Every finding on record at Betty Dare Wellness & Rehabilitation LLC

Based on record review, interview, and observation, the facility failed to ensure the MDS was accurate for 1 (R #18) of 3 (R #16, R #17, and R #18) residents reviewed for pneumonia treatment. This deficient practice could likely result in the facility not having an accurate assessment of the residents' needs. The findings are:A. Record review of the Resident Assessment Instrument (RAI, a comprehensive guidebook that provides instructions and coding guidelines needed to evaluate resident clinical status and develop individualized care plans) Process Policy, revised 08/22/24, revealed the facility will utilize the RAI to complete accurate assessments for each resident. B. Record review of R #18's admission record, no date, revealed the following:1. R #18 was admitted to the facility on [DATE].2. R #18 had a diagnosis of pneumonitis due to inhalation of food and vomit (a severe lung inflammation caused by breathing stomach contents or food particles into the airway). C. On 06/15/26 at 1:32 PM, an observation of R #18 in his room revealed he had his eyes closed and had not signs or symptoms of distress. D. Record review of R #18's quarterly MDS assessment, dated 04/16/26, revealed staff documented R #18 had pneumonia within the previous seven (7) days. E. Record review of R #18's provider progress note, dated 06/10/26, revealed R #18 had been admitted to the hospital on [DATE] due to aspiration pneumonia. F. On 06/16/26 at 10:59 AM, during an interview, the MDS Coordinator stated the following:1. The pneumonia diagnosis automatically pulled into the quarterly MDS. 2. She believed the system documented R #18 had pneumonia due to his diagnosis of pneumonitis due to inhalation of food and vomit that was entered on 10/13/25.3. She confirmed a diagnosis of pneumonia should not have been documented on R #18's quarterly MDS. G. On 06/16/26 at 12:06 PM, during an interview, the Medical Director confirmed the following:1. R #18 had not had a diagnosis of pneumonia since October 2025. 2. R #18's diagnosis of pneumonitis due to inhalation of food and vomit should have been resolved after he was treated in October 2025.3. R #18's quarterly MDS, dated [DATE], was inaccurate.4. Staff should not have documented that R #18 had pneumonia within the previous seven (7) days of the MDS assessment.

Based on record review, interview, and observation, the facility failed to ensure residents received quality treatment and care for 1 (R #17) of 3 (R #16, R #17, and R #18) residents reviewed for pneumonia care and treatment, when staff failed to: 1. Administer R #17's antibiotic as ordered. 2. Ensure R #17 received all doses of his ordered antibiotic. These deficient practices could likely lead to worsening of resident's medical conditions. The findings are:A. Record review of the Medication Administration Policy, no date, revealed staff were to administer medication per the order of the physician or licensed independent practitioner. B. Record review of R #17's admission Record, no date, revealed the following:1. R #17 was admitted to the facility on [DATE].2. R #17 had a diagnosis of pneumonia (an infection that inflames the air sacs in one or both lungs, causing them to fill with fluid or pus). C. On 06/15/26 at 12:17 PM, during an observation and interview with R #17, the following was revealed:1. R #17 denied any respiratory concerns.2. During observation, R #17 did not show signs of difficulty breathing. D. Record review of R #17's hospital discharge documents, dated 05/22/26, revealed the following:1. R #17 had pneumonia in his right lung.2. R #17 had an order for Amoxicillin-Pot Clavulanate (a broad-spectrum prescription antibiotic used to treat bacterial infections like pneumonia, sinusitis, and infections of the ear, skin, and urinary tract) 500-125 MG to be administered at bedtime for 5 days. E. Record review of R #17's physician's order, dated 05/22/26, revealed an order for Amoxicillin-Pot Clavulanate Oral Tablet 500-125 MG (Amoxicillin & Pot Clavulanate), Give 1 tablet by mouth one time a day for pneumonia until 05/27/26. F. Record review of R #17's MAR, dated May 2026, revealed staff documented the following for R #17's order for Amoxicillin-Pot Clavulanate Oral Tablet 500-125 MG:1. On 05/22/26, staff documented code 9 (see nurse note).2. On 05/23/26, staff documented code 9.3. Staff documented administering the medication on 05/24/26, 05/25/26, 05/26/26, and 05/27/26 (4 doses). G. Record review of R #17's progress notes revealed the following:1. On 05/22/26, staff did not document a note regarding why R #17's Amoxicillin-Pot Clavulanate was not administered.2. On 05/23/26, staff documented, not in facility. H. Record review of R #17's entire medical record, no date, revealed staff did not document notifying the provider that R #17 did not receive all five (5) doses of Amoxicillin-Pot Clavulanate, or enter an order to extend R #17's Amoxicillin-Pot Clavulanate to ensure he received all five (5) ordered