare providers and patients to serious, potentially life-threatening, or permanently disabling adverse reactions) A gradual reduction in the dose, rather than abrupt cessation, is recommended when discontinuing therapy with Effexor XR. Abruptly stopping the use of Effexor can lead to Discontinuation syndrome. Suddenly stopping EFFEXOR XR may cause you to have serious side effects. Your healthcare provider may want to decrease your dose slowly. Symptoms may include: Seizures (convulsions) . Other adverse reactions that may occur include agitation, anorexia, anxiety, confusion, impaired coordination and balance, diarrhea, dizziness, dry mouth, dysphoric mood, fasciculation, fatigue, flu-like symptoms, headaches, hypomania, insomnia, nausea, nervousness, nightmares, sensory disturbances (including shock like electrical sensations), somnolence, sweating, tremor, vertigo, and vomiting. Further record review reveals that Resident #1 also had a Physician's Order dated 10/21/2025 for Pregabalin (Lyrica, an anticonvulsant [anti-seizure] and gabapentinoid [used to treat nerve pain]) 25 mg per day for pain. Review of the Resident's Progress notes and December 2025 and January 2026 MARs revealed that the prescribed Lyrica was not available and not administered from 12/29/2025 - 1/5/2026. The FDA Black Box Warning states Do not stop taking LYRICA without talking to your healthcare provider. If you stop taking LYRICA suddenly you may have headaches, nausea, diarrhea, trouble sleeping, increased sweating, or you may feel anxious. If you have epilepsy and you stop taking LYRICA suddenly, you may have seizures more often. Talk with your healthcare provider about how to stop LYRICA slowly. Warnings and Precautions include: Abrupt or rapid discontinuation may increase the risk for seizures. Withdrawal symptoms or suicidal behavior and ideation have been observed after discontinuation. Taper LYRICA gradually over a minimum of 1 week. A progress note dated 1/3/2026 reads Walked into residents room and found resident lying on the floor on [her/his] left side. Resident crying stating [her/his] head was pounding and [her/his] left hand was hurting. [blood pressure] 206/104- [according to the American Heart Association could signal severe hypertension or hypertensive emergency] [pulse] 98- [Oxygen Saturation] 97% Resident noted to have seizure activity x 2.The Resident was sent to the emergency department .Another progress Note dated 1/3/2026 reads Received an update from the ER [emergency room] nurse [name omitted] (RN) at [hospital] on [the Resident]. Resident is being admitted on observation and is currently alert and oriented x3, resident is waiting for further testing and evaluations. Resident also have orders for [diagnostic testing], serial troponins, and is started on Keppra to prevent any further seizure activities . Resident denies having any chest pain or discomfort. ER nurse reported [her/him] being noncompliant with the telemetry monitoring and won't keep the leads on. Overall [s/he] also have been having changes with her personalities while in the ER but have not been combative so far .Review of the hospital Discharge Summary reveals that there was a suspicion for organic seizure [events that look like epileptic seizures but are caused by a direct physical issue in the brain] and a recommendation for Keppra 500 mg twice daily was made. Discharge diagnoses of seizure-like activity with known history of nonepileptic shaking, resolved elevated troponin and elevated lactic acid [diagnostic tests used to confirm heart damage]. The assessment and plan states Possibly nonepileptic seizure, but elevated troponin and lactic somewhat concerning. Review of laboratory results revealed that Resident #1's Troponin T level on 1/3/2026 was 38.90 at 6:23 PM (the normal range is less than 14.00). The Discharge Summary also stated, The Patient be going back on all [her/his] standard meds there was some question if she missed a couple of [her/his] meds at Mission care by [her/his] friend. The note does not address which medications may have been missed or whether the Resident had been evaluated for rapid withdrawal contributing to her/his condition. While being evaluated at the hospital Resident #1 experienced behavior changes and it was determined that it was best for her/his overall emotional wellbeing s/he would discharge back to the facility with orders to continue previous medications. Per progress notes dated 1/4/2026 Resident #1 returned to the facility with no new orders.A communication note dated 1/5/2026 states This nurse was made aware that both Effexor and Lyrica had still not arrived from pharmacy despite multiple contacts made with the pharmacy. Spoke with [name omitted] (Pharmacy Rep), states she will have medication sent STAT [without delay]. Spoke with [Medical Director] ordered to continue with medication as scheduled. Resident was made aware. Further review of Resident #1's progress notes revealed that on 1/11/2026 nursing staff were again unable to administer the ordered Effexor due to unavailability. Further record review revealed that on 1/6/2026 Resident #1 had laser iridotomy (an out-patient procedure that uses a focused laser beam to create a tiny hole in the iris, allowing fluid to drain and reducing eye pressure in patients with or at high risk of, narrow-angle glaucoma) to both eyes. S/he returned to the facility with an order to continue to use Prednisolone 1% (used to reduce eye swelling, redness, and irritation caused by injury, surgery, or allergies) one drop in each eye daily for a total of 7 days to start on 1/7/2026. Review of Resident #1's January MAR revealed that the order for the Prednisolone 1% was not transcribed until 1/8/2026 and was not implemented until 1/9/2026.A SBAR (Situation, Background, Assessment, Request, used to communicate a change in condition to the provider) dated 1/9/2026 reads Nursing observations, evaluation, and recommendations are: Resident complains of right eye pain and throbbing this morning. Recommendations were called performing surgeon who has asked to see the resident in office today.Per interview on 1/21/2026 at 11:04 AM, the Director of Nursing (DON) confirmed the above medication errors occurred. 2. Per record review a Minimum Data Set (MDS, an assessment used to develop a plan of care) dated 12/1/2025, Resident #2 has diagnoses that include anxiety disorder and bipolar disorder. S/he has a physician's order with a start date of 5/27/2025 for Depakote Delayed Release (DR) 1000 mg by mouth one time a day and 500 mg at bedtime for mood disorder for a total of 1500 mg daily. Per review of a Health Note written by an on-call provider dated 7/6/2025, [Resident's] diet changed to pureed, [Resident] not able to swallow Depakote due to the size/coating. Nurse requests liquid or crushable formulation. Only comes in sprinkles or extended release formulation. Changing to sprinkles will necessitate dosing modification, so will defer to Pharmacy for their expertise. Orders: Notify a clinician of any change in condition. change depakote DR 500mg 2 tabs daily and 1 tab at bedtime to depakote sprinkles, dosing as per Pharmacy recommendations. Per review of an Administration Order Summary and Resident #2's July 2025 Medication Administration Record, the Depakote order from admission on [DATE] was placed on hold on 7/6/2025 because there was a new order for Depakote sprinkles. However, the Depakote sprinkles were not implemented for 19 days, until 7/25/2025. According to the Food and Drug Administration Depakote delayed-release tablets are also used to treat manic episodes associated with bipolar disorder. Stopping Depakote suddenly can cause serious problems.Per interview on 1/21/2026 at 2:47 PM, the Director of Nursing stated that the Depakote order had been placed on hold until the order for the Depakote sprinkles could be obtained from the pharmacy. The DON confirmed that Resident #2 did not receive Depakote from 7/6/2025 to 7/25/2025.3. Per record review, Resident #3 had a Physician's Order for Pregabalin (Lyrica, a prescribed medication used to treat nerve pain) 50 mg three times daily for neuropathy (nerve damage that often causes pain, numbness, or weakness). Progress notes dated 12/30/25 - 1/2/26 state that the medication was not available. There is no documentation that supports that the physician was notified of the missed doses of Lyrica and no evidence of increased monitoring for adverse reactions related to abrupt cessation of the Lyrica.The FDA Black Box Warning states Do not stop taking LYRICA without talking to your healthcare provider. If you stop taking LYRICA suddenly you may have headaches, nausea, diarrhea, trouble sleeping, increased sweating, or you may feel anxious. If you have epilepsy and you stop taking LYRICA suddenly, you may have seizures more often. Talk with your healthcare provider about how to stop LYRICA slowly. Warnings and Precautions include: Abrupt or rapid discontinuation may increase the risk for seizures. Withdrawal symptoms or suicidal behavior and ideation have been observed after discontinuation. Taper LYRICA gradually over a minimum of 1 week. Further record review revealed a SBAR dated 1/4/2026 revealed that Resident #3 was experiencing painful urination. Provider feedback included Pyridium (used to treat pain, burning, urgency, and increased urination caused by urinary tract infections [UTIs]) 100 mg BID x 3 days and Keflex (n antibiotic used to treat various bacterial infections) 500 mg BID for 5 days for suspected UTI. A physician's order dated 1/4/2026 reads start on keflex 500 mg [twice daily] for 5 days,,, start on pyridium 100 mg [twice daily] for 3 days Notify a clinician of any change in condition. Per review of the Resident's January Medication Administration Record, the order for Keflex was not implemented until 1/6/2026 and the Pyridium was documented on 1/6/26 as awaiting pharmacy.Per interview with the Director of Nursing (DON) on 1/21/2026 at 11:04 AM, the facility has had ongoing issues with contracted Pharmacy not providing prescribed medications (See F755). The DON confirmed the above medication errors occurred.Per interview on 2/3/2026 at 2:52 PM the Director of Nursing confirmed that Keflex was not implemented until 1/6/2026 and the Pyridium was not available for administration on 1/6/2026. Drugs@FDA: FDA-Approved Drugs

Based on interview and record review the facility failed to ensure that a resident's representative was informed of benefits, risks, and alternatives prior to initiating an anti-anxiety medication for 1 of 5 sampled residents (Resident #2). Findings include: Per record review, Resident #2 was admitted to the facility 5/27/2025 with physician's orders for Depakote (anticonvulsant), Vistaril (antihistamine), and Zoloft (anti-depressant) for mood disorder. There is no documented evidence that the Resident's representative was informed of the benefits, risks, or alternatives until a consent form was completed by the Unit Manager on 6/20/2025 indicating that she had obtained verbal consent from the responsible party.On 7/17/2026 a physician's order was written for Buspirone (anti-anxiety) 10 mg by mouth twice daily for anxiety. Further review revealed that there was no documented evidence that Resident #2's responsible party was informed of the benefits, risks, alternate treatment, or initiation of the physician ordered Buspirone. A progress note dated 7/25/2025 reads Note: Order to DC Buspirone per provider and guardian request carried out. [vital signs every] shift order implemented along with behavior monitoring X3 days entered. Care plan updated. Responsible party aware. Per interview with Resident #2's responsible party on 2/3/2026 at 1:30 PM, s/he had not been made aware of the initiation of the Buspirone and when s/he was made aware s/he asked that it be discontinued. Per interview on 2/2/2026 at 2:15 PM the Director of Nursing confirmed that there was no evidence that Resident #2's representative had been offered informed consent prior to the initiation of the Buspirone.

Based on observations, interviews, and policy reviews, the facility failed to store food in accordance with professional standards for food service safety. This deficiency has the potential to impact all residents in the facility. This is a repeat deficiency for this facility, with the violation cited during a previous partial survey dated 7/16/25. Findings include:1. Per the initial tour of the Kitchen on 12/8/25 at 10:49 AM, a rack containing dishware was revealed. The Dietary Manager stated the dishware was ready for use. There was half a tray of cups that had been flipped upside down and were observed to be wet on the sides, and the bottoms of each cup. The Dietary Manager confirmed the cups were ready for use but hadn't been dried correctly. The Dietary Manager stated the cups should've remained on a drying rack to allow air to circulate and complete the drying process.The tour of the dry storage area revealed an open brownie mix and a package of elbow pasta with no dating. The Dietary Manager confirmed that both items should have labels indicating the dates they were opened.The refrigerators revealed one pitcher of a yellowish fluid that the Dietary Manager stated was lemonade, a red substance in a clear, square container with a lid that the Dietary Manager stated was cranberry sauce, shredded vegetables with dressing in a clear, square container that the Dietary Manager stated was coleslaw, and diced, beige product which the Dietary Manager stated was diced chicken that were not labeled with what the items were or dates of production or expiration. The Dietary Manager confirmed that all items should be labeled with the item name, the date they were placed in the refrigerator, and the date they should be disposed of. Eleven packages of flour tortillas expired on 11/21/25, and a clear, square container of [NAME] expired on 11/14/25. The Dietary Manager confirmed that expired items should be removed and disposed of, not left in storage. She showed signage posted on the refrigerators indicating the task of labeling and dating items.The freezer revealed an open ravioli package that wasn't dated, and a box of hamburger patties was open to the air and not dated. The Dietary Manager confirmed that the items should be dated and stored in closed containers to protect their integrity per policy.2. A tour of the Kitchen on 12/10/25 at 1:15 PM with the Chef revealed an open, undated egg substitute carton in the refrigerator, which he confirmed should be dated when the seal is broken.The Chef was shown a picture provided by a resident showing a hot dog bun with a green-gray discoloration. He confirmed he was aware of the moldy bread, stating that the Kitchen was contacted during service on the day it was served, and the Kitchen staff remade the Resident's meal. The Chef said, It has been a struggle to balance the stock of bread, as the freezer space is limited.3. Per review of a facility policy Date Marking (dated 9/11/2020), states Date Marking systems are in place to reduce foodborne illness caused by, Listeria monocytogenes (a type of disease-causing bacteria which can have mild symptoms such as fever, muscle aches, nausea, vomiting, and diarrhea or more severe symptoms may include headache, stiff neck, confusion, loss of balance, and convulsions, FDA 1/16/25), a pathogen that continues to grow in refrigerated temperatures. The policy continues to state, Foods will be date marked with the name of the product, the date of production or opening. Refer to Quick Reference List (reference list of shelf lives of products) for discard date. Per interview on 12/10 at 3:54 PM, the Dietary Manager confirmed that the practice and facility policy require that items in storage be covered or placed in a container, labeled, and dated.Referencehttps://www.fda.gov/food/foodborne-pathogens/listeria-listeriosis

Based on observations, interviews, and record review, the facility failed to ensure that residents who require dialysis receive services consistent with professional standards of practice and the comprehensive, person-centered care plan for one of one residents (Resident #5). Findings include: Per record review, Resident #5 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease, anemia in chronic kidney disease, and dependence on renal dialysis (a type of treatment that helps your body remove extra fluid and waste products from your blood when the kidneys cannot). The Resident has a central venous catheter (a soft plastic tube, tunneled under the skin and placed in a vein in the neck, chest, or groin, which enters a central vein that leads to the heart). Review of Resident #5's Care Plan reveals a Focus area for the Resident is at risk for worsening impaired renal function and is at risk for complications related to hemodialysis, which was initiated on 10/7/25. One of the interventions listed is to maintain smooth catheter clamps at the bedside (and on patient when out of bed) in case of breakage or excessive bleeding from catheter, which was also initiated on 10/7/25. During observations on 12/8/25 at 1:00 PM, no smooth clamps were located at the bedside in Resident #5's room.Per interview on 12/9/25 at 2:30 PM with the Unit Manager (UM), she stated that the Resident should have an Emergency Kit at the bedside, including the smooth clamps. The UM then asked one of the nurses to check the kit for the clamps. He returned and stated the kit was at the bedside but didn't include the clamps. During an observation on 12/9/25 at 3:16 PM with the Director of Nursing (DON) and the UM, the kit in Resident #5's room didn't include the needed smooth clamps. The DON confirmed again that the clamps need to be added and that the emergency kit should be with the Resident at all times, including when they are off-site for dialysis.ReferenceNational Kidney Foundation. 2023, January 1. Dialysis (https://www.kidney.org/kidney-topics/dialysis)MedlinePlus. 2024, October 28. Daily assessment of the vascular access site is necessary to avoid infection, blood clots, and other problems. (https://medlineplus.gov/ency/patientinstructions/000591.htm)The American College of Surgeons. 2017. What Is a Central Venous Access Device (CVAD)? (https://www.facs.org/media/2tcnbb4f/understanding_your_central_line.pdf)

Based on interview and record review, the facility failed to provide or obtain laboratory services when ordered by a physician; and/or notify the physician when ordered labs were not completed for one resident [Resident #6] of 29 sampled residents.Findings include:Per review of Resident #6's medical record, a third eye health note [a telemedicine service which examines patients remotely via video and audio] dated 11/25/25 reveals the resident was seen for new-onset gross hematuria [where blood is visible in the urine]. [H/she] is noted to be on Eliquis [an anti-blood clotting medication] with no reports of hematuria in the past (although [h/she] was recently hospitalized for a Gastro-Intestinal Bleed two times in September and October).According to the Mayo Clinic, the healthy range for hemoglobin is: For men, 13.2 to 16.6, for women, 11.6 to 15.[Hemoglobin (abbreviated Hgb or Hb) is the protein molecule in red blood cells that carries oxygen from the lungs to the body's tissues].The telemedicine note continues: Recent Hgb levels [for Resident #6]: 8.2 on 11/13/2510.9 on 10/9/25Diagnosis, Assessment/Plan: - Gross hematuria (Primary). This is an acute new problem. Condition is worsening. Will hold AM Eliquis [anti blood clotting medication] if recurrent hematuria overnight and check CBC in A.M. [A complete blood count (CBC) is a blood test that measures amounts and sizes of red blood cells, hemoglobin, and other blood components].Review of Physician Orders for Resident #6 on 11/25/26 include Hold A.M. Eliquis for recurrent hematuria overnight - Check CBC/BMP [BMP (basic metabolic panel) is a test that measures several important aspects of blood, like electrolytes and blood sugar]. - Notify a clinician of any change in condition.Further review of Resident #6's medical record revealed no documentation that the Physician Order for CBC dated 11/25/25 was completed as ordered, and/or results obtained and the physician notified. An interview was conducted with the Director of Nursing [DON] on 12/9/25 at 4:42 PM. The DON confirmed that the Physician Order for labs for Resident #6 were never completed and/or the physician notified.The DON reported an order for the CBC was entered and completed after the interview with the surveyor on 12/9/25. Review of Change of Condition notes for Resident #6 on 12/9/25 regarding the newly completed labs reveal lab critical value reported by [hospital] lab for 7.8 hemoglobin down from 8.2 from previous lab. Resident #6's Physician responded by ordering a test for blood in the stool and to repeat the CBC blood work in two days.