doses. I. Record review of the pharmacy medication manifest, dated 05/22/26, revealed five (5) tablets of Amoxicillin-Pot Clavulanate were delivered to the facility for R #17 on 05/23/26. J. On 06/15/26 at 1:33 PM, during an interview, LPN #16 and RN #16 stated the following:1. R #17 was treated for pneumonia in May 2026.2. They confirmed that staff documented see nurse note for R #17's Amoxicillin-Pot Clavulanate medication administration on 05/22/26 and 05/23/26.3. If medications were not available, staff should check the medication dispensing system to see if the medication was available there. If not, they should notify the provider to see if they want to extend the order and document in the medical record.4. R #17 received dialysis three times a week, and returned to the facility late in the evening.5. Staff should have administered R #17's Amoxicillin-Pot Clavulanate when he returned from dialysis. K. On 06/15/26 at 1:44 PM, during an interview, the DON and Regional Nurse Consultant (RNC) confirmed the following:1. R #17 did not receive his Amoxicillin-Pot Clavulanate on 05/22/26 or 05/23/26.2. The Amoxicillin-Pot Clavulanate was delivered to the facility on [DATE].3. Staff should have administered R #17's Amoxicillin-Pot Clavulanate after he returned from dialysis on 05/23/26.4. Staff were expected to notify the provider when an antibiotic was not administered and get an order to extend the medication so the resident received all ordered doses of the antibiotic.

Based on record review, interview, and observation, the facility failed to ensure medical records were complete and accurate for 1 (R #18) of 3 (R #16, R #17, and R #18) residents reviewed for pneumonia care and treatment when staff failed to document R #18's change in condition. This deficient practice could likely cause staff to not have the most accurate resident information and adversely impact the care staff provides. The findings are:A. Record review of the Change in Condition Policy, revised June 2020, revealed staff must document date, time, and pertinent details of the incident and the assessment in the nursing notes. Staff must also document the time the physician was notified, the method they were contacted, and whether or not orders were received. B. Record review of R #18's admission record, no date, revealed R #18 the following:1. R #18 was admitted to the facility on [DATE].2. R #18 had the following diagnoses: a. Pneumonitis due to inhalation of food and vomit (a severe lung inflammation caused by breathing stomach contents or food particles into the airway). b. Chronic obstructive pulmonary disease (COPD, a progressive, incurable lung disease that blocks airflow and makes breathing difficult). c. Chronic respiratory failure with hypoxia (occurs when the lungs cannot adequately transfer oxygen into the bloodstream over a prolonged period). C. On 06/15/26 at 1:32 PM, an observation of R #18 in his room revealed he had his eyes closed and had not signs or symptoms of distress. D. Record review of R #18's physician's order, dated 12/19/25, revealed an order for azithromycin, give two tablets by mouth one time only for lung infection for one day and give one tablet by mouth one time a day for four days. E. Record review of R #18's progress notes, dated 12/19/25, revealed staff did not document that R #18 had a change in condition that required the provider to order antibiotics for a lung infection. F. On 06/16/26 at 10:06 AM, during an interview, LPN #16 stated the following:1. He entered the order for azithromycin for R #18 on 12/19/25.2. On 12/19/25, R #18 had a cough that wasn't normal for him.3. He notified the Medical Director (MD) that R #18 had a cough during her rounds.4. The MD assessed R #18 and gave him a verbal order for azithromycin.5. He confirmed he did not document in the medical record that R #18 had a change in condition or that he notified the provider about R #18's change in condition. G. On 06/16/26 at 12:06 PM, during an interview, the MD stated the following:1. On 12/19/25, LPN #16 notified her that R #18 had a cough.2. She assessed R #18 and determined he had a lung infection.3. She gave LPN #16 a verbal order for azithromycin for R #18.4. She did not document in R #18's medical record that she had assessed R #18 on 12/19/25.5. She usually writes a note with her assessment and plan for treatment in the medical record.6. Staff were expected to document any change in condition and any provider communication in the resident medical record. H. On 06/16/26 at 12:58 PM, during an interview, the DON confirmed the following:1. A newly developed cough would be considered a change in condition.2. Staff were expected to complete a change in condition in the resident's medical record and notify the provider about any changes in the residents' health status.3. Staff were expected to document any communication with the provider in the medical record. 4. The providers were expected to document all resident assessments and plans for treatment in the resident medical record.

F627 S/S E, HB Based on record review and interview, the facility failed to implement an effective discharge planning process for 3 (R #16, R #17, and R #18) of 3 (R #16, R #17, and R #18) residents reviewed for discharge planning, when staff failed to: 1. Conduct discharge planning for R #16 and R #18. 2. Update comprehensive care plans and discharge plans with treatment preferences and needs for R #16, R #17, and R #18. These failures have the potential for unsafe discharge and an increased risk of resident harm. The findings are: R #16 A. Record review of R #16's admission Record, no date, revealed R #16 was admitted to the facility on [DATE]. B. On 02/13/26 at 1:22 PM, during an interview, R #16's Power of Attorney (POA, the authority to act for another person in specified or all legal or financial matters) stated the following: 1. R #16 planned to discharge to an assisted living facility in the community. 2. The facility had not had any meetings with her to talk about what interventions were being implemented to assist R #16 with reaching her goal to discharge to an assisted living facility. C. Record review of R #16's care plan, dated 02/07/26, revealed the following: 1. Staff documented R #16's goal was to discharge to an assisted living facility. 2. Staff did not document specific interventions that were in place to assist R #16 with meeting her discharge goal. D. Record review of R #16's medical record, no date, revealed staff did not document discharge planning meetings with the IDT team, R #16, or R #16's representative. R #17 E. Record review of R #17's admission Record, no date, revealed the following: 1. R #17 was admitted to the facility on [DATE]. 2. R #17 was discharged from the facility on 02/10/26. F. Record review of R #17's care plan, dated 02/06/26, revealed the following: 1. R #17's discharge plan was to go home with home health services. 2. Staff did not document specific interventions that were in place to assist R #17 with meeting her discharge goal. R #18 G. Record review of R #18's admission Record, no date, revealed the following: 1. R #18 was admitted to the facility on [DATE]. 2. R #18 was discharged from the facility on 12/28/25. H. On 02/16/26 at 10:08 AM, during an interview, R #18's Family Member (FM) stated the following: 1. She received a call on 12/26/25 from the Social Services Clerk (SSC) stating that R #18's last day of Medicare Part A coverage (Medicare hospital insurance that covers inpatient hospital stays, skilled nursing facility care, hospice, and limited home health services) was 12/28/25. The SSC told her that if R #18 stayed at the facility after 12/28/25, they would be charged $308 per day. 2. A staff member (she was unsure of title) looked in R #18's medical record and told her that R #18 had to leave the facility by 12:00 PM on 12/28/25 so they would not be charged. 3. During R #18's stay, staff did not have a meeting with her or R #18 to discuss R #18's discharge or discuss what interventions were in place to help R #18 discharge home safely. 4. Staff did not discharge R #18 home with any medical equipment, medications, information for home health agencies, information about community providers, or information about follow-up appointments. I. Record review of R #18's care plan, dated 11/05/25, revealed the following: 1. R #18's discharge plan was to go home with home health services. 2. Staff did not document specific interventions that were in place to assist R #18 with meeting his discharge goal. J. Record review of R #18's NMNOC, dated 12/26/25, revealed R #18's last date of coverage was 12/28/25. K. Record review of R #18's nursing progress notes, revealed the following: 1. On 12/28/25, staff documented Resident left the facility with no medications. Wife helped transfer the resident into his wheelchair and transferred into a private vehicle. Per his wife he needed to leave as they are unable to pay for the stay at the facility. 2. On 12/29/25, staff documented: a. R #18 left against medical advice on 12/29/25 (see finding K:1, R #18 left on 12/28/25). b. Prior to the scheduled discharge, the interdisciplinary team had been working to coordinate discharge planning, including the arrangement of durable medical equipment (DME, doctor-prescribed, in-home medical devices intended for long-term due to illness or injury, such as wheelchairs, oxygen tanks, hospital beds, and walkers) and home health services to support a safe transition. c. At the time of departure, the resident left without ordered DME and without home health services in place. The resident verbalized concern that he would be financially responsible for continued stay at the facility, which contributed to his decision to leave prior to completion of discharge planning. L. Record review of R #18's medical record, no date, revealed staff did not: 1. Document discharge planning. 