Based on observation, interview, and record review the facility failed to ensure the contracting food service department employed sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service. This deficiency has the potential to impact all residents. Findings include: During observations of the facility kitchen on 7/15/2025 at 8:50 AM there were several concerns with kitchen cleanliness, food storage, safety, and sanitization noted. Review of the facility Grievance Log and actual grievances from April 2025 - July 2025 revealed 5 grievances dated 4/7, 4/21, 4/25, 6/10, and 6/12 related to food quality, temperature, raw meats, over and under cooked foods including chicken, pork, and hamburger. Per interview on 7/15/2025 at 10:35 AM with the Regional Dietary Manager (RDM) when asked if there was a process to ensure that staff were competent in food service activities, he stated that the Dietary Manager supervises the food service process. The RDM was asked to provide evidence of education for three cooks and three dietary aides regarding food services. Review of documented training provided by the RDM revealed the following:Cook #1 the RDM was unable to produce evidence of any documented training or competency. [NAME] #2 revealed that in 2023 he had completed in-service training and quizzes regarding topics such as food safety, preparation, and labeling. In 2024 the only documented trainings were an in-service quiz regarding cross contamination completed on 2/9/2024 and knives, slicers, and cutting boards completed on 1/22/24. There was no documented training for 2025. There was also no documented evidence that cook #1 had ever been assessed for competency related to food service activities. [NAME] #3 the only documented trainings regarding food service in 2024 were an in-service quiz regarding cross contamination completed on 2/9/2024 and knives, slicers, and cutting boards completed on 1/22/24. There was no documented training for 2025. There was also no documented evidence that [NAME] #2 had ever been assessed for competency related to food service activities.Dietary Aide #1 the RDM was unable to produce evidence of any documented training or competency in food service.Dietary Aide #2 the only training documented for 2024 was knives, slicers, and cutting boards in-service quiz completed on 1/22/24 and a cross contamination in-service quiz completed on 2/9/2024. There was no documented evidence the Dietary aide had ever been assessed for competency related to food service. Dietary Aide #3 the only training documented for 2024 was knives, slicers, and cutting boards in-service quiz completed on 1/22/24 and cross contamination in-service quiz completed on 2/9/2024. There was no documented evidence the Dietary aide had ever been assessed for competency related to food service. The RDM conformed that there was no documentation that demonstrated that the dietary staff had been assessed for competency related to dietary services including food storage, preparation, cooking, and serving. Per interview on 7/15/2025 at 3:00 PM with the facility Administrator, the consulting food service agency is responsible for training and competency of the food service staff. She was not aware of the status of training and competency. The Administrator confirmed the above concerns had been reported through the grievance process and had been addressed with the DM and RDM. Ref. F812

Based on observation and interview the facility failed to store food in accordance with professional standards for food service safety. This deficiency has the potential to impact all residents in the facility. Findings include:Per observation of the main kitchen on 7/15/25 at 8:50 AM, it was noted upon entry that there were fruit flies flying around the food prep and cooking area. The cook and the Dietary Manager (DM) were present. The DM stated that the fruit flies have been there for about a week. He also stated that they have been flushing the drains with bleach, and he has been cleaning and mopping the kitchen every morning. In the dish room there were more fruit flies flying around, an osculating fan was on and there was fly tape hanging from the ceiling that was being blown around by the fan with dead fruit flies stuck to it.On the bottom shelf of a 3-tier metal rack was a large bin of flour that was uncovered with the lid slid off to the side. on the 3rd shelf there were two uncovered bins filled with kitchen utensils. Further observations of the kitchen revealed that there was a large amount of dead fruit flies on the rack under the juice dispenser, live fruit flies in the dry storage area, an open box of potatoes, and an open box of watermelons on the third shelf of a metal rack. The large mixer was uncovered, and the bowl had dried debris in it. When asked about the mixer the DM stated, I keep that covered and removed the bowl.During observations of the walk-in refrigerator it was noted that there was an open large bag of cheddar cheese on a shelf and on the bottom shelf there was a cardboard box with two bags of raw chicken and a large build-up of liquid from the thawed chicken had formed. There was no date on the bags of chicken or the box identifying when it had been thawed or when it expired. The DM confirmed that there was no date.A two doored refrigerator holding prepped deserts, juices, and condiments was noted to have moisture on the outside. Each side of the refrigerator had thermometers one read 48 degrees Fahrenheit (F) and the other read 46 degrees F. The DM stated that it was probably because they had been opening and closing the doors and he would check them in an hour. During a walk-through of the kitchen with the regional Dietary Manager (RDM) on 7/15/25 at 10:35 AM he confirmed there were fruit flies in the on the fans in the dish room and the fly paper hanging from the ceiling, however the fans were not running at this time. He also confirmed that the bins with the utensils were not and should be covered. The raw chicken in the refrigerator remained but was now in a stainless-steel pan with a date on it. When the RDM was told that it was the chicken that had been in the box with no date on it during the initial observation he told the DM to throw it out. The RDM also confirmed that the refrigerator temperatures were still 46 degrees F and 48 degrees F. Per interview with the facility Administrator on 7/15/2025 at 3:00 PM she confirmed that there were concerns related to the cleanliness of the kitchen.

Based on observation, interview, and record review the facility failed to ensure that 1 of 5 residents in the applicable sample (Resident #1) who was moved from one room to another room within the facility was provided a safe homelike environment. Findings include: Per review of Resident #1's census information s/he was transferred to a new room within the facility on 7/12/2025.During an observation tour of the facility on 7/15/2025 at 12:22 PM Resident #1's room was noted to have two beds, one on each side of the room. The bed near the window was made with facility bedding, while the bed by the door was noted to be un-made with a bare mattress on the bed. On top of the mattress was a standing wet floor sign, two wheelchair leg rests, a cushion, a bare pillow, several papers, and an unattached foot board. There were four wheelchairs next to the bed. Along the wall there was a dresser with books and other items on the top, a desk with a laundry basket filled with personal items, and two shopping bags filled with items. There was a chair that had a large clear plastic bag that was filled with linens and three pillows without cases stacked on top of the bag. Per interview on 7/15/2025 at approximately 3:30 PM with the facility Administrator, Resident #1 had recently been moved to this room. The Administrator confirmed that Resident #1's room was not homelike, that their personal belongings should have been unpacked, the bed should not be piled with the items, and the wheelchairs did not belong to the Resident and should not have been in the room.

Based on interview and record review the facility failed to ensure that services being provided meet professional standards of quality for one of 3 sampled residents [Resident #1]. Resident #1 was receiving the medication Lithium Carbonate and physician orders for blood work were not completed as ordered and the physician was not notified of this or changes in the resident's condition. Additionally, the facility failed to act upon signs and symptoms of lithium toxicity while continuing to administer the medication, which eventually ended in the resident's death, and altered the resident's record to reflect compliance and notifications after they had been transferred out to the facility. This citation is at the immediate jeopardy level due to the lack of process for notification and consultation with the physician regarding lab work not completed as ordered and with significant changes in resident statuses putting all residents at risk for serious injury or death because of the noncompliance. Per record review, prior to their admission to the long-term care facility, Resident #1 was hospitalized with alteration in mental status- acute mania and psychotic break. At the end of their stay in the hospital, hospital notes dated [DATE] record Resident #1 is now taking [h/her] medication, has been in much better mood. [S/he] has been interacting much more with the staff, allowing personal care, showering, bed changes, etc. [S/he] has been up into the halls during the day in a wheelchair, going outside at times when the weather is good. Nursing Progress notes from the hospital dated [DATE] record the resident is acting with improved mood, patient is smiling and allowing care throughout shift. Patient resting comfortably.' Resident #1 was discharged from the hospital on [DATE] and transferred to the long-term care facility. Review of Resident #1's Nursing admission Assessment, dated [DATE], identified the resident as speaking clearly, alert, and oriented to person. During an interview with Resident #1's Unit Manager [UM] on [DATE] at 3:10 PM, the UM stated when Resident #1 came to the facility, [s/he] was quiet for a couple of days, afterwards [s/he] was very bubbly, [s/he] was funny, outgoing. While at the hospital, Resident #1 was receiving the medication Lithium for a diagnosis of Schizoaffective disorder [Schizoaffective disorder is a mental health condition that is marked by a mix of hallucinations and delusions, and symptoms such as depression and mania-an over-the-top level of activity or energy] [Lithium is a natural salt that reduces the symptoms of mania (high energy, racing thoughts, rapid speech). The medication has a narrow range of safety, so it doesn't take much to have too much lithium in your body. Lithium toxicity is a life-threatening condition that causes intestinal and neurological symptoms. It requires immediate medical care in a hospital. Lithium toxicity (overdose) happens when you have too much of the prescription medication lithium in your body. If you don't receive treatment for lithium toxicity, it can be fatal. Healthcare providers check lithium levels with a blood test.] (https://my.clevelandclinic.org/health/diseases/25207-lithium-toxicity) During their stay at the hospital, Resident #1 was receiving regular monthly blood work to check on their lithium levels. During their 7-month stay in the hospital, Resident #1's lithium level remained in therapeutic range all but one time, when the level was found to be high. It was immediately re-checked and found to be slightly below therapeutic range. The lithium levels were checked every month through [DATE], and the resident was discharged on [DATE] and transferred to the long-term care facility prior to a December lithium level being drawn. A Physician admission History & Physical was conducted at the long-term care facility on [DATE]. The Physician's Assessments/Plans records I do have some concerns that [s/he] may be overmedicated at this point .[s/he] may benefit from some titration of [h/her] mediations over a period of likely months . Records indicate [s/he] has not had some titration of [h/her] medications over the last several months, these could be considered for gradual dose reduction in the future. The Physician records the resident has managed currently on lithium [and 2 other medications]. We will check lithium levels for baseline. Review of Physician Orders dated [DATE] reveal an order for a lithium level to be obtained by a blood draw. Review of medication orders for Resident #1 reveals an order for Lithium Carbonate Oral Capsule 300 milligrams- give 2 capsules by mouth at bedtime. The start date for the medication order is the day of admission, [DATE]. Next to the medication on the Nursing Medication Administration Record [MAR] is a Black Box Warning. Per interview with Resident #1's Unit Manager [UM] on [DATE] at 11:40 AM, nursing should click on the box prior to administering the medication and read the warning in full. For lithium, the Black Box warning reads: Black Box Warning Details- Monitoring. Lithium toxicity is closely related to serum lithium levels and can occur at doses close to therapeutic levels facilities for prompt and accurate serum lithium determination should be available before initiating therapy. Per record review, Resident #1's medical record includes a Psychotropic Medication Administration Disclosure listing the risks and benefits of psychotropic medications the resident was prescribed. Under Lithium, the disclosure lists Of Special Concern: seizures, muscle reflex, stupor, coma. Toxic Levels of Lithium are close to therapeutic levels and require routine laboratory monitoring. Review of Resdient #1's Medication Administration Record and Treatment Administration Record [MAR/TAR] reveal the ordered lithium level blood draw signed off by nursing as 'completed' on [DATE] at 10:12 AM, one day after the Physician's order was entered. Of note, The MAR/TAR includes the notation no site of lab administration data found for lab administration record. Review of Resident #1's medical record includes a Nursing Progress note labeled Late Entry, with the entry marked as created on [DATE], with an effective date recorded as [DATE] [43 days earlier]. The [DATE] effective date is 2 days after the blood draw was signed off as completed and reads attempt x3 to obtain blood as ordered. Unable x3. MD notified, will attempt at later time. The note contains prompts to Show on Shift Report, Show on 24 hour Report, and Show on MD/Nursing Communications Report, with none of the prompts check marked to activate them. Per interview on [DATE] at 4:01 PM, the facility's Director of Nursing Services [DNS] confirmed that there was no documentation on [DATE] that the lithium blood draw was unable to be completed as ordered despite the MAR recording the blood draw had been done. The DNS confirmed the note reporting that the blood draw being unsuccessful was dated 2 days after the attempts were made but was written 43 days later on [DATE]. The DNS further confirmed that there was no documentation available to confirm the Physician had been notified 2 days after the unsuccessful blood draw attempts as the Late Entry recorded. Per interview with the Unit Manager [UM] on [DATE] at 3:10 PM, the UM confirmed the note reporting the blood draw was unsuccessful was dated 2 days after the attempts were made but was written 43 days later on [DATE]. When asked why Resident #1's medical record was altered on [DATE], 43 days later, the Unit Manger stated because we knew it was going to be looked at [by the state regulatory agency]. Further review of Resident #1's Medication Administration Record [MAR] reveals the resident continued to receive the lithium on a daily basis despite no lab results available to determine if their levels were out of therapeutic range. An interview with the Assistant Director of Nursing Services [ADNS] on [DATE] at 11:51 AM revealed that in addition to the information about the drug contained in the Black Box Warning, Nursing can view if lab work for the medication has been ordered and completed, and what the results are. The ADNS confirmed there were no results available for any lithium levels for Resident #1. The ADNS reported that if labs were not completed as ordered on a Black Box medication, staff should contact the Physician or On-Call Provider for further orders, including an order to hold the medication until it can be determined if the medication level in the resident is at a safe and therapeutic level. The ADNS stated the risk of holding the medication is less than the risk of giving it if the levels were not in range. The ADNS confirmed there was no documentation regarding any Physician response to lithium levels not being obtained for Resident #1, and the resident continued to receive daily lithium doses. According to the National Library of Medicine: Lithium toxicity signs are obvious and can be identified and managed easily; however, ignoring it can be fatal. Indeed, in some cases, lithium toxicity can lead to coma, brain damage, or even death. During lithium treatment, the healthcare team including physicians and nurses should make sure serum levels are checked regularly to make sure of the treatment course. If any signs of early toxicity appear, the patient should stop the medication and seek medical counsel. (https://www.ncbi.nlm.nih.gov/books/NBK499992/) Review of Resident #1's medical record records dated 1/5, 1/6, & [DATE] record the resident displaying behaviors. Nursing notes on [DATE] record resident noted to be yelling out, difficult to understand what [s/he] is saying, agitated with care, swinging at Nurses' Aides during care. Behaviors continued on 1/8 and 1/9, with the resident threw [h/her] drink at this nurse, refused to allow nebulizer treatment to be administered, very agitated at this nurse. Nursing Notes dated [DATE] reveal Resident #1 was hallucinating and delusional and staff were unable to get resident to cooperate. On [DATE], Resident #1 was yelling out, screaming, hysterically laughing and screaming out again, inconsolable. Resident #1 was evaluated remotely by a physician via Tele-Medicine [face to face via computer and camera] on [DATE]. The Physician noted upon admission [Resident #1] could communicate [h/her] needs, slowly transitioned to manic behaviors. Today, [Resident #1] is found in bed tearful and then angry, pointing and unable to communicate [h/her] needs. Under Assessment/Recommendations, the Physician records will need lab results to review prior to recommendations: lithium. A Change in Condition form was entered on [DATE] for altered mental status for Resident #1. Nursing observations record Resident is exhibiting signs of agitation with hallucinations and delusions. According to the Pharmaceutical Journal: Lithium toxicity may occur in some patients despite a normal lithium level; therefore, recognizing the clinical features of toxicity is important. The central nervous system (CNS) is most affected by chronic toxicity, with an altered level of consciousness being the most common sign. Other CNS signs and symptoms include slurred speech, confusion . Signs of severe toxicity include increased disorientation and seizures, possibly leading to coma. Patients with long-term conditions, including diabetes and schizophrenia are at increased risk of developing lithium toxicity. [Per record review, Resident #1's diagnoses include both diabetes and schizophrenia.] If there are signs or symptoms of lithium toxicity, lithium should be withheld, and an urgent lithium level should be taken, with specialist advice sought. (https://pharmaceutical-journal.com/article/ld/lithium-monitoring-and-toxicity-management) Nursing Progress notes dated [DATE], 3 days after the Telemedicine recommendation for lithium levels read unable to obtain blood draw for lithium level. Attempt x 3. A Nursing Progress note dated 4 days later is again labeled Late Entry with an effective date labeled [DATE], and created on [DATE] [27 days later]. The Late Entry note reads Dr. notified of difficulty obtaining lab draws. Per interview with the Assistant Director of Nursing Services [ADNS] on [DATE] the ADNS confirmed there was no documentation regarding any Physician response to lithium levels not being obtained for Resident #1, and the resident continued to receive daily lithium doses. An interview was conducted with Resident #1's physician on [DATE] at 4:30 PM. The physician stated if nursing observed symptoms consistent with medication toxicity, the medication should be held with notification to the physician. The physician stated s/he had not heard any organized characterizations or evolution of symptoms from nursing regarding possible medication side effects. The physician further stated that it was h/her expectation that lab work would be completed as ordered and after the blood work was unable to be drawn the first time on [DATE], the physician should have been notified and Resident #1 should have been sent to an outpatient facility to have it done. Per record review, 10 days later, on [DATE], a third attempt was made to obtain a lithium level. The sample obtained was determined to be too small to conduct the lithium test. Per interview on [DATE] at 4:01 PM, the facility's Director of Nursing Services [DNS] stated that the facility had the option to send the resident to a nearby hospital to have the blood draw completed, but this was not done after any of the three attempts performed at the facility. Review of Nursing Progress notes dated [DATE] record the resident is screaming out unrecognizable words, talks to self, hallucinations, delusions. On [DATE], the resident is assessed as semi- alert. On [DATE] the resident is refusing h/her continuous oxygen treatment. There is no documentation of the Physician being notified of the resident's hallucinations, delusions or semi-alert condition. An interview was conducted on [DATE] at 2:36 PM with Resident #1's nurse who was caring for the resident on [DATE]. The nurse stated I came in at 7:00 AM on [DATE], and my aides [Licensed Nurses' Aides] told me that [Resident #1] looked wrong. They were worried [s/he] was not themselves, not interacting, eyes were tracey[uncontrolled movements]. I had been off for 4 days, and it was a complete change in condition from when I last laid eyes on [h/her], their blood pressure was low, they weren't eating and drinking much. I called telehealth between 7:30 & 9:00 AM, telehealth said hold the psychotics [including lithium]. Then next shift nurse [the shift starting at 3:00 PM] called the provider and [Resident #1] was sent out to the hospital. On [DATE], at 10:51 AM, Nursing Progress notes record multiple medications being held due to the resident's altered mental status, lethargy. Per the National Library of Medicine regarding the levels of lithium toxicity: Severe intoxication: Coma, seizures, and hypotension [low blood pressure]. The Cleveland Clinic notes: If you have moderate to severe lithium toxicity, you'll likely get neurological symptoms. These include: Mental status changes that can range from mild confusion to delirium. Slurred speech (dysarthria). Uncontrolled eye movements (nystagmus). Seizures (severe cases). (https://my.clevelandclinic.org/health/diseases/25207-lithium-toxicity) A Change in Condition form was entered on [DATE] for Resident #1 five hours after medications were held. The Change in Condition form was for Altered mental status. Talks/communicates less. Tired, weak, confused or drowsy and Abnormal vital signs (low blood pressure). Nursing observations include Resident #1 in bed with eyes open, nystagmus noted both eyes. Resident looks when called but is unable to respond verbally. Unable to squeeze hands or apply pressure with feet when asked. Resident grimacing with what appears to be pain. Resident took one bite of dinner and vomited. The On-call Telemedicine Physician was contacted. Review of the Physician Notes dated [DATE] at 6:00 PM record the resident is Unresponsive . lying in bed with eyes fixed open, saliva running out of side of mouth, and unresponsive to stimuli. Staff states that [s/he] has been in this state since this AM and had some intermittent lateral eye movements that then resolves into the fixed stare. [S/he] has been unable to swallow since this AM, so no intake by mouth. Labs ordered during a previous consult, but RN was only able to draw enough blood for complete blood count [not lithium level]. Blood pressure is below baseline . Condition is guarded. This is an acute new problem: seizure vs hyperthyroid vs infection. Orders: Transfer to Emergency Department. Per review of Emergency Department notes dated [DATE]: Patient presents from [long term care facility] where [s/he] was recently admitted . [S/he] had possible seizure activity with staff where [s/he] had abnormal twitching movements and has been somnolent [sleepy, drowsy] throughout the day up to this point. Patient not following directions. Normally [s/he] is quite loud and boisterous per staff . Patient presents possible seizure activity and significant altered mental status. [S/he] does not have a documented history of seizures. Spoke with nursing staff there, decline started yesterday, normally alert and oriented to self and interactive and able to follow commands. Procedure: Critical Care. The high probability of life or limb threatening condition required a high level of direct monitoring and care. The services I provided to this patient involved treatment to stabilize presenting septic, altered mental status. In the early morning hours of [DATE], Resident #1 was transferred to the Intensive Care Unit [ICU]. ICU notes dated [DATE] at 6:30 AM record Rapid Response [emergency response team] was called because of seizure-like activities. Patient never presented this way before .loss of about 3-4 minutes. Per review of ICU Physician notes, dated [DATE], the resident is assessed with Severe lithium toxicity, altered mental status, seizure, acute renal failure. The physician notes that lithium has been on hold for at least 2 nights [since the resident was sent to the hospital] and that Patient's lithium level is 3.0 this morning. [Regarding Lithium toxicity: A safe blood level of lithium is 0.6 to 1.2 milliequivalents per liter (mEq/L). Lithium toxicity can happen when this level reaches 1.5 mEq/L or higher. Severe lithium toxicity happens at a level of 2.0 mEq/L and above, which can be life-threatening in rare cases. Levels of 3.0 mEq/L and higher are considered a medical emergency.] (https://www.healthline.com/health/lithium-toxicity) Per review of ICU Physician notes, dated [DATE]: Problem List: - Severe lithium toxicity associated with acute renal failure, seizure events and delirium - Unresolved toxic encephalopathy thought related to multiple seizure events associated with lithium toxicity with suspected brain injury - Free water deficiency in association with lithium toxicity - Initial shock thought related to medication toxicity Subjective: [Resident #1] remains in a poor condition. [S/he] is not wakeful. [H/her] eyes are open and [s/he] is staring off to the left. I have concerns that [s/he] has irreversible brain injury given [h/her] multiple seizure events and the prolonged nature of [h/her] lithium toxicity. Assessment and Plan: [Resident #1] has a history of schizophrenia who comes in with severe lithium toxicity shock secondary to lithium versus infection who has seizure activity and altered mental status, An infection was not definitively proven. Initial blood culture results are thought more likely to be contaminant. An additional seizure event took place on [DATE]. [S/he] had another seizure event that was very brief early this morning. - Severe lithium toxicity altered mental status seizure acute renal failure: Lithium has been on hold and will remain so for now - Seizure activity: This could be in the setting of lithium toxicity. Patient has not had history of seizures in the past. - Toxic metabolic encephalopathy: This is likely medication related - Acute renal failure: In the setting of lithium toxicity - Shock infectious versus lithium: Would favor lithium toxicity Disposition: Patient is Do Not Resuscitate/Do Not Intubate with a consideration of transition to comfort measures soon given [h/her] decline. Further record review reveals Resident #1 expired on [DATE] at 9:20 AM. Per review of the Lippincott Manual of Nursing, Common Departures from the Standards of Nursing Care include: failure to follow physician orders, follow appropriate nursing measures, communicate information about the patient. The standards of care for professional nursing include assessment, diagnosis, outcome identification, planning, implementation and evaluation. [Lippincott Manual of Nursing Practice-11th Edition 2018] The DNS confirmed that the facility failed to follow professional standards regarding: Failure to follow physician orders regarding obtaining blood draws and therapeutic drug levels. The DNS confirmed During lithium treatment, the healthcare team including physicians and nurses should make sure serum levels are checked regularly to make sure of the treatment course (https://www.ncbi.nlm.nih.gov/books/NBK499992/) and Resident #1's Medication Orders for Lithium included Black Box Warning Details- Monitoring. Lithium toxicity is closely related to serum lithium levels and can occur at doses close to therapeutic levels, Lithium toxicity is a life-threatening condition (https://my.clevelandclinic.org/health/diseases/25207-lithium-toxicity). The DNS confirmed that the facility had the option to send Resident #1 to a nearby hospital to have the blood draw completed, but this was not done after any of the three attempts performed at the facility, and there was no documentation to support Resident #1's physician was notified of the failed attempts. The DNS confirmed the facility failed to monitor signs and symptoms of lithium toxicity and continued lithium administration without knowledge of therapeutic levels. According to the National Library of Medicine: Lithium toxicity signs are obvious and can be identified and managed easily; however, ignoring it can be fatal .If any signs of early toxicity appear, the patient should stop the medication and seek medical counsel. (https://www.ncbi.nlm.nih.gov/books/NBK499992/) The DNS confirmed the facility documented signs and symptoms of lithium toxicity including altered mental status, confusion, delirium, low blood pressure, and nystagmus (uncontrolled eye movements) while continuing to administer the medication and without notifying the physician, with the resident's condition eventually transitioning into seizures and resulting in Resident #1's death. According to the American Nurses Association's, Principles for Nursing Documentation, professional standards of documentation include guiding principles as follows: * Documentation that is incomplete, inaccurate, untimely, illegible, or that is false, or misleading can lead to a number of undesirable outcomes such as jeopardizing the legal rights of patients and health care providers, impeding legal fact finding, and putting providers at risk of liability. * Authenticated: that is, the information is truthful, the author is identified, and nothing has been added or inserted inaccurately. The DNS confirmed the facility failed to maintain and accurately document resident records in a timely manner related to orders signed as completed and late entries added to Resident #1's medical record regarding physician notification and in fact physician orders not being completed. The DNS confirmed entries were added to the medical record after the resident had been transferred out the facility and were created without documentation to support their content.