2. Staff did not document attempts to obtain home health services or durable medical equipment (DME) for residents to safely discharge home. 3. Staff did not document what home health services or DME the resident would need to discharge home. 4. Staff did not document a post-discharge plan of care indicating: a. Where the resident will live after leaving the facility. b. Follow-up care the residents will receive from other providers, and the provider's contact information. c. Needed medical and non-medical services. d. Community care and support services, if needed. e. When and how to contact the continuing care provider. M. On 02/16/26 at 2:28 PM, during an interview, the Administrator confirmed the following: 1. She was unable to determine if the IDT team had discharge planning meetings for R #16 and R #18. 2. Staff did not update R #16, R #17, and R #18's care plans with interventions specific to assisting each resident meet their discharge goals. 3. Discharge planning was expected to begin at admission. 4. The IDT team was expected to meet with residents and their representatives to discuss discharge planning and interventions that were needed to help residents meet their discharge goals. 5. Staff were expected to document discharge planning meetings in the resident's medical record. 6. Staff were expected to update resident care plans with interventions to help the residents meet their discharge goals. 7. R #18's NOMNC indicated that R #18's last day of coverage was on 12/28/25. 8. She stated that staff planned for R #18 to be discharged on 12/29/25. 9. She was unable to determine if anyone discussed this discharge plan with R #18 or his FM. 10. She was unsure what staff member told R #18's FM that R #18 needed to leave the facility by 12:00 PM on 12/28/25.

Based on record review and interview, the facility failed to ensure care plan revisions and care plan meeting requirements occurred for 3 (R #1, R #16, and R #18) of 9 (R #1, R #2, R #3, R #16, R #17, R #18, R #19, R #20, and R #22) residents when staff failed to: 1. Ensure the IDT members participated in a care plan meeting within 7 days of the completion of the MDS assessment for R #16 and R #18. 2. Revise the care plan with the most current resident information for R #1. These deficient practices could likely result in the care plan not being updated with the most current resident conditions and appropriate interventions, staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are: Timing R #16 A. Record review of R #16's admission Record, no date, revealed R #16 was admitted to the facility on [DATE]. B. On 02/13/26 at 1:22 PM, during an interview, R #16's Power of Attorney (POA, the authority to act for another person in specified or all legal or financial matters) stated that staff had not had a meeting with her to discuss R #16's care plan. C. Record review of R #16's admission MDS, dated [DATE], revealed staff completed R #16's admission MDS on 12/15/25. D. Record review of R #16's medical record, no date, revealed staff did not document having an IDT care plan meeting for R #16. R #18 E. Record review of R #18's admission Record, no date, revealed R #18 was admitted to the facility on [DATE]. F. On 02/16/26 at 10:08 AM, during an interview, R #18's family member (FM) stated that staff did not meet with R #18 or her to discuss R #18's care plan. G. Record review of R #18's admission MDS, dated [DATE], revealed staff completed R #18's admission MDS on 11/18/25. H. Record review of R #18's medical record, no date, revealed staff did not document having an IDT care plan meeting for R #18. I. On 02/16/26 at 2:28 PM, during an interview, the Administrator confirmed the following: 1. IDT care plan meetings were not held for R #16 and R #18 since admission. 2. IDT care plan meetings were expected to occur quarterly based on the residents' MDS assessment dates. Care Plan Revision R #1 J. Record review of R #1's admission Record (no date) revealed the following: 1. R #1 was admitted to the facility on [DATE]. 2. R #1 diagnoses included hypokalemia (low blood potassium levels) and dementia. K. Record review of R #1's Provider Progress note dated 11/10/25 revealed the following: 1. Plan: Essential hypertension (abnormally high blood pressure that is not the result of a medical condition), Patient's blood pressure ranged from 121/71 to 162/79 (force of blood pushing against the walls of the arteries as the heart pumps it throughout the body and is measured using two numbers) on losartan (medication used to treat high blood pressure) 50 mg daily, consider titration for persistent elevated blood pressures. L. Record review of R #1's care plan dated 11/06/25 revealed staff did not update the care plan to include essential hypertension diagnosis. M. On 02/16/26 at 4:05 PM, during an interview, the DON confirmed R #1's care plan was not revised with the diagnosis of essential hypertension.