Based on interview and record review, the facility failed to carry out critical medication level monitoring that was ordered and failed to consider whether the onset or worsening of symptoms, or a change of condition, may be related to the medication and failed to respond to the presence of adverse consequences related to the use of a high-risk medication for 1 of 3 sampled residents [Resident #1], which resulted in Resident #1's death. This citation is at the immediate jeopardy level due to the lack of an effective process to ensure medications are only administered with adequate monitoring of laboratory values, per manufacturers specifications and accepted professional standards for high risk medications, and not administered in the presence of adverse consequences which indicate the dose should be reduced or discontinued, putting all residents at risk for serious injury or death because of the noncompliance. Findings include: Per record review, prior to their admission to the long-term care facility, Resident #1 was hospitalized with alteration in mental status- acute mania and psychotic break. At the end of their stay in the hospital, hospital notes dated [DATE] record Resident #1 is now taking [h/her] medication, has been in much better mood. [S/he] has been interacting much more with the staff, allowing personal care, showering, bed changes, etc. [S/he] has been up into the halls during the day in a wheelchair, going outside at times when the weather is good. Nursing Progress notes from the hospital dated [DATE] record the resident is acting with improved mood, patient is smiling and allowing care throughout shift. Patient resting comfortably.' Resident #1 was discharged from the hospital on [DATE] and transferred to the long-term care facility. Review of Resident #1's Nursing admission Assessment, dated [DATE], identified the resident as speaking clearly, alert, and oriented to person. During an interview with Resident #1's Unit Manager [UM] on [DATE] at 3:10 PM, the UM stated when Resident #1 came to the facility, [s/he] was quiet for a couple of days, afterwards [s/he] was very bubbly, [s/he] was funny, outgoing. While at the hospital, Resident #1 was receiving the medication Lithium for a diagnosis of Schizoaffective disorder [Schizoaffective disorder is a mental health condition that is marked by a mix of hallucinations and delusions, and symptoms such as depression and mania-an over-the-top level of activity or energy] [Lithium is a natural salt that reduces the symptoms of mania (high energy, racing thoughts, rapid speech). The medication has a narrow range of safety, so it doesn't take much to have too much lithium in your body. Lithium toxicity is a life-threatening condition that causes intestinal and neurological symptoms. It requires immediate medical care in a hospital. Lithium toxicity (overdose) happens when you have too much of the prescription medication lithium in your body. If you don't receive treatment for lithium toxicity, it can be fatal. Healthcare providers check lithium levels with a blood test.] (https://my.clevelandclinic.org/health/diseases/25207-lithium-toxicity) During their stay at the hospital, Resident #1 was receiving regular monthly blood work to check on their lithium levels. During their 7-month stay in the hospital, Resident #1's lithium level remained in therapeutic range all but one time, when the level was found to be high. It was immediately re-checked and found to be slightly below therapeutic range. The lithium levels were checked every month through [DATE], and the resident was discharged on [DATE] and transferred to the long-term care facility prior to a December lithium level being drawn. A Physician admission History & Physical was conducted at the long-term care facility on [DATE]. The Physician's Assessments/Plans records I do have some concerns that [s/he] may be overmedicated at this point .[s/he] may benefit from some titration of [h/her] mediations over a period of likely months . Records indicate [s/he] has not had some titration of [h/her] medications over the last several months, these could be considered for gradual dose reduction in the future. The Physician records the resident has managed currently on lithium [and 2 other medications]. We will check lithium levels for baseline. Review of Physician Orders dated [DATE] reveal an order for a lithium level to be obtained by a blood draw. Review of medication orders for Resident #1 reveals an order for Lithium Carbonate Oral Capsule 300 milligrams- give 2 capsules by mouth at bedtime. The start date for the medication order is the day of admission, [DATE]. Next to the medication on the Nursing Medication Administration Record [MAR] is a Black Box Warning. Per interview with Res.#1's Unit Manager [UM] on [DATE] at 11:40 AM, nursing should click on the box prior to administering the medication and read the warning in full. For lithium, the Black Box warning reads: Black Box Warning Details- Monitoring. Lithium toxicity is closely related to serum lithium levels and can occur at doses close to therapeutic levels facilities for prompt and accurate serum lithium determination should be available before initiating therapy. Per record review, Resident #1's medical record includes a Psychotropic Medication Administration Disclosure listing the risks and benefits of psychotropic medications the resident was prescribed. Under lithium, the disclosure lists Of Special Concern: seizures, muscle reflex, stupor, coma. Toxic Levels of Lithium are close to therapeutic levels and require routine laboratory monitoring. Review of Resident #1's Medication Administration Record and Treatment Administration Record [MAR/TAR] reveal the ordered lithium level blood draw signed off by Nursing as completed on [DATE] at 10:12 AM, one day after the Physician's order was entered. Of note, The MAR/TAR includes the notation no site of lab administration data found for lab administration record. Review of Resident #1's medical record includes a Nursing Progress note labeled Late Entry, with the entry marked as created on [DATE], with an effective date recorded as [DATE] [43 days earlier]. The [DATE] effective date is 2 days after the blood draw was signed off as completed, and reads attempt x3 to obtain blood as ordered. Unable x3. MD notified, will attempt at later time. The note contains prompts to Show on Shift Report, Show on 24-hour Report, and Show on MD/Nursing Communications Report, with none of the prompts check marked to activate them. Per interview on [DATE] at 4:01 PM, the facility's Director of Nursing Services [DNS] confirmed that there was no documentation on [DATE] that the lithium blood draw was unable to be completed as ordered despite the MAR recording the blood draw had been done. Per interview with the Unit Manager [UM] on [DATE] at 3:10 PM, the UM confirmed the note reporting the blood draw was unsuccessful was dated 2 days after the attempts were made but was written 43 days later on [DATE]. When asked why Resident #1's medical record was altered on [DATE], 43 days later, the Unit Manger stated because we knew it was going to be looked at [by the state regulatory agency]. Further review of Resident #1's Medication Administration Record [MAR] reveals the resident continued to receive the lithium on a daily basis despite no lab results available to determine if their levels were out of therapeutic range. An interview with the Assistant Director of Nursing Services [ADNS] on [DATE] at 11:51 AM revealed that in addition to the information about the drug contained in the Black Box Warning, nursing can view if lab work for the medication has been ordered and completed, and what the results are. The ADNS confirmed there were no results available for any lithium levels for Resident #1. The ADNS reported that if labs were not completed as ordered on a Black Box medication, staff should contact the Physician or On-Call Provider for further orders, including an order to hold the medication until it can be determined if the medication level in the resident is at a safe and therapeutic level. The ADNS stated the risk of holding the medication is less than the risk of giving it if the levels were not in range. The ADNS confirmed despite lithium levels not being obtained for Resident #1, the resident continued to receive daily lithium doses. An interview was conducted with Resident #1's physician on [DATE] at 4:30 PM. The physician stated it was h/her expectation that lab work would be completed as ordered and after the blood work was unable to be drawn the first time on [DATE], Resident #1 should have been sent to an outpatient facility to have it done. The physician further stated that if nursing observed symptoms consistent with medication toxicity, the medication should be held with notification to the physician. According to the National Library of Medicine: Lithium toxicity signs are obvious and can be identified and managed easily; however, ignoring it can be fatal. Indeed, in some cases, lithium toxicity can lead to coma, brain damage, or even death. During lithium treatment, the healthcare team including physicians and nurses should make sure serum levels are checked regularly to make sure of the treatment course. If any signs of early toxicity appear, the patient should stop the medication and seek medical counsel. (https://www.ncbi.nlm.nih.gov/books/NBK499992/) Review of Resident #1's medical record records dated 1/5, 1/6, and [DATE] record the resident displaying behaviors. Nursing notes on [DATE] record resident noted to be yelling out, difficult to understand what [s/he] is saying, agitated with care, swinging at Nurses' Aides during care. Behaviors continued on 1/8 and 1/9, with the resident threw [h/her] drink at this nurse, refused to allow nebulizer treatment to be administered, very agitated at this nurse. Nursing Notes dated [DATE] reveal Resident #1 was hallucinating and delusional and staff were unable to get resident to cooperate. On [DATE], Resident #1 was yelling out, screaming, hysterically laughing and screaming out again, inconsolable. Resident #1 was evaluated remotely by a physician via Tele-Medicine' [face to face via computer and camera] on [DATE]. The Physician noted upon admission [Resident #1] could communicate [h/her] needs, slowly transitioned to manic behaviors. Today, [Resident #1] is found in bed tearful and then angry, pointing and unable to communicate [h/her] needs. Under Assessment/Recommendations, the Physician records will need lab results to review prior to recommendations: lithium. A Change in Condition form was entered on [DATE] for altered mental status for Resident #1. Nursing Observations record Resident is exhibiting signs of agitation with hallucinations and delusions. According to the Pharmaceutical Journal: Lithium toxicity may occur in some patients despite a normal lithium level; therefore, recognizing the clinical features of toxicity is important. The central nervous system (CNS) is most affected by chronic toxicity, with an altered level of consciousness being the most common sign. Other CNS signs and symptoms include slurred speech, confusion . Signs of severe toxicity include increased disorientation and seizures, possibly leading to coma. Patients with long-term conditions, including diabetes and schizophrenia are at increased risk of developing lithium toxicity. [Per record review, Res.#1's diagnoses include both diabetes and schizophrenia.] If there are signs or symptoms of lithium toxicity, lithium should be withheld, and an urgent lithium level should be taken, with specialist advice sought. (https://pharmaceutical-journal.com/article/ld/lithium-monitoring-and-toxicity-management) Per interview with Resident #1's physician on [DATE] at 4:30 PM the physician stated a change in mental status would be a departure from the normal [for Resident #1] with new clinical features and confirmed that telehealth notes on [DATE] recorded a change in mental status and that having Resident #1 sent out for a blood draw would have been appropriate. Review of Resident #1's medical record reveals no order for lithium levels to be drawn per the tele-health recommendation on [DATE], and no documentation that any attempts were made for 3 days after the tele-health note. Nursing Progress notes dated [DATE], 3 days after the Telemedicine recommendation for lithium levels read unable to obtain blood draw for lithium level. Attempt x 3. Further record review reveals Res.#1 continued to receive daily doses of Lithium Carbonate despite displaying clinical features of toxicity. Per record review, 10 days later, on [DATE], a third attempt was made to obtain a lithium level. The sample obtained was determined to be too small to conduct the lithium test. Per interview on [DATE] at 4:01 PM, the facility's Director of Nursing Services [DNS] stated that the facility had the option to send the resident to a nearby hospital to have the blood draw completed, but this was not done after any of the three attempts performed at the facility. Review of Nursing Progress notes dated [DATE] record the resident is screaming out unrecognizable words, talks to self, hallucinations, delusions. On [DATE], the resident is assessed as semi- alert. On [DATE] the resident is refusing h/her continuous oxygen treatment. There is no documentation of the Physician being notified of the resident's hallucinations, delusions or semi-alert condition. An interview was conducted on [DATE] at 2:36 PM with Resident #1's nurse who was caring for the resident on [DATE]. The nurse stated I came in at 7:00 AM on [DATE], and my aides [Licensed Nurses' Aides] told me that [Resident #1] looked wrong. They were worried [s/he] was not themselves, not interacting, eyes were tracey[uncontrolled movements]. I had been off for 4 days, and it was a complete change in condition from when I last laid eyes on [h/her], their blood pressure was low, they weren't eating and drinking much. I called telehealth between 7:30 & 9:00 AM, telehealth said hold the psychotics [including lithium]. Then next shift nurse [the shift starting at 3:00 PM] called the provider and [Resident #1] was sent out to the hospital. On [DATE], at 10:51 AM, Nursing Progress notes record multiple medications being held due to the resident's altered mental status, lethargy. Per the National Library of Medicine regarding the levels of lithium toxicity: Severe intoxication: Coma, seizures, and hypotension [low blood pressure]. The Cleveland Clinic notes: If you have moderate to severe lithium toxicity, you'll likely get neurological symptoms. These include: Mental status changes that can range from mild confusion to delirium. Slurred speech (dysarthria). Uncontrolled eye movements (nystagmus). Seizures (severe cases). (https://my.clevelandclinic.org/health/diseases/25207-lithium-toxicity) A Change in Condition form was entered on [DATE] for Res.#1, five hours after medications were held. The Change in Condition form was for Altered mental status. Talks/communicates less. Tired, weak, confused or drowsy and Abnormal vital signs (low blood pressure). Nursing observations include Resident #1 in bed with eyes open, nystagmus noted both eyes. Resident looks when called but is unable to respond verbally. Unable to squeeze hands or apply pressure with feet when asked. Resident grimacing with what appears to be pain. Resident took one bite of dinner and vomited. The On-call Telemedicine Physician was contacted. Review of the Physician Notes dated [DATE] at 6:00 PM record the resident is Unresponsive . lying in bed with eyes fixed open, saliva running out of side of mouth, and unresponsive to stimuli. Staff states that [s/he] has been in this state since this AM and had some intermittent lateral eye movements that then resolves into the fixed stare. [S/he] has been unable to swallow since this AM, so no intake by mouth. Labs ordered during a previous consult, but RN was only able to draw enough blood for complete blood count [not lithium level]. Blood pressure is below baseline . Condition is guarded. This is an acute new problem: seizure vs hyperthyroid vs infection. Orders: Transfer to Emergency Department. Per review of Emergency Department notes dated [DATE]: Patient presents from [long term care facility] where [s/he] was recently admitted . [S/he] had possible seizure activity with staff where [s/he] had abnormal twitching movements and has been somnolent [sleepy, drowsy] throughout the day up to this point. Patient not following directions. Normally [s/he] is quite loud and boisterous per staff . Patient presents possible seizure activity and significant altered mental status. [S/he] does not have a documented history of seizures. Spoke with nursing staff there, decline started yesterday, normally alert and oriented to self and interactive and able to follow commands. Procedure: Critical Care. The high probability of life or limb threatening condition required a high level of direct monitoring and care. The services I provided to this patient involved treatment to stabilize presenting septic, altered mental status. In the early morning hours of [DATE], Resident #1 was transferred to the Intensive Care Unit [ICU]. ICU notes dated [DATE] at 6:30 AM record Rapid Response [emergency response team] was called because of seizure-like activities. Patient never presented this way before .loss of about 3-4 minutes. Per review of ICU Physician notes, dated [DATE], the resident is assessed with Severe lithium toxicity, altered mental status, seizure, acute renal failure. The physician notes that lithium has been on hold for at least 2 nights [since the resident was sent to the hospital] and that Patient's lithium level is 3.0 this morning. [Regarding Lithium toxicity: A safe blood level of lithium is 0.6 to 1.2 milliequivalents per liter (mEq/L). Lithium toxicity can happen when this level reaches 1.5 mEq/L or higher. Severe lithium toxicity happens at a level of 2.0 mEq/L and above, which can be life-threatening in rare cases. Levels of 3.0 mEq/L and higher are considered a medical emergency.] (https://www.healthline.com/health/lithium-toxicity) Per review of ICU Physician notes, dated [DATE]: Problem List: - Severe lithium toxicity associated with acute renal failure, seizure events and delirium - Unresolved toxic encephalopathy thought related to multiple seizure events associated with lithium toxicity with suspected brain injury - Free water deficiency in association with lithium toxicity - Initial shock thought related to medication toxicity Subjective: [Resident #1] remains in a poor condition. [S/he] is not wakeful. [H/her] eyes are open and [s/he] is staring off to the left. I have concerns that [s/he] has irreversible brain injury given [h/her] multiple seizure events and the prolonged nature of [h/her] lithium toxicity. Assessment and Plan: [Resident #1] has a history of schizophrenia who comes in with severe lithium toxicity shock secondary to lithium versus infection who has seizure activity and altered mental status, An infection was not definitively proven. Initial blood culture results are thought more likely to be contaminant. An additional seizure event took place on [DATE]. [S/he] had another seizure event that was very brief early this morning. - Severe lithium toxicity altered mental status seizure acute renal failure: Lithium has been on hold and will remain so for now - Seizure activity: This could be in the setting of lithium toxicity. Patient has not had history of seizures in the past. - Toxic metabolic encephalopathy: This is likely medication related - Acute renal failure: In the setting of lithium toxicity - Shock infectious versus lithium: Would favor lithium toxicity Disposition: Patient is Do Not Resuscitate/Do Not Intubate with a consideration of transition to comfort measures soon given [h/her] decline. Further record review reveals Resident #1 expired on [DATE] at 9:20 AM. An interview was conducted with the facility's Administrator [ADM], Director of Nursing Services [DNS], the Director of Operations, and the Regional Clinical Director on [DATE] at 4:01 PM. During the interview, the facility's Director of Nursing Services [DNS] confirmed the facility recognized that Resident #1 was ordered and administered a critical medication with which presented significant risks to the resident. The DNS confirmed that in addition to monitoring lab levels of the medication, it was essential to monitor the physical and mental/neurological status of the resident and report these changes to the Physician to ensure the resident's health and safety. The DNS confirmed that Medication Administration Records prompted Nursing to review lab levels and assess for signs and symptoms of toxicity with every administration of the lithium, which was given daily. The DNS confirmed that therapeutic levels of lithium differ only slightly from levels that can result in serious harm. Per the interview on [DATE] at 4:01 PM, the DNS and ADM confirmed that blood work orders for Resident #1 were not completed as ordered. The DNS & ADM confirmed that attempts to obtain critical lab values of lithium levels were conducted weeks apart with no rationale for the delay. The DNS confirmed the facility failed to contact the Physician in regard to whether to continue or hold the lithium administration while blood work monitoring was not completed. The DNS & ADM confirmed that Resident #1 exhibited signs and symptoms of lithium toxicity on multiple days without the Physician being notified, including [DATE], when Resident #1 was unable to accept medications due to lethargy and unspecified altered mental status and the Physician was not contacted until approximately 4 hours later, at 3:51 PM.

Based on interview, record review, and policy review, the facility failed to ensure the Medical Director assisted the facility with the development and implementation of resident care policies, specifically related to laboratory services. This deficient practice has the potential to affect all residents residing in the facility. Findings include: Per record review, Resident #1 was admitted to the facility on [DATE] after being hospitalized with alteration in mental status- acute mania and psychotic break, and the diagnosis of Schizoaffective disorder [Schizoaffective disorder is a mental health condition that is marked by a mix of hallucinations and delusions, and symptoms such as depression and mania-an over-the-top level of activity or energy]. Resident #1's physician orders reveal an order for Lithium Carbonate Oral Capsule 300 milligrams- give 2 capsules by mouth at bedtime, with a start date of [DATE]. A Physician admission History & Physical dated [DATE] reads do have some concerns that [s/he] may be overmedicated at this point .[s/he] may benefit from some titration of [h/her] mediations over a period of likely months . The Physician records the resident has managed currently on lithium [and 2 other medications]. We will check lithium levels for baseline. Review of Physician Orders dated [DATE] reveal an order for a lithium level to be obtained by a blood draw. There was no evidence in Resident #1's medical record that lithium levels were obtained prior to being transferred to the hospital on [DATE]. There was no documentation in Resident #1's medical record that the physician was notified that the lithium blood draw was unable to be completed as ordered until [DATE]. Resident #1's Medication Administration record reveals that s/he received lithium every day prior to [DATE]. A [DATE] Change in Condition form reveals that Resident #1 was transferred to the hospital on [DATE] for altered mental status. Per review of ICU Physician notes, dated [DATE], the resident was assessed with Severe lithium toxicity, altered mental status, seizure, acute renal failure. Further record review reveals Resident #1 expired on [DATE] at 9:20 AM. See F658 for more information. Per interview on [DATE] at 3:09 PM, the Unit Manager acknowledged that the facility identified problems related to obtaining Resident #1's lithium levels. She was unsure if there was a policy or written process regarding lab services and results, but stated that the facility has done education about the process since the facility identified the issue. Per interview on [DATE] at 3:01 PM, the Administrator provided a policy titled Lab Draw Collection Policy which revealed a process in which the physician should be notified, and attempts should be documented in the resident's medical record, when blood specimens cannot be obtained. This policy is dated effective as of [DATE], 81 days after the physician had ordered Resident #1's lithium level to be obtained by a blood draw. The Administrator provided evidence of when the Medical Director last reviewed nursing policies and procedures. A sign off sheet documenting who participated in a review of nursing policy and procedures revealed that the Medical Director last reviewed nursing policies and procedures on [DATE]. Per phone interview on [DATE] at 4:18 PM, the Medical Director stated that there should be a policy and a process that is followed regarding laboratory services. He revealed that he was unaware that the facility did not have a laboratory services policy and confirmed that there should be. The physician stated s/he was not familiar with how policy is created and couldn't say what they [the policies] are.

Based on interview and record review, the facility failed to ensure that licensed nurses have the specific competencies necessary to care for Residents' needs as identified through resident assessments and the plan of care. Findings include: Per review of 5 licensed nurses' employee education files, 3 Licensed Practical Nurses did not have evidence that they had been assessed for medication administration competencies. The Facility Assessment (an assessment that determines what resources are necessary to care for the residents competently during both day-to-day operations and emergencies), dated 1/23/25, reads, The staff competencies and skill sets that are necessary to provide the level and types of care need for the Facility's specific resident population are as follows and lists the competencies and skills needed for licensed nursing staff which include medication administration. Per interview and record review, on 3/25/25 at approximately 1:45 PM, the Director of Nursing (DON) explained that all licensed nurses are evaluated prior to taking an assignment to see if they are competent to provide nursing care using the checklist, Nurse Skills Day Checklist. A review of this checklist shows a list of skills that nurses need to demonstrate. This list does not include medication administration skills, other than injections and Narcan administration. The DON was unable to produce a medication administration competency check for licensed nurses. Per interview on 3/25/25 at 3:01 PM, the Administrator confirmed that licensed nurse competencies did not include medication administration.

Based on observation, interview and record review, the facility failed to assess Residents for urinary and bowel incontinence on admission to ensure that a resident who is incontinent receives appropriate treatment and services to restore continence to the extent possible for 3 of 4 Residents in the sample (Resident #31, #48, and #105). Findings include: Per record review Resident #105 was admitted in October 2024. A care plan focus and the Resident Kardex indicate that he/she is incontinent, interventions identified include 1 assist with perineal care as needed, multi-void disposable briefs to contain incontinence. Another care plan focus reflects that Resident #105 is incontinent of urine and is unable to cognitively or physically participate in a retraining program due to Dementia. There is no documented evidence of a urinary or bowel continence assessment in the record. Per interview on 10/22/2024 at 2:45 PM a Licensed Nursing Assistant (LNA) stated that on admission, staff were told that Resident #105 was continent of urine however, he/she was not. The LNA stated that staff check the Resident's brief about every two hours and s/he did not know if there was a specific schedule when to do so. The LNA said that he/she would have to check the Resident's care plan to know if there was a schedule. Review of Resident #105's toileting documentation shows several hour gaps, between toileting assistance. Examples of these gaps include 10/18/24, when staff documented that the Resident was toileted at 9:47 AM and then not until 10:11 PM; on 10/20/24, when staff documented that the Resident was toileted at 8:42 AM then not until 7:56 PM; and on 10/22/24 when staff documented that the Resident was toileted at 12:13 AM and then not until 1:23 PM. Per facility Continence Management policy, if the Resident is incontinent upon admission, complete a Urinary Incontinence Evaluation, address the transient causes for incontinence and initiate the Three Day Continence Management Diary. Per interview with the Unit Manager (UM) on 10/23/2024 at 11:30 am residents are evaluated for bowel and bladder continence on admission using the Nursing V 11 Admission Assessment. During the interview the UM accessed Resident #105's Admission Assessment; the urinary continence evaluation had not been completed. The Admission Assessments for Residents #31 and #48 were also reviewed with the UM revealing that their urinary continence evaluations were also not completed. The UM confirmed that Residents #105, #31, and #48 had not been assessed for continence on admission, and that the facility policy had not been followed.

Based on interview and record review the facility failed to notify a Resident Representative of a change in condition related to a worsening wound, abnormal laboratory results, and transfer to the hospital. Findings include: Per interview on 10/23/2024 at 9:35 AM Resident #104's Representative stated that s/he had not been notified by the facility that Resident #104's wound had worsened. The Representative also stated that s/he had not been notified by the facility that the Resident's blood work was abnormal, and that the Resident had been transferred to the hospital. Per record review Resident #104 was admitted to the facility in September 2024 with a stage 2 pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an open/ruptured serum-filled blister) on his/her coccyx and venous stasis ulcers. A care plan focus for Advanced Directives states Inform resident/patient and/or healthcare decision maker of any change in status or care needs. A skin assessment was completed on 9/8/23 reveals a wound measuring: 1. Area 0.4 cm2 2. Length 1.4 cm 3. Width 0.5 cm 4. Depth 0.2 cm 5. Undermining Not Applicable 6. Tunneling Not Applicable On 9/18/23 the wound measured 1. Area 1.9 cm2 2. Length 2.0 cm 3. Width 1.3 cm 4. Depth Not Applicable 5. Undermining Not Applicable 6. Tunneling 0.3 cm Review of the Nurse Practitioner progress note dated 9/17/2024 stated the wound had progressed to a stage 3 pressure ulcer (Full-thickness skin loss with damage to subcutaneous tissue extending down to (but not including) the underlying fascia (connective tissue)). There is no documented evidence that the Resident #104's Representative was notified of the worsening wound. Review of progress notes dated 9/24/23, Resident #104 was noted to be lethargic and seems different than usual. The Physician was notified and the nurse received orders for blood work. The Resident's Representative was notified of the Resident's condition and the order for blood work. Upon receiving the results of the blood work Resident #104 was sent to the Emergency department for treatment. Per the hospital Emergency Report the Resident had a markedly elevated sodium level. There is no documented evidence that the facility notified the Resident's Representative of the elevated sodium level, or the need to transfer the Resident to the hospital. During interview on 10/23/2024 at approximately 2:15 PM the Assistant Director of Nursing confirmed that there was no documented evidence that the Representative was notified of the worsening wound, the results of the blood work, or the transfer to the hospital. *https://learning.lww.com/files/BacktotheBasicsWoundAssessmentManagementandDocumentation-1662480009184.pdf

Based on interview and record review the facility failed to monitor weights and verify potential significant weight loss and gains as needed for 5 of 6 residents sampled (Residents #2, #3, #4, #5, and #6). Findings include: 1. Per record review Resident #2 has a Physicians order for monthly weights. Review of the Resident's Weight Summary revealed significant weight changes of 12.60% weight loss over one month and 10.82% over six months. On 1/3/24 the Resident's weight was documented as 245 lbs. one month later, on 2/3/24 the weight was documented as 256.0 lbs., an 11 lb. weight gain. There is no evidence that the resident was reweighed. On 5/15/24 the Resident's weight was documented as 250 lbs., on 6/3/24 the weight was documented as 218.5 lbs., a 31.5 lb. weight loss. There is no documentation that reweighs were obtained. 2. Per record review Resident #3 had documented significant weight loss of 6.72% over one month and 10.39% loss over six months. Review of the Resident's Weight Summary reveals that on 1/16/24 the Resident weighed 139.5 lbs., on 5/15/24 the Resident weighed 134 lbs., and on 6/19/24 the Resident's weight was 125 lbs., a 9 lb. weight loss over one month and 14.5 lb. weight loss. There were no documented reweighs in the record. 3. Per record review Resident #4 was admitted to the facility on [DATE]. Review of Resident #4's care plan reveals that they are at risk for unplanned weight changes with a goal of maintain weight within +/- 5 pounds [for] 90 days. Review of Resident #4's weight record for 5/30/24- 6/28/24 reveals that daily weights were not obtained on 8 of the 30 days. Further review also revealed that Resident #4 had significant fluctuations in weight with no documented reweight. On 6/3/2024 the Resident's weight was documented as 408.5 Lbs. On 6/4/2024 the Resident's weight was documented as 368.4 Lbs., a 40.1 lb. discrepancy. On 6/9/24 their weight was documented as 372.0 Lbs., and on 6/10/2024 it was documented as 379.3 Lbs., a 7.3 lb. weight gain in one day. On 6/19/24 their weight was 370.2 lbs., and on and 6/21/2024 358.0 lbs. indicating a 22 lb. weight loss. There was no documentation that Resident #4 was reweighed on any of the following dates to rule out changes in clinical status or verify if it was an accurate weight. 4. Per record review Resident #5 has a Physicians Order for monthly weights. Review of the Resident's Weight Summary reveals a significant weight gain over one month. On 6/3/24 the Resident's weight was documented as 302.7 lbs., and on 7/1/24 their weight was 319.4 lbs., indicating a 16.7 lb. weight increase which is a 5.52 % gain. There is no documented evidence that the Resident was reweighed to ensure accurate weights and rule out a clinical change in health status. 5. Per record review Resident #6's weight record shows that Resident #6's monthly weights from 1/8/2024 - 6/18/2024 identified a gradual weight loss of 11 lbs. On 6/18/2024 Resident #6 was weighed using a mechanical lift, their weight was documented as 203.2 lbs. On 7/1/2024 Resident #6 was weighed using a mechanical lift and their weight was documented as 194.8 lbs., an 8.4 lb. (4.13 %) weight loss in one month. There was no documented evidence that Resident #6 was reweighed to rule out a clinical change in condition or ensure the results were accurate. Per review of the facility procedure titled Weights and Heights Section 1. Obtaining and Documenting Weight: 1.1.4 If the body weight is not as expected, re-weigh the patient. Section 1.2 1.2.1 The Weights Exception Report will be reviewed by a licensed nurse with follow-up as indicated. Section 2. Significant Weight Change Management: 2.1 Significant weight changes will be reviewed by the licensed nurse for assessment. 2.1.1 Significant weight change is defined as: 2.1.1.1 5% in one month 2.1.1.2 10% in six months 2.2 The licensed nurse will: 2.2.1 Notify the physician/APP and Dietician of significant weight changes; 2.2.2 Document notification of physician/APP and Dietician in the PCC [Point Click Care] Weight Change Progress Note. 2.3 The licensed nurse will notify the: 2.3.1 Physician/APP of the Dietician recommendation; 2.3.2 Patient representative of the weight change and Dietician recommendations. Notification will be documented. Per interview with the Dietitian on 7/2/24 at 2:16 PM when a resident is weighed and there is a significant discrepancy from the previous documented weight, they should be reweighed to determine accuracy of the weight. The Physician and Dietitan should be notified if the weight discrepancy is found to be accurate. The Dietician confirmed that the facility policy was not consistently being followed. During an interview on 7/3/24 at 1:20 PM The Director of Nursing (DON) stated that if there was an identified discrepancy when weighing a resident staff should reweigh them to verify the change. The DON confirmed that the facility policy was not followed, and that documented reweighs were not available for review in the record.

Based on interview, and record review, the facility failed to ensure that pain management was consistent with professional standards of practice and the comprehensive person-centered care plan was followed for 1 of 3 residents in the sample (Resident #1) as evidenced by a lack of documentation for monitoring of the presence of pain and evaluating the effectiveness of regularly scheduled pain medication. Findings include: Per record review Resident #1 has diagnoses that include chronic pain syndrome, opioid dependence, opioid use disorder /substance abuse disorder (OUD/SUD), and arthritis. Per review of physician's orders Resident #1 has been receiving opioid medications for pain control since admission. A Physician's order dated 6/25/24 states Buprenorphine HCl Sublingual [under the tongue] Tablet Sublingual 8 MG (Buprenorphine HCl) Give 1 tablet sublingually every 12 hours for pain. Another Physician's order dated 6/26/24 states Buprenorphine HCl Sublingual [under the tongue] Tablet Sublingual 2 MG (Buprenorphine HCl) Give 3 tablet sublingually two times a day for pain for 28 Days . The resident was receiving the pain medication on a routine basis; however, the record does not reflect consistent pain monitoring or the resident's response to the administration of the pain medication. A care plan focus initiated on 8/2/2023 related to verbal and physical behaviors lists an intervention of Attempt non-pharmacologic interventions to alleviate pain and document effectiveness. Administer pain medication as ordered and document effectiveness/side effects. Another care plan focus states that Resident #1 exhibits or is at risk for alterations in comfort related to chronic pain and history of opiate dependency [and] chronic [right] shoulder pain. Listed interventions include Evaluate pain characteristics: quality, severity, location, precipitating/relieving factors, Utilize pain scale, Medicate [resident] as ordered for pain and monitor for effectiveness and monitor for side effects, report to physician as indicated. Review of Resident #1's documented Pain Level Summary for the months of April, May, and June 2024 revealed that a numeric pain rating was documented 3 of 30 days in April. There were 6 documented numeric pain ratings in May. Per facility policy titled NSG227 Pain Management, Section 2.1 When opioids are used, the lowest possible effective dosage should be prescribed for the shortest amount of time possible after considering all medical needs. the patient should be monitored for effectiveness and any adverse drug reactions. Section 5. states At a minimum of daily, patients will be evaluated for the presence of pain by making an inquiry of the patient or observing for signs of pain. Section 9. Patients receiving interventions for pain will be monitored for the effectiveness and/or side effects/adverse reactions ( .) Document: 9.3 Ineffectiveness of routine or PRN [as needed] medications including interventions, follow-up, and physician . notification; Per interview on 7/3/24 at 1:20 PM, the Director of Nursing confirmed that there was no regular pain monitoring or evaluation for effectiveness performed for Resident #1.

Based on observation, interviews, and record review the facility failed to ensure that staff was provided the necessary training and possessed the necessary competencies to care for residents with diagnoses of OUD (opioid use disorder), SUD (substance abuse disorder), and PTSD (post-traumatic stress disorder) for 1 of 7 sampled residents (Resident #1). Findings include: Per review of 3 Licensed Nursing Assistant's (LNA's) employee training files. 2 of the 3 LNAs had not received any training related to OUD or SUD. 1 of 3 LNAs files revealed no evidence of training related to PTSD and trauma informed care. Per review of 3 Staff Nurse employee files, 1 Registered Nurse (RN) file revealed no evidence of training related to SUD, OUD, PTSD, and trauma informed care. Per interview with the Registered Nurse assigned to Resident #1 on 7/3/24 at 8:35 AM S/he was recently hired on 7/3/24. The RN confirmed that S/he had not received resident specific training regarding SUD, OUD, PTSD, and trauma informed care since being hired. When asked if S/he knew of any residents on her/his assignment who had a diagnosis of SUD, OUD, or trauma, the RN stated that they did not know of any residents with those diagnoses.