Based on record review and interview, the facility failed to ensure residents received quality treatment and care for 4 (R #1, R #19, R #20, and R #22) of 7 (R #1, R #2, R #3, R #17, R #19, R #20, and R #22) residents reviewed for care and treatment, when staff failed to: 1. Ensure staff monitored R #1's blood pressure. 2. Ensure orders for hospice services (specialized, team-based care for individuals with a terminal illness focusing on comfort, pain management, and quality of life rather than curing the illness) were entered timely for R #19 and R #20. 3. Ensure orders for therapy services were discontinued when hospice services were started for R #19 and R #20. 4. Ensure orders were entered correctly into R #22's medical record. These deficient practices could likely lead to resident's needs not being met and/or a worsening of their medical condition and prognosis. The findings are: Blood Pressure Monitoring R #1 A. Record review of R #1's admission Record, no date, revealed the following: 1. R #1 was admitted to the facility on [DATE]. 2. R #1 diagnoses included hypokalemia (low blood potassium levels) and dementia. B. Record review of R #1's Provider Progress Note dated 11/10/25 revealed the following: 1. Plan: Essential hypertension (abnormally high blood pressure that is not the result of a medical condition), Patient's blood pressure ranged from 121/71 to 162/79 (force of blood pushing against the walls of the arteries as the heart pumps it throughout the body and is measured using two numbers) On losartan (medication used to treat high blood pressure) 50 mg daily, consider titration (process of gradually adjusting the dose of a medication to find the optimal amount that is effective while minimizing side effects) for persistent elevated blood pressures. C. Record review of R #1's Physician's orders revealed the following: 1. Order date 11/24/25, order discontinue date 12/08/25: Losartan tablet 50 mg, give one tablet by mouth one time a day (scheduled to be given every morning) for hypertension. 2. Order date 12/08/25, order discontinue date 01/12/26: Losartan tablet 50 mg, give one and a half tablets by mouth one time a day (scheduled to be given every morning) for hypertension, hold for SBP (top number of blood pressure reading) less than 110. D. Record review of R #1's MAR dated December 2025 revealed staff did not document checking R #1's blood pressure prior to the administration of Losartan on the mornings of December 9th through December 30th. E. Record review of R #1's MAR dated January 2026 revealed staff did not document checking R #1's blood pressure prior to the administration of Losartan on the mornings of January 1st through January 12th. F. Record review of R #1's blood pressure readings for December 2025 revealed staff did not document checking R #1's blood pressure on the mornings of December 9th, 11th, 12th, 14th, 16th, 17th, 18th, 20th, 21st, 22nd, 23rd, 25th, 28th, 30th, and 31st. G. Record review of R #1's blood pressure readings for January 2026 revealed staff did not document checking R #1's blood pressure on the mornings of January 1st, 3rd, 8th, 11th and 12th. H. On 02/16/26 at 4:16 PM, during an interview, the DON confirmed the following: 1. R #1's blood pressure was not checked every morning from December 9, 2025, through January 12, 2026. 2. It is unclear if R #1's physician's orders to hold Losartan if SBP is less than 110 were being followed. 3. Staff are expected to check and document blood pressures prior to giving medication to ensure specific parameters (specific measurements used to assess a person's health and determine effectiveness of medication) in the physician's orders are being followed. Hospice I. Record review of R #19's admission Record, no date, revealed R #19 was readmitted to the facility on [DATE]. J. Record review of R #19's physician's orders, revealed the following: 1. An order dated 12/16/25, to admit R #19 to the Skilled Nursing Facility (SNF, a licensed, 24-hour healthcare facility providing short-term, intensive rehabilitation and medical care to patients transitioning from hospital to home). 2.An order dated 01/22/26, to admit R #19 to hospice on 01/15/26. 3. An order dated 12/18/25, for speech and language pathology (SLP, a rehabilitation service that treats communication, language, cognitive, and swallowing disorders) three (3) times a week for eight (8) weeks. 4. An order dated 12/18/25, for physical therapy (PT, a healthcare specialty focused on restoring, maintaining, and improving movement, strength, and function) five (5) times a week for eight (8) weeks. 