Based on observation, interview, and record review the facility failed to ensure that 2 of 29 residents in the sample were free from significant medication errors related to the administration of a medication prescribed for seizure management (Resident #1), and an antithrombotic (treatment and prevention of blood clots) medication (Resident #9). 1. Per observation of the lunch meal on 10/30/2023 at 11:45 AM Resident #1 was sitting in a specialized wheelchair eating her/his meal. S/he was observed with her/his arms raised above her/his head with a scared facial expression and drool coming from her/his mouth. This surveyor asked her/him if they were alright, and s/he stated in a barely audible voice can you help me? The nurse who was assisting another resident with their meal was alerted, and after speaking to Resident #1 they took her/him to their room. When the nurse came back into the dining area s/he stated that the resident was sick. At 5:20 PM Resident #1 was still in her/his room. S/he stated that s/he still did not feel good. Per record review Resident #1 has received clonazepam 1 MG by mouth three times a day for seizure management since 11/9/2020. A physician's order with a start date of 9/25/23 states clonazepam 1 MG by mouth three times a day for seizure management. Review of Resident #1's medication administration record (MAR) for the month of October 2023 revealed that clonazepam is to be administered at 9:00 AM, 1:00 PM, and 9:00 PM. The MAR also revealed that clonazepam was not administered per order on 10/28/23 at 9:00 AM through 10/30/23 at 9:00 PM, missing 9 doses. According to the American Addiction Center Clonazepam should not be stopped suddenly or without direct supervision and guidance of a medical professional. and Withdrawal from clonazepam can be dangerous and even life threatening. Progress notes written between 10/28 - 10/30 reflect that the medication was not available and had not been delivered from the pharmacy. There was no documented evidence that the physician was notified at the time of any of the omissions. A summary to the physician written on 10/30/23 at 3:05 PM states that the resident was experiencing nausea and/or vomiting. Per interview with the Unit Manager (UM) on 10/31/23 at 3:01 PM the nurse who was responsible for medication administration should have checked the Pyxis (an automated medication dispensing machine that is used to provide storage of commonly prescribed medications) to see if the clonazepam was available. If the medication was not available in the Pyxis, the nurse then should have called the on-call provider to inform them that the medication was not available and inquire about any alternative orders. The UM agreed that based on the symptoms that Resident #1 had been exhibiting on 10/30/23 s/he may be experiencing withdrawal from the missed medication. Review of the facility's policy titled NSG306 Medication Errors: A medication error is defined as a discrepancy between what the physician/advanced practice provider ordered and what the resident/patient received. Types of errors include; medication omission . The facility Medication Error procedure states: 1. Evaluate the patient for adverse effects. 2. Report immediately to the Director of Nursing or designee. 3. Notify physician/advanced practice provider, patient, and responsible party. Obtain orders, if indicated. 4. Initiate orders, if any. 5. Monitor the patient On 10/31/23 at 5:15 PM while observing the Pyxis machine on the 2 North Unit the medication nurse stated that s/he did have access to the Pyxis however, she was unable to do so because s/he had never used it. S/he went to get the UM who provided a list of medications that are available in the Pyxis. The UM confirmed that clonazepam was on the list as being available. A physician's progress note dated 11/1/23 states that Resident #1 had an episode last weekend as [s/he] went without clonazepam for several doses due to system issues. [S/he] had fatigue, altered mental status over the weekend in concurrence to that event. [/S/he] is feeling better today with no complaints. Per interview on 11/1/23 at 12:58 PM with the UM the physician had a phone conversation with Resident #1 this morning. The physician gave no new orders and instructed the UM to continue to monitor for further symptoms of withdrawal from the clonazepam. 2. Per record review Resident #9 has a diagnosis of Atrial Fibrillation (afib, an irregular, often rapid heart rate that commonly causes poor blood flow increasing the risk of blood clots). Physician's orders reflect an order for Pradaxa 150 MG orally two times a day for afib. Review of Resident #9's Medication Administration Record revealed that the morning dose of Pradaxa was not administered on 9/5/2023 and 9/11/2023. Electronic Medication Administration Record Progress Notes dated 9/5/2023 and 9/11/2023 state that the Pradaxa is on order from pharmacy. According to the American Heart Association missing doses of Pradaxa may increase your risk of stroke. There is no evidence in the record that the physician was notified of the missed doses or contacted for alternative orders. During an interview on 11/1/23 at 1:04 PM the Unit Manager confirmed that Resident #9 did not receive the Pradaxa as ordered on 9/5/23 and 9/11/23 and that the nurse should have notified the physician of the missing doses. References: American Addiction Center, Clonazepam Withdrawal Symptoms, Timeline & Detox Treatment, americanaddictioncenters.org American Heart Association, A Patient's Guide to Taking Dabigatran Etexilate (Pradaxa), ahajournals.org

Based on observations, record review and interviews the facility failed to ensure that all nursing staff possess the competencies and skills necessary to protect residents from exposure to COVID-19 during an outbreak by maintaining proper infection control practices, and to provide care to residents based on their individual medical care needs. The lack of staff training and competency in infection prevention and control placed the residents in immediate jeopardy of harm and/or death related to exposure to COVID-19. Findings include: 1. During observation on 10/9/2022 at approximately 9:15 PM a Licensed Nursing Assistant (LNA) assigned to 3 South was observed entering the room of a COVID-19 positive resident (room [ROOM NUMBER]) without applying a gown or gloves. A sign on the door indicated that Transmission Based Precautions should be followed when entering the room to include the donning of a gown and gloves. When asked if the residents in room [ROOM NUMBER] were Covid positive the LNA stated I don't know. When directed to the sign on the door that indicated the use of Personal Protective Equipment (PPE), the LNA confirmed that s/he should have used PPE when entering the room. The LNA was asked if anyone from the facility had shown her/him how and when to don PPE s/he stated No. 2. Per interview with 3 agency LNAs on 10/11/2022 at approximately 9:30 AM they had been assigned to the facility due to the Covid 19 outbreak. They all confirmed that they had not received any training prior to beginning their assignment nor had the facility assessed them for competency in proper use of PPE and hand hygiene. During interview on 10/13/2022 at 10:46 AM the staff educator confirmed that the facility had not provided the emergency staff with training related to infection control such as proper use of PPE nor were they assessed by the facility for the skills necessary to prevent the spread of COVID-19 prior to their assignment. Review of a list provided by the facility of emergency response staff, there were 15 emergency response staff which included 7 nurses and 8 LNAs scheduled during the current Covid outbreak. Of the 15 emergency responders the there was no evidence that they received training or were assessed for competency related to proper use of PPE and other infection control practices prior to assuming a resident assignment. 3. On 10/12/2022 at 12:00 PM a LNA who was observed entering and exiting a room while wearing the following PPE: a plastic uniform covering gown, gloves, N95 mask and eye protection. They identified themself as agency staff and admitted to not knowing when to wear PPE or how to dispose of it. Per interview with the RN (registered nurse) Staff Educator and the RN Infection Control Preventionist on 10/11/22 at 10:30 AM agency/contract staff were not evaluated or trained prior to assuming an assignment to ensure their competencies and skills to care for the facility's resident population during the current Covid-19 outbreak. Per the Infection Preventionist aside from getting them computer access we don't even know who they are. Per the Staff Educator who had been working on the unit and was relieved by one agency staff nurse, I reviewed the medication room location, door codes, personal protection equipment location, I did not review any competencies. On 10/13/2022 at 10:46 AM during a subsequent interview with the Staff Educator it was further clarified that when nursing staff are obtained through a staffing agency it is the expectation of the facility that all competencies are completed by the staffing agency. When asked to provide facility documentation to review required competencies for agency/contract staff, the facility contacted the staffing agency and obtained evidence of staff self-evaluations and check lists indicating training provided by the staffing agency. 4. Review of the Resident Roster Matrix and the nursing assignment sheet for the second floor, revealed that Resident #52 had a midline IV (Intravenous) for antibiotic administration related to a diagnosis of an infected wound. Review of the residents TAR (Treatment Administration Record) revealed that the resident had an order for a wound vac (a treatment that promotes vacuum-assisted closure of a wound) to her/his left thigh related to a community acquired stage 4 pressure ulcer that was surgically debrided. Interview on 10/10/22 at 10:05 AM with the LPN Rapid Response nurse who stated she had not received any training or competencies specific to the care and medication administration of the Midline IV or the wound vac. Review of Resident #52's 10/1/2022 - 10/31/22 MAR (Medication Administration Record) revealed the following orders: Biopatch on Midline, change with weekly and prn [as needed] dressing changes one time a day every 7 day(s) for IV Care with a start date of 10/01/2022 - this order was signed off as being done on 10/8/22; Ertapenem Sodium Solution Reconstituted 1 GM [gram] Use 1 gram intravenously one time a day for Infected Wound for 28 Days SASH [saline antibiotic saline heparin] FLUSH via MIDLINE with a start date of 10/01/2022 - this order was signed off as being done every day from 10/1/22 - 10/13/22; Heparin Lock Flush Solution 10 UNIT/ML [milliliter] (Heparin Lock Flush) Use 3 ml [milliliter] intravenously two times a day for SASH technique for 28 Days after administration of saline with a start date of 10/01/2022 - this order was signed off every day from 10/1/22 - 10/13/22 at 1000 hours and every evening from 10/1/22 - 10/5/22 and 10/7/22 - 10/8/22, and 10/10/22 - 10/12/22 at 2100 hours; IV: Change Midline Needless Connector one time a day every 7 day(s) for IV Care weekly with a start date of 10/1/2022 at 0900 hour - this order was signed off on 10/8/22 (Monday, 10/1/22 was not signed as being completed); Normal Saline Flush Solution Use 10 ml Intravenously one time a day for SASH/SAS [saline antibiotic saline] technique after med administration with a start date of 10/01/2022 at 1000 hour - this order was signed off every day from 10/1/22 - 10/13/22; Normal Saline Flush Solution Use 10 ml Intravenously one time a day for SASH/SAS technique prior to med administration with a start date of 10/01/2022 - this order was signed off every day at 0900 hours from 10/1/22 - 10/13/22. Review of Resident #52's 10/1/2022 - 10/31/2022 TAR revealed the following orders: Negative Pressure Wound Therapy To LLE SET Unit to 125 mmhg [millimeter of mercury] specify CONTINUOUSLY Cleanse with (NSS[Normal Sterile Saline]/Wound Cleanser/other) Place black foam into wound. Apply skin prep to intact skin around the wound Cover with occlusive dsg [dressing] and secure tubing per manufacturer guide as needed for Surgically Debrided Stage IV [4] PU [pressure ulcer] if NWPT [Negative Wound Pressure Therapy] needs to be turned off for any care, tests/procedures (Bathing, MRI, etc), or for transport; remove dsg entirely, cleanse wound (NSS/Skinintegrity [sic]) and apply hydrogel gauze and secure with ABD [abdominal pad] with a start date of 09/30/2022 at 1711 hours - this order was indicated as completed on 10/11/22. Negative Pressure Wound Therapy To LLE SET Unit to 125 mmhg [millimeter of mercury] specify CONTINUOUSLY Cleanse with (NSS[Normal Sterile Saline]/Wound Cleanser/other) Place black foam into wound. Apply skin prep to intact skin around the wound Cover with occlusive dsg and secure tubing per manufacturer guide every day shift every Mon, Wed, Fri for Debrided Stage IV PU prior to admission - with a start date of 10/03/2022 at 0700 - this order was indicated as completed on Monday 10/3/22 and Wednesday 10/5/22. There was no documentation to represent the the order was implemented/completed on 10/7/22, 10/10/22 or 10/12/22. Interview on 10/14/22 at 10:30 AM with the Infection Control Preventionist (ICP) regarding when and how nurses receive training and competencies to ensure residents are receiving the correct care and treatment of midline IV's and wound vacs. The ICP stated she/he could not find any competencies or policy and procedures regarding trainings for nurses specific to these specialty services. The ICP agreed that nurses are not typically trained to provide care of these specialties unless there was a need in the building. Since there is a wound vac and a midline in the building, he confirmed that training should have been provided as well as competencies on those who are providing care to the midline and the wound vac. There has been no training provided to any of the nurses, per the ICP. Interview on 10/14/22 at 1:05 PM with the Market President for Genesis, which is the owner/licensee of the facility, confirmed that there were no trainings or competencies provided to the facility staff or the emergency response staff for midline IV's or wound vacs. A Google search at www.cdc.gov under Infection Control, subtitled: Guidelines for the prevention of Intravascular Catheter-Related Infections, (2011) under section 1, titled, Education, training and staffing revealed the following guidance: '1. Education, Training and Staffing Educate healthcare personnel regarding the indications for intravascular catheter use, proper procedures for the insertion and maintenance of intravascular catheters, and appropriate infection control measures to prevent intravascular catheter-related infections. Periodically assess knowledge of and adherence to guidelines for all personnel involved in the insertion and maintenance of intravascular catheters. Designate only trained personnel who demonstrate competence for the insertion and maintenance of peripheral and central intravascular catheters.

Based on observations, interviews, and review of documentation, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to prevent the development and transmission of COVID-19 and other communicable diseases and infections. The deficient practices related to lack of infection control measures specifically to source control and containment led to the determination that the residents who resided in the facility were in immediate jeopardy of harm and/or death. At the time that immediate jeopardy was called on [DATE], review of the facility provided list of residents who had tested as COVID-19 positive since the beginning of the facility outbreak that began on [DATE], there were 30 COVID-19 positive residents residing throughout the facility. During the outbreak, there had been three residents who died while COVID-19 positive. Findings include: 1. Per record review Resident # 7 was found by facility staff to be unresponsive on [DATE] and was transferred to the local Emergency Department. Review of the hospital Emergency Department Report written on [DATE] revealed that the admitting diagnoses were acute hypoxic respiratory failure, shock, and COVID-19. Review of Resident #7's [NAME] Certificate of Death states that the primary cause of death was COVID-19 infection. 2. Per observations made during the initial tour of the third floor (Unit 3 North and South) on [DATE] at 8:45 PM, the 3 South Licensed Practical Nurse (LPN) was observed in the hall preparing medications for administration without eye protection. When asked how many of the residents on the South unit were positive for COVID-19 s/he stated, I think three However, there were 11 confirmed COVID-19 positive residents in her/his care. 3. On [DATE] at approximately 9:15 PM a Licensed Nursing Assistant (LNA) assigned to 3 South was observed entering two COVID-19 positive resident's room (#316) without the required personal protective equipment (PPE), a gown or gloves. A sign on the door indicated that Transmission Based Precautions should be followed when entering the room of a COVID-19 positive resident to include the donning of a gown and gloves. When asked if the residents in room [ROOM NUMBER] were Covid positive the LNA stated I don't know. When directed to the sign on the door that indicated the use or PPE, the LNA confirmed that s/he should have used PPE when entering the room. The LNA was asked if anyone from the facility had shown her/him how and when to don PPE s/he stated No. On [DATE] at approximately 9:20 PM the Director of Nursing (DNS) entered the facility. When approached by this surveyor s/he stated that s/he had not been feeling well and that s/he was going to take a COVID test. When this surveyor returned the DNS stated that she was positive for COVID and that s/he was trying to contact the Executive Director. The DNS remained in the facility in her/his office. S/he was there when the surveyors exited the facility at approximately 1:00AM. On [DATE] at approximately 9:45 PM the Infection Control Preventionist (ICP) was informed of the infection control concerns related to the use of PPE (personal protective equipment) and the potential spread of COVID-19 that had been identified. S/He was asked if it was the expectation that staff wear a face shield or goggles as PPE when on the unit the ICP stated yes, it is. At approximately 10:15 s/he was seen on the unit talking with staff. 4. On [DATE] at 10:20 PM an agency LNA assigned to the 3rd North and South Unit was observed exiting a room of a COVID-19 positive resident (room [ROOM NUMBER]), without removing the gown and gloves that s/he had been wearing in the room. The LNA walked down the hall with the contaminated gown and gloves from the COVID-19 positive room, to retrieve incontinence care products. S/he then returned walking back into the resident's room. When asked if s/he should have removed the gown and gloves and washed her hands when s/he exited the room s/he confirmed that s/he should have. 5. Review of the facility list of residents who were Covid-19 positive, provided by the ICP on [DATE], revealed that 7 of the 12 residents residing on the 2nd floor (2 North) were COVID-19 positive, and one additional resident was currently admitted to the hospital with COVID-19. Of the 19 residents on the 3rd floor North Hall, 12 of them were COVID-19 positive. On the 3rd floor South Hall there were 20 residents total with 11 that were COVID-19 positive. On [DATE] at 9:34 AM during interview with the facility Executive Director s/he confirmed the above COVID-19 cases and provided documentation (the facility Heat list On [DATE] the list was updated to reflect two new COVID-19 positive residents on 2nd floor Unit 2). When informed of the multiple concerns identified throughout the facility on [DATE], s/he stated we are in the middle of a COVID outbreak, and we have travelers and emergency staff working. Things were getting better until this outbreak happened. 6. Per observation on [DATE] at 12:15 PM, a LNA was seen in a resident's room (#317) delivering a lunch tray to a COVID-19 positive resident without wearing the required gown and gloves. Upon leaving the room, s/he did not perform any hand sanitization. Signage was posted on the wall outside the room indicating that Transmission-Based Precautions (TBP) were to be followed and that required Personal Protective Equipment (PPE) was to be worn prior to entering the room. When asked why s/he failed to wear the required PPE or wash hands or perform any hand sanitizing, s/he stated, I just didn't think about it, I'm agency. 7. The sanitizer mechanism located on the wall unit outside of room [ROOM NUMBER], on the left side of the North Hall, was empty and did not contain any hand cleaning product. room [ROOM NUMBER], a room which required the use of PPE for transition-based precautions, did not contain any hand sanitizer, and there was no receptacle available to place soiled PPE in prior to exiting the room, thus causing staff to exit the room and remove their gown in the receptacle in the hall, increasing the risk of spread. The missing sanitizer and receptacles were confirmed by housekeeping at the time they were found to need replacing. 8. Observation on [DATE] at 12:30 PM revealed an LNA in the resident hallway outside of room [ROOM NUMBER], wearing an N95 mask with the top elastic strap laying across the top of mask on her/his nose. At the time of this observation, the LNA was observed walking by the ICP, who acknowledged the LNA and failed to correct her/his inappropriate use of PPE. Interview on [DATE] at 12:55 PM with the ICP regarding the observation noted above. The ICP confirmed that the LNA was not wearing her/his PPE correctly, as the top elastic strap should be placed around her/his head as per the manufacturer's recommendations for use. 9. During observation on Unit 3 South on [DATE] at 9:20AM an agency LNA was observed entering a Covid positive resident's room (#317) without the required person protective equipment (PPE) on, other than a face shield. When s/he exited the room s/he was asked if the resident in that room was positive for COVID-19 and if the resident was on precautions s/he stated yes, I should have put on a gown before I went in there. 10. During observation on Unit 3 South on [DATE] at 11:00 AM a LNA was seen entering a room (#324) of two COVID-19 positive residents without a protective gown and gloves and set up a meal tray for the resident. Upon exit of the room this surveyor asked the LNA if the residents in the room were positive for COVID or if they no longer required use of PPE, the LNA confirmed that they were COVID-19 positive, and s/he should have had it on. 11. Per observation on [DATE] at 12:00 PM an LNA entered a resident room on a COVID-19 positive unit on the third floor to respond to a call light. The facility was amid a Covid 19 outbreak and following transmission-based precautions to include all staff wearing N-95 masks and eye covering. When entering a resident room designated as having residents with Covid-19 by a sign at the door the additional infection control measure included donning a disposable plastic gown to protect clothing and protect residents from cross contamination. The LNA approached the room already dressed in PPE to include plastic clothes covering gown, gloves, an N-95 mask and a face shield, upon entering the room the LNA handled the call bell to turn it off, put his/her hand on the resident's arm and exited the room without removing the PPE or sanitizing his/her hands. The LNA confirmed he/she was unsure of when to Donn or doff his/her PPE. 12. Per observation on [DATE] at 12:10 PM a trash receptacle inside room [ROOM NUMBER] designated as having Covid-19 positive residents was observed to be overflowing with disposable PPE with soiled linens on the floor next to it. This practice increases non-infected residents' risk of exposure to COVID-19. The unit LPN confirmed used PPE and linens did not belong on the floor. 13. Per observation at [DATE] 12:15 PM on the third floor in the empty resident dining area 2 LNA's were observed standing near the food service area having a conversation without wearing masks or eye protection, when questioned both LNA's confirmed they should be wearing N-95's and eye protection. On [DATE] at approximately 12:50 PM the Regional Nurse Consultant confirmed that the staff should be wearing masks and eye protection when on the Unit. 14. Observation on [DATE] at 1:34 PM an LNA was observed coming out of resident room [ROOM NUMBER] which housed a resident who was COVID-19 positive. The LNA leaned out over the door threshold with a tray of dishes and attempted to flag down a staff member to come take the tray. Another LNA came and took the tray without gloves on and placed the tray inside the tray cart. She/he did not perform hand hygiene and immediately proceeded to room [ROOM NUMBER], where she/he was observed going into this room and no hand hygiene was performed before entering. room [ROOM NUMBER] does not house a COVID-19 positive resident at the time of this observation. The same LNA was observed coming out of room [ROOM NUMBER] with a tray that contained dishes, paper towels were observed as a barrier between the tray and her/his hands. She/he took the tray to the tray cart, placed the tray inside the cart and proceeded to the kitchenette entrance door where she/he entered the lock code on the code pad, opened the door to the kitchenette and entered. She/he did not perform hand hygiene between putting the tray from room [ROOM NUMBER] into the tray cart and entering the lock code on the kitchenette door. Interview on [DATE] at 1:38 PM with this above noted LNA, regarding the differences in her/his practice of picking up trays from a COVID-19 positive room vs. the non-COVID-19 positive room. She/he said it was not clear what she/he was supposed to be doing at that point. She/he stated that she/he had received some additional training regarding infection control practices, but it was quick and not entirely clear what the process is supposed to be for tray pick up. 15. On [DATE] at 9:40 AM a laundry person was noted putting a gown on and going into room [ROOM NUMBER] (not designated a covid positive room). She/he was interviewed on [DATE] at 9:42 AM regarding her/his practice of wearing a disposable gown into a non-covid room and she/he stated that the gowns and gloves are required in rooms that have signs on the doors. When asked if room [ROOM NUMBER] had a sign on the door and she/he didn't know. room [ROOM NUMBER] did not have a sign indicating the room was a precaution room. At 9:52 AM on [DATE] this same laundry staff was observed going into a COVID-19 positive resident's room (#213) with a few hangers of laundry and entered the room without a disposable gown or gloves. There was a sign outside room [ROOM NUMBER] indicating the requirement for the use of PPE. Interview with the laundry staff who confirmed that she/he should be wearing a disposable gown and gloves to enter any room that is indicated by a sign that the room is a precaution room. The laundry staff member did not see any sign - the sign was pointed out to the laundry staff, as well as the orange sign that was inside the door on the left side of the wall indicating the need to wear PPE, she/he stated that she/he was used to the sign being a little higher and that she/he did not see it. 16. Interview on [DATE] at 1:20 PM with the ICP regarding the training and competency of staff related to infection control and COVID-19 prevention, revealed that Genesis employees must do their annual mandatory educational training on the Vital Learn Electronic System. The ICP can run reports for tracking and states I do spot checks for extra training when we have unit managers. The ICP keeps records of education but not always. If agency staff are hired, when they come through the door, the ICP reviews their agency packet to see what's needed. Per the ICP We lag on this. Audits are conducted in the housekeeping/laundry department on a weekly basis. Observations of meal service are conducted weekly to observe hand hygiene, gloving, and wearing proper personal protective equipment (PPE) during delivery of meal trays to COVID positive rooms and dietary staff serving behind the line. Observations are done in the kitchen monthly to observe preparation of food, and cleanliness of kitchen. The ICP states audits have not been done in a while since we came back to Genesis [this occurred in July] and no evidence related to the above was provided. On [DATE] at 09:21 AM a list of examples of training/audits (minus the mandatory annual education which another nurse educator works on) was given to the ICP. This list included items such as cleansing of equipment (glucometer, mechanical lift, wheelchairs, et.), hand hygiene, COVID education, reporting breaches of the integrity of equipment. There is no documented evidence of audits related to infection control. The ICPs response at 11:52 AM when asked for the above information regarding any audits/education was No, I don't have any of this. Additional findings of non-compliance related to infection control that were identified during the survey include: 1. Observation in room [ROOM NUMBER], on [DATE] at 10:45 AM of Resident #52's midline IV was place in her/his left upper arm. A dressing was observed over the midline IV that was grayish in color and appeared dirty - the dressing was dated [DATE]. Interview on [DATE] at 10:45 AM with the resident, who is A&Ox3 and stated that this dressing is the dressing that was put on at the hospital prior to her/his admission to this facility. This was reviewed with the nurse, who confirmed she/he was part of the emergency response team and was an LVN (Licensed Vocational Nurse). She/he confirmed that Resident #52's dressing appeared dirty, and she/he also confirmed the date on the dressing as being [DATE] and that this resident was admitted to this facility on [DATE]. 2. Observation on [DATE] at 8:40 PM of the second floor (Unit 2) revealed a long hallway with an open nurses station in the middle. The portion of hall to the left of the nurses station housed 12 residents, 7 of these residents were Covid-19 positive. One additional COVID-19 positive resident was currently admitted to the hospital. The portion of the hallway to the right of the nurses station was empty of residents. The hallway that was housing residents was observed to have a lot of debris on the floor, consisting of gloves, clear plastic wrappers, small pieces of paper, and long pieces of thin blue plastic, as well as dirt/sand. To the right side of the resident's hallway were 2 uncovered bins, 1 contained what appeared to be dirty gloves, and the other appeared to be empty. Interview on [DATE] at 8:35 PM with an LNA, who stated one bin is for trash and the other bin she/he believed was for linens. She/he stated, I do not know if they should be covered, this is only my third shift here and I don't know the policy for having the bins covered or uncovered. Interview on [DATE] at 8:50 PM with the nurse on duty who identified her/himself as an emergency response nurse, confirmed the hallway where resident rooms are located was littered with debris that consisted of gloves, pieces of blue plastic that she/he identified as pieces of the disposable gowns that are used to go into the rooms of residents who are on precautions due to a covid positive status, clear plastic wrappers, she/he identified as the packaging to protective eyewear, small pieces of paper and dirt. She/he stated that staff have not had time to clean on the unit and to her/his knowledge there are no housekeeping staff available. When asked about the uncovered bins in the resident's hallway, she/he stated they were for dirty linens and disposable items and thought they probably should be covered and labeled, she/he did not know the facility policy regarding bins in the hallway. 3. Observation on [DATE] at 9:08 PM of the tub/shower/whirlpool room revealed a shower area that was separated from a second shower area and a whirlpool tub area. Upon entering the tub/shower/whirlpool room to the left is a shower area that was noted to be dirty, the floor had many broken tiles, some missing pieces of tile, most of the grout that was between the remaining tiles was gray, black, or yellow in color, there was a washcloth that was draped over the shower bar at the right side of the shower wall. The washcloth appeared dirty, it was gray in color, it was hard/crusty and formed to the shower bar. To the right of the entrance door, across from the first shower area (referenced above) was a bariatric sized tub chair and upon it was an unfolded towel hanging off the left side of the shower chair. To the left of the tub/shower/whirlpool room, to the right of the first shower area was a second shower area that revealed a PVC (polyvinyl chloride) pipe shower bed with thick plastic foam covered mattress that was in disrepair. The headrest of the plastic foam covered mattress revealed 3 slits and a piece of clear plastic tape that exposed the foam mattress. Upon touch of the foam mattress, it was noted to be moist and with a little applied pressure a clear liquid oozed out of the foam mattress. On the floor of this second shower area was a gray plastic strap that is used to secure residents in the tub chair for transport and use of the whirlpool tub. To the right of this second shower area was a covered plastic bin and atop of the cover was a neatly folded [NAME] that had some pieces of white plastic type material that resembled drier sheets, and 2 face masks around and on top of the [NAME]. Interview on [DATE] at 9:30 PM with the emergency response nurse, who confirmed that the shower room was a mess, had several infection control issues as noted above, and that s/he would leave a note for the oncoming shift nurse to address these identified concerns. Interview on [DATE] at 1:00 AM with a facility staff nurse who had relieved the emergency response nurse, who stated she/he was not aware the equipment was in disrepair but confirmed the slits in the plastic covering of the mattress which exposed the foam mattress. She/he also confirmed that the tub/shower/whirlpool room was dirty, tiles were broken or missing. 4. Observation on [DATE] at 9:15 PM of the Clean Utility room revealed a small room that was dirty, the floor had empty syringe wrappers, a covered blood draw needle, trash can with what appeared to be a dried bouquet of flowers that was holding the cover of the trash can open, a box of N95 masks open to and laying on its side on a dusty metal shelf, 4 glass jars, 1 labeled BANDAGES and contained cotton balls and was covered with a metal cover, 1 labeled GAUZE that was empty and was covered with a metal cover, a second glass jar that was labeled GAUZE that was full of 2x2 gauze squares and was not covered , and 1 labeled APPLICATORS that was full of tongue depressor sticks, that was not covered. 5. Observation on [DATE] at 9:30 of the 2nd floor kitchenette and dining area revealed a full trash can, dishes with food on trays, a refrigerator with dirty shelves and inside doors, a large mouse trap under a commercial utility shelving unit, a rat trap between the kitchenette wall and the refrigerator of the serving area, dried food on counters, doors, and the microwave. The bottom part of the doorway and floor into the kitchenette had a thick black substance that was also present in the spaces between the wood floor at the doorway. The 3 compartments in the steam table each had dirty water in them with what appeared to be food particles and debris. 6. Observation on [DATE] at 11:53 PM the survey team did a walkthrough of the facility's main kitchen with the ICP, the following issues were observed: a.) Ice scoop was inside the ice machine with the handle of the scoop exposed to the ice. b.) A box of Instant Food Thickener was observed in an open plastic bag and set inside a box that was labeled by the manufacturer as the contained food product. c.) The commercial blender was dirty with crumbs and debris around the blender motor and on the table the equipment was sitting on d.) The food puree machine pitcher was cracked all the way around the bottom of the container just above where the blades are located inside the pitcher e.) An air conditioner was observed in one of the windows across from the table where the mixer, puree machine and various other equipment for food prep were stored. The air conditioner was noted to have a thick and sticky substance on the front grill where the cool air comes out of the conditioner and into the environment. Within this thick and sticky substance was noted some hair, dust, and insects. In front of the air conditioner was a spray can of non-stick spray that was without the cover, and beside that spray can of non-stick spray was a second can of the same product, also without a cap. f.) An opened box of cornstarch was noted on the counter next to the air conditioner, in front of three, 4-inch binders - 1 labeled Breakfast, 1 labeled Lunch, and 1 labeled Dinner g.) On a 3-tiered utility rack, it was noted the top and middle rack housed 18 plastic containers of spices on the top rack of which 6 were open to the environment h.) A commercial sized mixer was noted on a table and was covered with a black trash bag. Upon removing the black trash bag to view the mixer, it was noted to be dirty - the wire guard, the mixing bowl, and underneath the mixer above where the mixing bowl would sit were all spattered with dried material, as was the table the mixer sat on. i.) A commercial can opener was attached to a table and was noted to have a thick sticky red substance on the blade of the can opener and the bracket that holds the removable can opener had a thick black and yellow sticky substance with what appeared to be hair. j.) A large refrigerator was observed and upon opening the doors, a full container/pitcher with a light-yellow liquid inside, revealed a tag and upon the tag was written Orange - Use by ,d+[DATE]. A full second container/pitcher was noted with a tangerine-colored liquid inside and there was no tag on the container. k.) A steam table with 3 separate sections were noted to be full of hot dirty water l.) A sideboard attached to the steam table was visibly dirty with a white greasy substance m.) In the corner of the kitchen, behind the 2nd entrance/exit door was a sticky mouse trap that was covered with various sizes of black spots. Upon closer inspection these black spots were ants, spiders, flies (large and small), and various other insects and dirt. To the left of the sticky trap was a large mousetrap. n.) In front of the above-mentioned sticky trap was a substance that was dark brown with variations of brown, yellow, black, and red. This substance appeared wet and was noted to be sitting in an area that was wet with a clear grayish color that extended from the sticky trap and mouse trap and encompassed this unidentified brown object. The object could not be identified. This was shown to the ICP person who stated that she/he did not know what this brown object was as I'm not a biologist but I can tell you that's not mouse shit or rat shit. o.) The grout in the kitchen was noted to be black and crusty over most parts of the floor. p.) A large commercial utility rack revealed stacked square and round plastic containers and there were moisture/water droplets between the layers of stacked containers. q.) A second large commercial utility rack revealed stacked square metal containers and there were moisture/water droplets between the layers of stacked containers. r.) A steam machine was noted to be wet inside on the sides and top of the machine. s.) Under the oven/stove was a thick sticky and greasy substance black in color, that extended under a utility rack and a light-yellow substance was noted dripping down the front of the stove on the oven door and was pooling on the lip at the bottom of the stove/oven. t.) The inside of the oven was noted to have a large thick pool of black and red gel like substance on the inside base of the oven. At the time of the kitchen walk-through, the ICP was present for the entire walk-through, and as issues presented, they were shown and confirmed by the ICP person. The ICP confirmed that it is the expectation that the dietary staff clean the kitchen prior to leaving for the night, especially when managing an identified issue with rodents. 7. Observation on [DATE] at 8:45 AM in the kitchen revealed a staff member in the dish room with her/his mask under her/his chin. Interview with this staff person regarding her/his role was in the kitchen, she/he pulled her/his mask up under her/his nose. The Food Service Director (FSD) and her/his supervisor were present at the time of this observation and interview with the staff, and when ask if the staff member was wearing her/his mask/PPE (Personal Protective Equipment) correctly, the Food Service Director Supervisor confirmed she/he was not and she/he spoke to the staff member telling her/him that she/he needed to wear her/his mask correctly. The staff member at that time pulled her/his mask up over her/his nose demonstrating appropriate PPE use at that time. A walk-through of the kitchen with the Food Service Director and her/his supervisor, the above findings from [DATE] were discussed and confirmed by the FSD's supervisor. 8. Observation on [DATE] at 12:33 PM it was noted that a tray with dishes, utensils, and napkins were placed on top of the infection control cart outside of room [ROOM NUMBER]. This was brought to the attention of the Infection Control Preventionist (ICP) on [DATE] at 1:32 PM. The ICP confirmed the tray atop the infection control cart and stated that nothing should be placed on top of the infection control carts as these carts are considered a clean surface. 9. On [DATE] at 08:45AM observation of the 3rd floor unit, revealed a door across from nurse station which is labeled clean utility with a key code pad. This same room is also labeled as such on the facility map. This surveyor asked a Licensed Nurse Assistant (LNA) what the door code was. This LNA knew the door code and stated, it's the same for all other utility rooms and proceeded to let two surveyors in. Upon entrance, the small room appeared to be a medication storage area rather than a Clean Utility room. It contained over the counter medications in a cabinet, a blue plastic tote full of medications on the floor, Lab supplies, syringes with needles (box of 26G x,d+[DATE] syringe) in a cabinet, and other supplies. The utility room was filthy with debris on the floor and a dark quarter sized area of sticky substance. The LNA confirmed that the floor was dirty, and that s/he did not ever really need anything in here. 10. Observation on [DATE] at 01:27 PM of the laundry department, contains laundry carts, for the transport of soiled linens. One cart was noted to be unclean with various items of built-up debris such as used gloves, food particles, paper products, a hair tie, a meal ticket, and other unrecognizable particles. There were layers of lint, dust and debris under a wooden pallet that contains large buckets of washing machine chemicals. Interview at the time of observation with a laundry attendant, confirmed the appearance of the dirty laundry cart and dirt/grime build up under the wooden pallet. Another observation of the laundry department and interview with the Infection Control Preventionist (ICP) was conducted the same afternoon on [DATE] at 4:15PM. The ICP confirmed that the laundry cart and under the wood pallet near the washing machines were filthy. The ICP confirmed that cleaning visible soiled areas and disinfecting linen carts had not been done. Observation and interview on [DATE] at 2:17PM with a housekeeper confirmed that the floor was dirty and s/he does usually wash the clean Utility floor but has been out for two weeks. This housekeeper revealed that all of 3rd floor is her/his cleaning responsibility. S/he stated that s/he had never had a nurse observe while [s/he] cleans the floor to this room and was not aware that [s/he] should not enter due to it containing medications but did know the code. 11. Observation of the 3rd floor Clean Utility room and Interview on [DATE] at 4:45PM with the ICP confirmed that the floor was dirty and that the room was clearly labeled Clean Utility outside the door and on the facility map but was being used as a medication room which did not contain such items as one would expect to have in a clean utility room. For example, Linens. The ICP confirmed that this room had not been cleaned in a while and that only nurses should have access. A day later, on the afternoon of [DATE] at 2:30PM, Observation and interview with a Genesis Nurse Consultant confirmed the room was not being used as a Clean Utility and indeed did not contain linens as one would expect, and the floor was still dirty. 12. Observation on [DATE] upon exiting room [ROOM NUMBER] at 10:58 AM, it was noted that the mattress on the bed next to the door in room [ROOM NUMBER] had been stripped of linens leaving just the mattress and at the foot of the mattress there was an area of approximately 2-foot diameter that showed significant wear to the fabric covering the mattress. This area was where the manufacturer had stamped on the mattress the name of the company, mattress type and various other unreadable information - most of this manufacturer stamp was gone. The integrity of the mattress is poor and unable to be cleaned adequately. The nurse, who was exiting the room at the same time confirmed the appearance of this mattress and she/he stated that the mattress was not usable and needed to be replaced. This was brought to the attention of the Clinical Quality Consultant and the Market President on [DATE] at approximately 11:15 AM.

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan to assure that the resident's care needs were met for 4 of the 37 residents in the survey sample (Residents #5, #256, #204, & #37). Findings include: 1. Per record review Resident #5 has a care plan focus regarding assistance for ADLs [activities of daily living] care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfers, locomotion, and toileting related to dx [diagnosis] of CHF [congestive heart failure] and COPD [chronic obstructive pulmonary disease]. Review of ADL interventions reveal the only ADL that specifies the assistance needed is ambulation. The care plan does not identify the level of staff assistance needed for; bathing, bed mobility, dressing, transfer, toileting, or eating. Resident #5 also has a care plan focus that was initiated on 1/6/2022 and revised on 4/20/2022 that states Resident may be nutritionally at risk related to [prior] covid recovered, hx [history] of pressure areas, use of mechanically altered diet, use of diuretic therapy, obesity status, diabetes, CHF, recent hospitalization with sig wt [significant weight] change r/t [related to] diuresis' An intervention initiated on 1/6/2022 directs staff to Record and monitor intakes and Record and monitor weights Another care plan focus initiated on 1/5/2021 of [Name omitted] has a diagnosis of diabetes: non-insulin dependent with an intervention initiated on 1/5/2021 of monitor meal consumption each meal. Per review of the licensed nursing assistant documentation for 10/1 - 10/14/22 meal intakes were not consistently monitored per care plan. There were 42 opportunities to document the assistance provided and the percentage of the meal consumed. Of the 42 opportunities, 36 were left blank, not completed. Per interview with a Registered Nurse (RN) on 10/14/2022 at approximately 2:45 PM regarding the above concerns s/he stated that the licensed nursing assistants (LNAs) would find the ADL interventions to include assistance needed for eating on the resident care Kardex. However, while viewing the Kardex the RN confirmed that the care plan and Kardex were not complete, and the care needs were not identified on the resident Kardex or care plan. S/he also confirmed that the LNA documentation was not complete. 2. Per record review Resident # 256 was transferred to the facility from another Genesis facility 5/25/2022 with a discharge summary written on 5/25/2022 that states that her/his skin was intact. During her/his stay at this facility s/he has refused getting out of bed and refused assistance with personal hygiene putting her/him at risk for developing pressure ulcers. A Nursing Evaluation completed on 5/25/2022 indicates that the resident is a high risk for pressure ulcers. Per review of the resident's nursing progress notes, a note written on 8/21/2022 reflects that a Licensed Nursing Assistant informed the Licensed Practical Nurse that the resident was found to have an open area on her/his left calf. The progress notes states Area red and draining yellow/green drainage. Resident reports pain in the area 7/10. Scheduled Tylenol administered. Open area measured 4cm L by 1.5 cm W. Information given to {Name omitted RN (Registered Nurse) supervisor to f/u [follow up] with PCP [Primary care Physician] for treatment . A progress note written on 8/21/2022 reflects that an antibiotic was ordered to treat the new open area to L (left) medial leg. No ill effects noted. The resident's care plan was reviewed and revealed that there is no care plan focus in place that addresses the high risk of pressure ulcer development and no interventions implemented to decrease or manage the risk or the actual pressure ulcer that developed on 8/21/2022. During an interview with the Executive Director on 10/10/2022 at 9:30 AM when asked if s/he recalled a resident by the name of [name omitted] s/he said yes s/he did. S/he was asked if there had been review of pressure ulcers or injuries to her/his left leg during morning meeting or any type of risk meeting. The ED stated No, I don't remember anything with her/him like that. The ED was asked if there was any documentation related to the wound. The ED did not provide additional information to this surveyor throughout the survey. 46442 3. Per record review Resident # 204 was admitted to the facility on [DATE] with medical diagnoses that include: Type 2 Diabetes Mellitus, Frontal Lobe and Executive Function Deficit Following Cerebral Infarction, Other Reduced Mobility, Pressure Ulcer of Sacral Region, Stage 2, Dysphagia Oropharyngeal Phase. Muscle Weakness (Generalized) Unspecified Convulsions. a) Observation on 10/11/22 10:00 AM of Resident #204 revealed her/his breakfast tray was placed in front of her/him unsupervised on the over bed table and had been unopened. An attempt to interview Resident #204 revealed s/he was very groggy and lethargic and was not able to participate in the interview. At 12:22 PM revealed Resident #204's room door was closed, and upon the doorframe was a picture of a star. Interview on 10/11/22 at 12:24 PM with Licensed Nursing Assistant (LNA) who confirmed the sign was an indication that the resident was a fall risk, stated she/he was not sure if Resident #204 was an actual fall risk or not. Review of the Minimum Data Set (MDS) with an Assessment Reference date (ARD) 10/5/22, (5-day assessment), Care Area Assessment (CAA) revealed that resident is a fall risk, and the facility will proceed with a fall risk care plan. There was no comprehensive care plan in place for fall risk for Resident #204. The facility fall policy, titled, NSG215 FALL MANAGEMENT under Practice Standards, section #2, reads Implement and document patient-centered interventions according to individual risk factors in the patient's plan of care. Interview on 10/14/22 at 12:09 PM with the MDS Coordinator, Licensed Practical Nurse (LPN) who confirmed the resident's admission assessment revealed the resident is a fall risk, it was triggered on the Care Area Assessment (CAA), and was indicated to proceed with care plan for fall risk. The LPN MDS Coordinator confirmed there was no fall care plan in place for resident #204. Per record review Resident #204 was admitted to the facility with a G-Tube. Physicians' orders revealed there are no orders for G-Tube care or flushes, Medical Director progress note dated 10/06/22 does revealed that the resident required a G-tube in the hospital due to severe oropharyngeal dysphagia. A MD progress note dated 10/6/22, revealed the following order for Resident #204: speech and swallow to follow. Interview on 10/14/22 at 8:30 AM the COTA (Certified Occupational Therapy Assistant) stated that the speech-language pathologists (SLP) was aware of the G-tube and the diagnosis of dysphagia on residents' admission. She/he confirmed that SLP has not screened Resident #204. She/he stated that SLP is only per diem, and s/he was the only therapist in the building on this day. Review of Resident #204's Care Area Assessment (CAA) revealed Nutritional status is triggered as an area where the resident required additional assistance and the facility documented that they would proceed with care plan. There was no evidence of a nutritional care plan for Resident #204. Interview on 10/14/22 at 12:09 PM with the LPN MDS coordinator confirmed that the CAA did trigger for Nutrition and Resident #204 does not have a care plan in place for nutrition that would help to prevent nutritional decline. b) Record review on 10/12/22 04:09 PM revealed a Physician's orders for Santyl External Ointment 250 UNIT/GM (Collagenase) that read: Apply to Right Groin and coccyx topically everyday shift for wound care cleanse with normal saline (NS) and pat dry, cover with dry protective dressing AND apply to right groin topically as needed for wound care. Admission assessment dated [DATE] revealed resident was admitted with a Right groin incision dehisced, coccyx open, left, and right buttocks shearing multiple areas. Section M 0210 Unhealed pressure ulcers was code as: Does this resident have one or more unhealed pressure ulcers/injuries was coded Yes. The 5-day admission MDS with Assessment Reference Date (ARD) of 10/5/22, the Care Area Assessment (CAA) section revealed the facility documented they would proceed with care plan for Pressure ulcer. Review of the resident's care plans revealed there was no care plan in place for pressure ulcers. Interview on 10/13/22 12:58 PM with the LPN MDS Coordinator confirmed the MDS section M0100 A is coded incorrectly, since the resident does have a stage 2 pressure ulcer on her/his coccyx, and there is no care plan that addresses the resident's stage 2 pressure ulcer. Review of facility policy on 10/14/22, titled NSG236 Skin Integrity and wound management Policy stated, A comprehensive initial and ongoing nursing assessment of intrinsic and extrinsic factors that influence skin health, skin/wound impairment, and the ability of a wound to heal will be performed. The plan of care for the patient will be reflective of assessment findings from the comprehensive patient assessment and wound evaluation. Staff will continually observe and monitor patients for changes and implement revisions to the plan of care as needed. 4. Per record review Resident #37 was readmitted to the facility after a hospital admission with the following diagnoses: Hemiplegia and Hemiparesis following cerebral infarction affecting left non dominant side, calculus of Gallbladder and Bile Duct without Cholecystitis without obstruction, and Cerebral infarction. Review of Physicians' orders reflects that Resident # 37 does not have a physician order for a diet. The Minimum Data Set (MDS) with an assessment reference date (ADR) of 8/17/22, Section G revealed the resident required Supervision and set up only. The CAA revealed the facility documented they would proceed with a care plan for nutrition for Resident's #37. Review of the resident's care plan revealed that the resident does not have a care plan in place for nutrition with goals and intervention to avoid decline. Interview on 10/14/22 at 11:54 AM with LPN MDS coordinator confirmed the facility documented they would proceed with a dietary care plan, and there is no dietary care plan in place for resident #37.

Based on observation, interview, and record review the facility failed to ensure that 5 of 7 residents reviewed for pressure ulcers (Residents #5, 14, 45, 256, and 204) received necessary treatment and services consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. 1. Per record review of three Skin & Wound Evaluations completed on 10/6/2022 reflects that Resident #5 has three inhouse acquired stage 2 pressure ulcers that include a 0.5 cm2 area, 1.0 cm Length, 0.8cm width, 0.2cm depth stage 2 pressure ulcer on her/his coccyx, a 3.0 cm2 area, 3.3cm Length, 1.2 width stage 2 pressure ulcer on her/his right buttock, and a 0.4 cm [squared] area, 1.4cm length, 0.8cm width stage 2 pressure area on her/his left buttock. There is a care plan focus of [Name omitted] is at risk for skin breakdown related to limited mobility, muscle weakness, and chronic pain. ***Has chronic recurrent MASD (moisture related skin damage inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage) areas bilateral buttocks. 5/26/2022 chronic recurrent MASD buttocks wounds are re-open. 9/26/2022 Coccyx newly reopened and 10/6/2022 Coccyx resolved. A care plan goal states [Name omitted] will not show signs of skin irritation or breakdown through next review period, and 9/12/2022 [Name omitted] continues to have chronic open wounds revised on 10/10/2022. Interventions include Daily dressing change to bilateral buttocks, cleanse wounds, place calcium alginate and sure view dressing. and Treatments as ordered. A Physicians order for cleanse buttocks wounds (MASD) with Wound Cleanser apply calcium alginate to wounds, skin prep surrounding skin and cover with Derma view Transparent Dressing Daily and PRN (as needed) Apply Transparent Dressing so that there are no bridges, gaps, or air spaces. every day shift for MASD AND as needed for dressing soiled or comes off. During observation of incontinence care on 10/9/2022 at approximately 10:00PM Resident #5 was laying on their back in bed, the Licensed Nursing Assistant asked her/him to roll to the left and removed the resident's brief exposing her/his buttocks. There was an open redden wound on both right and left buttocks and a pink and red coccyx, there was no dressing in place. There was no evidence in the brief that there had been a dressing that had fallen off. Per interview with the Licensee Practical Nurse on 10/9/2022 at approximately 10:20 PM s/he was not aware of any wound or treatment ordered. S/he stated that the nurse that s/he relieved may have done a dressing, but s/he did not have it on her/his list. Resident #5 has also experienced a severe (greater than 10%) weight loss of 14.1% over a six-month period that was not identified and/or addressed. On 10/14/22 at 09:27 AM the Registered Dietician (RD) was asked about concerns related to resident #5's weight loss as nutritional status effects the prevention and healing of pressure ulcers. S/he stated that s/he is aware of Resident #5's pressure ulcers and the resident is on liquid proteins. 2. Per record review Resident #14 developed an in house acquired wound that was identified on 10/10/2022, and experienced a delay in treatment of the wound. A Nursing Evaluation completed on 7/27/2022 identified the resident as being very high risk for pressure ulcer development. On 9/10/2022 an assessment note was written that states A skin check was performed. the following skin injury/wound(s) were previously identified and were evaluated as follows: MASD-Moisture Associated Skin Damage(s): Location(s): buttocks A progress note written by a licensed Practical nurse (LPN) on 10/10/2022 at 11:33 PM states Pt. [resident] coccyx is open and bleeding. There are 2 purple areas with redness all around. [Name omitted], RN (Registered Nurse) came and looked at [her/his] wound. No treatment order at this time. The area was kept clean and dry. Pt. was positioned off the area, from side to side. During observation of incontinence care on 10/12/2022 at 2:20 PM as the licensed nursing assistant (LNA) began to remove resident #14's brief the resident stated oh, don't hurt my [NAME]! as the LNA pulled the brief away from her skin the resident said ouch, ouch, ouch that hurts! There was a beefy red open wound noted on the right buttock with no dressing covering it and a patch of thick white paste covering an open area on the left buttock. Per LNA there should be a dressing over it and the thick white paste was not what should be used on the wounds. When exiting the room, the LNA asked if I would ask the nurse to come to the room to see the wound. Per Licensed Practical Nurse (LPN) there was no treatment ordered but s/he would go and look at it. A progress note written on 10/12/2022 at 16:21 states Pt [patient] remains alert [with] confusion. Pt noted [with] open areas to left and right buttocks. Area cleansed [with] saline and pat dried. pt. repositioned to l side. communication left [regarding] need for wound care consult/orders. On 10/12/2022 at 2:35 PM during an interview with the RN who was identified in the above note written on 10/10/2022, s/he stated I think that I had heard something about [the Resident] having a pressure ulcer in morning meeting but I'm not sure. On 10/13/2022 during record review it was noted that there was no evidence of physician notification of the wound, any treatment, or other interventions in place after the identification of the wounds. There had also been no weekly skin checks documented since 9/10/2022. Per interview with the Unit 2 Nurse Manager (UM) on 10/13/2022 at approximately 10:15 AM confirmation was made that there was no treatment in place for the pressure ulcer that had been identified on 10/10/2022. At approximately 11:00 AM the UM informed this surveyor that a skin evaluation had been complete and a physician's order to cleanse the area to coccyx and apply Opti foam was obtained. 3. Per record review Resident # 256 was transferred to the facility from another Genesis facility 5/25/2022 with a discharge summary written on 5/25/2022 that states that her/his skin was intact. During her/his stay at this facility s/he has refused getting out of bed and assistance with personal hygiene putting her/him at risk for developing pressure ulcers. A Nursing Evaluation completed on 5/25/2022 indicates that the resident is a high risk for pressure ulcers. On 8/21/2022 a Licensed Nursing Assistant informed the Licensed Practical Nurse that the resident was found to have an open area on her/his left calf. The progress notes states Area red and draining yellow/ green drainage. Resident reports pain in the area 7/10. Scheduled Tylenol administered. Open area measured 4cm L by 1.5 cm W. Information given to {Name omitted} RN (Registered Nurse) supervisor to f/u [follow up] with PCP [Primary care Physician] for treatment . A progress note written on 8/21/2022 at 23:16 reflects that an antibiotic was ordered to treat the new open area to L (left) medial leg. No ill effects noted. The resident's care plan was reviewed and revealed that there is no care plan that addresses the high risk of pressure ulcer development and no interventions implemented to decrease or manage the risk or the actual pressure ulcer that developed on 8/21/2022. During an interview with the Executive Director on 10/10/2022 at 9:30 AM when asked if s/he recalled a resident named [name omitted] and s/he said yes s/he did. S/he was asked if there had been review of pressure ulcers or injuries to her/his left leg during morning meeting or any type of risk meeting. The ED stated No, I don't remember anything with her/him like that. When asked if s/he did have any documentation related to the wound to provide it to this surveyor. The ED did no provide additional information to this surveyor throughout the survey. 43524 4. A Nurses Note, titled Admission Note, dated 9/30/2022 at 15:50 revealed, [proper name omitted] was admitted to 205-B. Arrived by ambulance stretcher information upon admission obtained Patient Chart Reason for admission is Special Treatment Program. An assessment note dated 9/30/2022 at 17:10 revealed, A new pressure wound Stage 4 presented on admission Location: Left Thigh (Lateral) was assessed today. A Nurses Note dated 9/30/2022 at 17:52 revealed, .[pronoun omitted] does have a pressure injury noted to left thigh. Resident has an above the knee amputation to right leg. Resident will require wound care to left thigh three days a week on M-W-F [Monday Wednesday Friday] using a wound vac at this time. A Nursing assessment dated [DATE] at 15:50, page 5 of 15 revealed the residents mental status was alert, her/his memory was unimpaired, her/his mood was sadness/Depression, and her/his affect was Appropriate. Page 14 of 15 revealed she/he had a skin impairment that was present and the site was documented as, pressure injury noted to left thigh. A Skin & Wound Evaluation was noted in the resident medical record that revealed she/he had a pressure ulcer that was a Stage 4 (full thickness skin and tissue loss) and it was present on admission. Wound measures were listed as Area 32.2 cm2, Length 10.0 cm, Width, 5.0 cm, and Depth was listed as Not Applicable and a dressing was noted to be intact, the Primary Dressing was listed as Negative Pressure Wound Therapy. A Nurses Note, titled General dated 10/1/2022 at 05:55, revealed ,Alert/oriented/Pleasant/Wound VAC intact and running. A Nurses Note, titled, General, dated 10/11/22 at 13:33 revealed, .pt is receiving skilled services for l thigh wound w/ wound vac, wound infx [infection] and Wound vac in place. [pronoun omitted] continues on iv [intravenous] abx [antibiotic] for wound infx w/ good results. A Nurses Note, titled, notification note, on 10/12/22 at 5:51 PM, revealed Primary Chief Complaint: Lines / Tubes / Pump Issues: Wound Vac Issue and a summary, Patient currently has a wound VAC and is receiving IV antibiotics. The wound VAC has failed and they are currently awaiting delivery of supplies however [pronoun omitted and incorrect] currently does not have any dressing. Staff is requesting an order for appropriate dressing to be applied. A Nurses Note, titled, General on 10/12/2022 at 07:53 revealed, Slept in long naps\No c/o [complaint] pain during night/Dressing to left thigh intact (l). A Nurses Note, titled, General dated 10/12/2022 at 20:22 revealed, [physician's name from telehealth contractor services omitted] ordered a more appropriate dressing be applied until the wound vac supplies arrive. The dressing is Maxorb II in wound covered with Optifoam changes q3 [every 3] days and PRN [as needed]. Review of Resident #52's TAR (Treatment Administration Record) for the 10/1/2022 - 10/31/2022 period, revealed the following order: Negative Pressure Wound Therapy to LLE SET Unit to 125 mmHg specify CONTINUOUSLY Cleanse with (NSS/Wound Cleanser/other) Place black foam into wound. Apply skin prep to intact skin around the wound Cover with occlusive dsg and secure tubing per manufacturer guide every day shift every Mon, Wed, Fri for Debrided Stage IV [4] PU [pressure ulcer] surgically Debrided prior to admission -Start Date- 10/3/2022 0700. Entries for the NPWT dressing change should have been documented on Friday 10/7/22, Monday 10/10/22, Wednesday 10/12/22, and Friday 10/14/22. The only documentation for the NPWT dressing change was dated on Monday 10/3/22 and Wednesday 10/5/22. The following new order revealed: apply temporary dressing until wound vac supplies arrive: pack wound with Maxorb II Ag and cover with Optifoam change q3days [every 3 days] and PRN [as needed] every day shift every 3 day(s) for Wound care Discontinue when wound vac supplies arrive. -Start Date- 10/15/2022 0700. Interview on 10/12/22 at approximately 11:30 AM, with RN/NPE, who was working as a floor nurse on this date revealed that the residents dressing failed last Friday, which would have been 10/7/22. She/he stated that she/he had already called and notified the doctor that the dressing had failed and requested a temporary order for a dressing until the supplies for the residents wound vac were received. Review of the resident MAR (Medication Administration Record) revealed the following order: Biopatch on Midline, change with weekly and prn dressing changes one time a day every 7 day(s) for IV Care - Start Date- 10/1/2022 0900. This order was noted to be signed off as having been completed on 10/8/22, however, the Biopatch is applied around the Midline IV at the entrance site of the body and was covered by a dressing - the dressing was dated 9/29/22. The following order was also noted on the same MAR: IV: Change Catheter Site Transparent Dressing. Indicate external catheter length and upper arm circumference (10 cm above antecubital space), Notify practitioner if the external length has changed since last measurement as needed for IV Care -Start Date- 09/30/2022 1706. Interview on 10/14/22 at approximately 2:30 PM, with Resident #52, who was alert and oriented to person, place, time, and situation. She/he confirmed that her/his wound vac dressing was last changed on last Friday, 10/7/22. The resident did have a dressing in place to her/his left posterior thigh that was quite saturated and had been leaking onto her/his bed linens. This was confirmed by the travel nurse that accompanied this writer to Resident #52. The resident was also noted to have a midline IV in her/his left upper arm, that was covered by dressing that appeared soiled and was grayish in color and was dated 9/29/22 - Resident #52 confirmed that her/his midline IV dressing was last changed at the hospital, prior to coming to this facility. The travel nurse confirmed that the Midline dressing was dated 9/29/22 and did not look very clean. The travel nurse stated that for the Biopatch to have been changed, the outer dressing would had to have been removed to access the Biopatch since the Biopatch is placed around the Midline IV, at the entrance where the Midline IV enters the upper arm and the outer dressing is the one that was dated 9/29/22. Therefore, the Biopatch had not been changed since admission to this facility and the outer dressing had not been changed since admission to this facility. 46442 5. Per record review Resident # 204 was admitted to the facility on [DATE] with medical diagnoses of Non-ST Elevation (NSTEMI) Myocardial Infarction, Type 2 Diabetes Mellitus Without Complications, Acute Pulmonary Edema, Frontal Lobe and Executive Function Deficit Following Cerebral Infarction, Other Reduced Mobility, Pressure Ulcer of Sacral Region, Stage 2, Dysphasia Oropharyngeal Phase. Muscle Weakness (Generalized) Unspecified Convulsions (Not all inclusive). Record review on 10/12/22 reveals a Physician diagnosis of Pressure Ulcer of Sacral Region, stage 2. Physician orders reflect order for Santyl External Ointment 250 UNIT/GM (Collagenase) Apply to Right Groin and coccyx topically every day shift for wound care cleanse with NS and pat dry, cover with dry protective dressing AND apply to right groin topically as needed for wound care. Unable to find measurements/description of the coccyx wound in the medical record. Review of medication administration record (MAR) reveals Santyl External Ointment 250 UNIT/GM (Collagenase) Apply to Right Groin and coccyx topically everyday shift for wound care cleanse with NS and pat dry, cover with Dry protective dressing and Santyl External Ointment 250 UNIT/GM (Collagenase) Apply to right groin topically as needed for wound care. The above treatment for the month of [DATE] There were no nurse initials for the dates of 10/6/22 and 10/7/22, 10/10/22, 10/11/22. Which indicates the treatment was not done on those dates. 10/1/22 was initialed but coded as unknown 10/12/22 was coded see nurse note. Progress notes of 10/12/22 at 1940 (7:40 PM) reflects that the resident refused a number of time and treatment was not administered. The Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 10/5/22 Section M- A skin conditions is coded as follows; Resident has a pressure ulcer/ injury a scar over boney prominence or a non-removable dressing/ device, this was coded NO. However there was a pressure ulcer presant at the time of the MDS completetion. Section M 0210 Unhealed pressure ulcers. Does this resident have one or more unhealed pressure ulcers/injuries coded Yes. Care plan has no problem for a stage 2 pressure ulcer to provide goals, and interventions to encourage heeling or to prevent pressure ulcer from becoming worse. On 10/13/22 at 12:58 PM, interview with Licensed Practical Nurse (LPN) MDS Coordinator confirms that the MDS section M0100 A is coded incorrectly the Nurse confirms that the resident does have a state 2 pressure ulcer on her coccyx and the care plan does not reflect that there is a stage 2 pressure ulcer.

Based on observation, interview, and record review the facility failed to ensure that 4 of 7 residents in the sample (Residnet #9, #5, #18, & #37) recieved adequate assistance, assessment, and monitoring of nutritional status to meet prevent significant weight loss and maintain acceptable parameters of nutritional status. 1. Per record review Resident #9 was admitted on [DATE] with diagnoses that include adult failure to thrive and cerebral palsy. An admission weight of 94.5lbs was documented on 3/18/2022. Review of weekly weights documented between 3/18/2022 and the last documented weight on 7/11/2022 the resident had experienced a severe weight loss of 18.1%. There is no evidence of weights being obtained after 7/11/2022. A care plan focus reflects that [name omitted] may be nutritionally at risk related to severe protein-calorie malnutrition, dysphasia, and adult failure to thrive, low body weight/BMI, use of mechanically altered diet, total dependence for food/fluid intake. Care plan goals include [name omitted] will consume [greater than]50% at all meals through the next review period. and Maintain weight of 82.4# with no significant wt [weight] loss thru next review and Weight gain would be beneficial for resident, and [name omitted] will consume [greater than] 75% of nutritional supplements daily through next review. A Dietary note written by the previous Registered Dietician on 5/27/2022 at 2:07 PM states Weight monitoring: reweight obtained and resident current wt 77.9#. This represents a 2.1#/2.6% wt decrease x 30 days and an overall decrease of 6.6#/7.8% since admission in March. [S/He] has nutrition interventions in place currently to promote kcal/protein intake. [Her/His] intakes while variable appear to be at his baseline. Reviewed available advanced directives which indicate an interest in short-term feeding tube. Attempted to have discussion with [Resident] to review that desire however [s/he] is asleep at this time after eating lunch. Discussed with floor nurse. Left message for social services. Will reattempt to determine if this is still [her/his] desire. There are no further documented dietary notes to indicate follow up on the resident's nutritional status. On 5/27/2022 the Social Service (SS) Director wrote a note stating Spoke with Dietitian about [resident's] health care wishes for wanting a feeding tube for short time due to weight loss. SS reviewed Advanced Directivities. SS went to speak to resident however resident was fast asleep. SS and Nurse Manager will talk to [her/him] about [her/his] wishes/wants. After that conversation with resident occurs with resident, SS will reach out to [her/his] Health Care proxy and soon to be POA to update. Resident at this time is able to make [her/his] own health care needs, unless [s/he] states [s/he] wants [her/his] Health Care proxy to make the decision for [her/him]. Review of Resident #9's weekly weights documented between 3/18/2022 and 5/27/22 the resident had been experiencing a severe weight loss of 17.57%, not the 7.8% that the dietician had documented. The last documented weight on 7/11/2022 revealed that the resident had been experiencing a severe weight loss of 18.1% over the 4 months residing in the facility. There have been no weights obtained since, and there have been no Dietary notes addressing this severe weight loss or follow up related to the use of a feeding tube documented since 5/27/2022. Per phone interview with the RD on 10/14/22 at 09:27 AM s/he is new to this position since September. S/he stated that if there is an issue identified related to resident's weights the Unit Managers would reach out to her/him for a consult. reviews weights monthly and if the resident is at risk s/he would review weekly. Confirmed that based on her/his BMI he would be considered at nutritional risk and that there was no documented weight since July 11, 2022. 2. Per record review Resident #5 experienced a severe (greater than 10%) weight loss of 11.7% over a six-month period. Review of the resident's weight record revealed the recorded weight on 4/1/2022 was 248.5 lbs. and on 10/3/2022 the recorded weight was 221lbs, a 27.5 lb. weight loss over 6 months. A care plan focus of [Name omitted] requires assistance for ADL [activities of daily living] care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfers, locomotion, and toileting related to dx [diagnosis] of CHF [congestive heart failure] and COPD [chronic obstructive pulmonary disease]. However, the only ADL addressed under the care plan interventions is ambulation. The care plan does not identify the level of staff assistance needed for eating. A care plan focus initiated on 1/6/2022 and revised on 4/20/2022 states that Resident may be nutritionally at risk related to [prior] covid recovered, hx [history] of pressure areas, use of mechanically altered diet, use of diuretic therapy, obesity status, diabetes, CHF, recent hospitalization with sig wt [significant weight] change r/t [related to] diuresis' An intervention initiated on 1/6/2022 directs staff to Record and monitor intakes and Record and monitor weights Resident #5 also has a care plan focus initiated on 1/5/2021 of [Name omitted} has a diagnosis of diabetes: non-insulin dependent with an intervention initiated on 1/5/2021 of monitor meal consumption each meal. Per phone interview with the consulting Registered Dietician (RD) on 10/14/22 at 9:35 AM s/he started consulting in September of 2022. When asked if s/he was aware that the resident has had a 11.7% weight loss in six months s/he stated yes, I was going to do [her/his] quarterly review today. When asked how staff communicated high risk residents or weight concerns to her/him, s/he stated I gave them a list of weights that I was missing and asked if there were any nutritional risks. There was nothing that they noted as a concern when I sent the email. The RD confirmed that she had not been notified of any concerns related to Resident #5's weight loss or nutritional status. The RD was asked about concerns related to resident #5's pressure ulcers and s/he stated that s/he is aware of pressure ulcer concerns and the resident is on liquid proteins. Per review of the licensed nursing assistant documentation for 10/1 - 10/14/22 there were 42 opportunities to document the assistance provided and the percentage of the meal consumed. Of the 42 opportunities, 36 were left blank, not completed. Per interview with the MDS (Minimum Data Set) Nurse on 10/14/22 at 2:14 PM the Rehab Director had not been notified of the resident's weight loss and the resident will now be screened by Occupational Therapy. Per interview with a Registered Nurse (RN) on 10/14/2022 at approximately 2:45 PM regarding the above concerns s/he stated that the licensed nursing assistants (LNAs) would find the ADL interventions to include assistance needed for eating on the resident care Kardex. However, while viewing the Kardex the RN confirmed that the care plan and Kardex were not complete, and the care needs were not identified on the resident Kardex or care plan. S/he also confirmed that the LNA documentation was not complete. 3. Per record review Resident #18 was admitted on [DATE]. An admission weight on 4/28/2022 was documented as 153.5 Lbs. A physician order states, Weigh every bath day/shower day every day shift every Thursday (every Thursday) for Health Monitoring AND everyday shift for weight monitoring daily X 3 days until 5/2/2022 23:59. The last weight documented was 150.5Lbs. on 7/26/2022. The resident had experienced a three Lb. weight loss since admission and had not been monitored for additional weight loss or basic nutritional health status since the 7/26/2022 weight. A care plan focus of Resident may be nutritionally at risk related to recent history of aspiration pneumonia, dementia, bipolar disorder, and hypothyroidism. Care plan goals include resident will consume >50% of all meals through next review and maintain weight of 154lbs +/- 5 lbs. thru next review. In addition to the nutrition care plan Resident #18 also has a care plan focus of [name omitted] requires assistance with dressing, personal hygiene, walking, transferring, toileting, changing position in bed, and eating related to: Anxiety, Behavioral symptoms, Change in Cognitive Status, [Pneumonia [spelling corrected], Recent hospitalization . The documented interventions list eating but do not specify the amount of assistance from staff that the resident needs. Review of LNA documentation for the month of September 2022, revealed that out of 90 meals assistance and percentage of meal consumed were only documented on 24 occasions, and 6 of the 24 documented meals were refused. Review of the October 1-11th 2022 LNA documentation revealed that out of 33 meals assistance and consumption was only documented 4 times. Per interview with the RD on 10/14/2022 at 9:31 AM s/he confirmed that there had been no recent weights documented as ordered for Resident #18. S/he stated that s/he had learned from staff that the resident often refuses to allow weights but did not know if this was the issue and why it is not documented. Also, staff had not made her/him aware that the resident was at nutritionally at risk, or that there were concerns related to meal intake. During interview on 10/14/2022 at 3:30 PM a RN confirmed that the care plan did not identify the residents need for assistance for meals. S/He also confirmed that it was not reflected on the Kardex. 46442 4. Per record review Resident #37 was readmitted to the facility on [DATE] after a hospital admission with the following diagnoses: Hemiplegia and Hemiparesis following cerebral infarction affecting left non dominant side, calculus of Gallbladder and Bile Duct without Cholecystitis without obstruction, Paroxysmal Atrial Fibrillation, Cerebral infarction unspecified, Major Depressive Disorder, Recurrent Moderate, Shortness of Breath, abnormal weight loss. Observation on 10/11/22 at 9:15 AM revealed Resident #37 sitting up on the edge of her/his bed with a breakfast tray in front of her/him unsupervised. Resident declined interview at this time. Record review revealed that resident #37 did not have a physician order for her/his diet. Review of Minimum Data Set (MDS) with an assessment reference date (ADR) of 8/17/22, Section G revealed Supervision set up only. On the Care Area Assessment (CAA), the facility documented that they would proceed with a nutrition care plan. Review of Resident #37's care plans revealed the resident does not have a dietary care plan in place. Interview on 10/14/22 at 11:54 AM with Licensed Practical Nurse (LPN) MDS coordinator who confirmed the MDS CAAs revealed the facility documented they would proceed with developing a dietary care plan. The LPN/MDS Coordinator confirmed that there was no current dietary order in place and there was no dietary care plan in place for resident #37.

Based on observations, interview, and record review the facility failed to ensure that two of six residents in the applicable sample (Residents #1 and #2) received adequate supervision to prevent accidents, injury, and/or potential abuse. Findings include: 1. Per record review Resident #1 has diagnoses that include major depressive disorder, and Alzheimer's Disease. S/he has a history of exhibiting verbal and sexual behaviors toward staff and other residents. A Social Service Note written on 5/8/2022 reflects a care plan focus of behavior problem due to acute [CONDITION(S)] as evidenced by agitation, combativeness, wandering, yelling, refusing food, fluid, medications, **Calling all [women/men] [s/he] sees [significant other's name] and asking them to inappropriately touch [her/him]. On 7/22/2022 at approximately 7:30 PM another resident was found leaning over Resident #1 with their hands under a lap blanket. A statement written by a Licensed Practical Nurse who was on duty states [Her/His] hand appeared to be near [Resident #1's] groin region . [Resident #1] was yelling out as this contact was happening but in a more amplified way than any of [her/his] other behaviors that night. When the residents were separated, Resident #1 began to remove her/his brief and was noted to have been incontinent of bowel. The other resident was later found to have feces on her/his hand. On 7/25/2022, three days after the incident, a care plan intervention was added to Attempt to keep [resident] away from [Female/Male] Dementia Residents who don't know not to respond to [her/his] inappropriate invitations to touch [her/him]. An intervention added to the care plan on 7/26/2022 states Dr in and ordered increase in [MEDICATION(S)] due to unrelenting behaviors of screaming, crying for [SO] and [her/his] parents and calling out (often times calling to [female/male] residents to come to [her/him] with sexually explicit requests for them to do to [her/him]). and Medication Changes to decrease inappropriate sexual invitations. However, there were no interventions in the resident's care plan regarding the need for supervision related to aggressive behaviors or the risk for potential inappropriate touching or sexual abuse. During interview with a Registered Nurse (RN) on the 3 South Unit on 8/17/2022 at approximately 2:30 PM, s/he confirmed that there had not been a specific plan to ensure Resident #1 was safe from undesired sexual contact due to her/his known behaviors. The RN stated that staff try their best to supervise the residents, but it is impossible to supervise them all the time and do medication pass and help the LNAs when they need it. During phone interview on 8/11/2022 at 4:06 PM with the Director of Nursing (DNS) at the time of the incident, Resident #1 has a history of thinking others are her/his significant other and requesting that they touch her/him and do things to her/him that are sexual in nature. S/he stated that s/he believed that Resident #1 asked the other resident to touch her/him, and the other resident did. The previous DNS confirmed that the resident had a long history of behaviors however, there had been no specific plan in place to prevent negative outcomes resulting from them. 2. Per record review Resident #2 has diagnoses that include repeated falls, unsteadiness on feet, difficulty walking, anxiety, dementia, [CONDITION(S)], cognitive communication deficit, and tremor. Review of nurse progress notes revealed that the resident has had 41 documented falls between 1/1/2022 - 8/17/2022. 35 of the documented falls were unwitnessed with the 6 others documented as witnessed by staff. Per progress notes the resident suffered minor injuries from falls on 1/1, 3/7, 3/8, 5/1, 6/9 (head injury with visit to emergency room for scan), 6/20, and 8/17. A care plan focus initiated on 2/7/2021 states [Resident] has a potential for falls related to: Agitation, Cognitive Impairment, and [CONDITION(S)] (hypertension). Care plan interventions implemented on 2/24/2022 that state Staff should intervene and accompany [resident] as soon as they note [her/him] attempting to walk unassisted were changed on 4/5/2022 to Line of Sight supervision and not allowed to enter rooms unaccompanied because [s/he] is unsafe in [her/his] judgement as to where and when to sit. The Activities of daily living care plan does not address the resident's ambulation status or level of assistance needed for ambulation. During unit observations on 8/11/2022 at 11:00 AM, Resident #2 was observed on the floor in her/his room. The Licensed Practical Nurse (LPN) on duty confirmed that the resident had just had an unwitnessed fall and they were getting her/him up off the floor. Per review of progress notes from 8/11/2022 there was no documentation that the resident had a fall or that s/he had been assessed for injury. On 8/17/2022 Resident #2 sustained two unwitnessed falls and was sent to the emergency room for evaluation. On 8/17/2022 at 2:30 PM during interview a Licensed Nurse Assistant (LNA) who works on 3 North stated that Resident #2 needs 1:1 supervision to prevent falls, but the facility does not provide that kind of care. S/he stated that even though it's kind of the dementia unit we don't have the ability to provide true dementia care. Per interview with a LNA on 8/17/2022 at approximately 4:30 PM Resident #2 has multiple unwitnessed falls especially on the evening shift. There is not enough staff to provide the kind of supervision or assistance that s/he needs. On 8/19/2022 at 11:27 AM during a phone interview with a Registered Nurse (RN) who is frequently assigned to Resident #2 s/he stated we don't have the staff to take care of [her/him] [s/he] should be 1-1 but never is. We just don't have the staff to do the basics. The RN also stated The resident was sent out the day before. S/he has a [CONDITION(S)] [urinary tract infection] and dozens of undocumented and unreported falls, especially on evening shift. When asked if there is any specific expectation for supervision, the RN stated S/he is care planned to fall, low bed with mats to prevent injury from fall. The RN confirmed that the resident is care planned for line of site supervision for safety however, most of the falls sustained by the resident are unwitnessed.

Based on staff interview and record review the facility failed to develop and implement a comprehensive care plan related to the elimination needs of a resident with an identified history and risk of constipation for 1 of 3 residents in the applicable sample (Resident #1). Findings include: Per record review resident #1 was admitted to the facility on [DATE] for post-surgical care of a left [CONDITION(S)] with surgical repair. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of December 2021 Licensed Nursing Assistant Flowsheets and Nurse Progress Notes there is no record of Resident #1 having a bowel movement from admission on 12/18/2021 - 12/29/2021. The December 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility standing orders are as follows: * If no bowel movement in three days, give milk of magnesia (MOM) 30ml PO (by mouth) x one dose at bedtime * If no bowel movement within the next shift, give Dulcolax suppository PR (per rectum) x one * If no bowel movement within two hours, give Fleet enema * If no results from Fleet enema, call physician/advanced practice provider for further orders On 12/29/2021 at 5:51 PM Resident #1 received [MEDICATION(S)] Suspension (MOM) 30 ml by mouth as needed for Constipation Once daily for no BM (bowel movement), then at 8:02 PM s/he received a Fleet Enema. At 10:17 PM a nurse documented that the MOM and enema were effective. On 12/30/2021 at 12:18 AM Resident #1 received a Dulcolax Suppository with no results and at 2:13 PM s/he received a Fleets enema. At 2:48 PM nursing documented that they were ineffective. A skilled nursing note dated 12/31/2021 at 2:53 PM states Pain/Interventions: C/O abdominal pain this shift; given scheduled [MEDICATION(S)] per order for constipation Abdominal Evaluation/Bowels/Continence: Abdomen soft but tender to palpation; C/O abdominal pain and nausea; given ginger ale and saltines; attempted to eat chicken noodle soup and lunch and didn't feel well enough to finish it; drinking well; continent of bowel and bladder; no BM today but had large BM this AM in ER. New Orders/Teaching: No new orders. Other Information: Resident arrived at facility this AM at 0730 from SVMC ER [local hospital emergency room ] after receiving [MEDICATION(S)] and soap suds enema with large results in the ER; stated his stomach felt better on re-admission. Per MDS (minimum data set, a standardized comprehensive assessment of all residents in a Medicare or Medicaid certified facility) dated 12/27/2021 Section H: Bowel and Bladder does reflect that constipation was present during the assessment reference date (ARD) of 12/24/2021. The residents care plan was not updated upon return from the hospital on 12/31/2021 to reflect risks, complications, or interventions related to constipation. Per interview with a Registered nurse on 1/20/2022 at 6:00 PM, nurses track resident bowel movements and follow the facility bowel protocol when needed. When residents have not had a bowel movement they are added to the list and tracked in the electronic medical record, triggering when intervention is required. It is the responsibility of the nurse to check if as needed bowel medications are needed. During interview on 12/20/2021 at approximately 6:30 PM the Registered Nurse Supervisor confirmed that there was no documented evidence that Resident #1 had a bowel movement from 12/18 - 12/29/2021. S/he also stated that s/he doesn't know why the nurses did not document any intervention related to bowel management for Resident #1.

Based on staff interview and record review, the facility failed to provide services in accordance with resident's care plan for one of one residents, Resident #3. Findings include: Per record review, Resident #3 sustained a skin tear of unknown etiology on 4/21/16. When the resident was put back to bed after lunch on 4/21/16, s/he was crying out in pain and upon exam, s/he was found to have a skin tear on the lower aspect of the right leg. The Licensed Nursing Assistant (LNA) that was responsible for the care of Resident #3 informed the nurse that the skin tear had not been present in the morning. On 4/24/16 the resident was sent to the emergency room secondary to increased pain in the right leg and upon examination of the X-ray, s/he was diagnosed with [REDACTED]. During the internal investigation, it was found that the LNAs that had transferred the resident from the wheelchair to bed had done so without use of a mechanical lift device as stated in the plan of care for Resident #3. A phone interview was conducted with one of the LNAs at 12:39 PM and s/he confirmed that the care plan had not been followed during the transfer of the resident and it was further confirmed by the second LNA at 12:58 PM via telephone conversation. The Director of Nursing Services (DNS) confirmed that the LNAs were suspended for failure to follow the care plan.