5. An order dated 12/17/25, for occupational therapy (OT, a treatment that helps people overcome physical, emotional and social challenges) five (5) times a week for 60 days. K. Record review of R #19's hospice visit note, dated 01/15/26, revealed R #19 was seen by a hospice nurse on 01/15/26 for R #19's start of hospice care. L. Record review of R #20's admission Record, no date, revealed the following: 1. R #20 was admitted to the facility on [DATE]. 2. R #20 was discharged from the facility on 02/01/26. M. Record review of R #20's physician's orders, revealed the following: 1. An order dated 01/22/26 to admit R #20 to hospice. 2. An order dated 12/08/25 and discontinued on 01/24/26, for PT four (4) times a week for 60 days. N. Record review of R #20's Hospice admission Agreement, dated 01/17/26, revealed it was signed by R #20's family member on 01/17/26. O. Record review of R #20's hospice visit note, dated 01/17/26, revealed R #20 was seen by a hospice nurse on 01/17/26 for R #20's start of hospice care. P. On 02/16/26 at 11:45 AM, during a joint interview, the Speech and Language Pathologist and the Physical Therapist, revealed the following: 1. When a resident is started on hospice services, they cannot receive SLP, PT, or OT services. 2. They confirmed that R #19 had been placed on hospice services on 01/15/26. 3. They confirmed that R #19 still had active orders in her medical record for SLP, PT, and OT. 4. They confirmed that R #20 was admitted to hospice on 01/17/26. 5. They confirmed that R #20's order for hospice admission was not entered into his medical record until 01/22/26. 6. They confirmed that after R #20 was admitted to hospice services, his order for PT was not discontinued until 01/24/26. 7. They stated that staff don't always communicate with the therapy team when a resident is admitted to hospice. 8. They stated that sometimes they go to do therapy with residents and staff tell them the resident is on hospice. They stated that when they look in the resident's medical record, they don't have any orders indicating that the residents have been placed on hospice. Q. On 02/16/26 at 2:55 PM, during an interview, the DON confirmed the following: 1. R #19 was receiving hospice services since 01/15/26. 2. Staff did not enter R #19's order to admit to hospice in her medical record until 01/22/26. 3. R #19 had an active order (an authorized, current directive written by a qualified healthcare provider) to be admitted to SNF. 4. R #19 had active orders for PT, OT, and SLP. 5. R #20 was admitted to hospice services on 01/17/26. 6. Staff did not enter R #20's order to admit to hospice services in his medical record until 01/22/26. 7. Staff did not discontinue R #20's PT order until 01/24/26. 8. Staff were expected to enter hospice admission orders in the medical record as soon as the resident was admitted to hospice. 9. Residents cannot continue receiving PT, OT, and SLP services after being admitted to hospice. 10. Staff were expected to discontinue SNF admission orders as soon as a resident was admitted to hospice. 11. Staff were expected to discontinue PT, OT, and SLP orders as soon as a resident was admitted to hospice. Correct Orders R #22 R. Record review of R #22's admission Record, no date, revealed R #22 was admitted to the facility on [DATE]. S. Record review of R #22's convalescent care orders (CCO's, physician-signed, temporary, medically necessary orders to admit a patient to a skilled nursing facility), dated 02/13/26, revealed the following: 1. An order for weight bearing as tolerated (placing as much weight as is comfortable on an injured or operated leg or arm, ranging from minimal pressure to full weight-bearing) for R #22's right leg. 2. An order for partial weight bearing (involves placing a specific, limited percentage of body weight (e.g., 20%, 50%) on an injured leg, typically using crutches, a walker, or a cane to reduce pressure) for R #22's left leg. T. Record review of R #22's orders, dated 02/14/26, revealed the following: 1. Weight bearing as tolerated. 2. Staff did not document that the order for weight bearing as tolerated was for R #22's right leg. 3. Staff did not document the order for partial weight bearing on R #22's left leg. U. On 02/16/26 at 1:41 PM, during an interview, LPN #17 confirmed the following: 1. R #22's CCO's had an order for weight bearing as tolerated on R #22's right leg and partial weight bearing on R #22's left leg. 2. R #22's order in the medical record was for weight bearing as tolerated. 3. R #22's order in the medical record did not specify that R #22 was supposed to be weight bearing as tolerated on R #22's right leg. 4. Staff did not document an order in R #22's medical record for partial weight bearing on R #22's left leg. 5. Staff were expected to enter all CCO's as ordered into the medical record. 6. R #22 could get hurt if he puts too much weight on his left leg. V. On 02/16/26 at 2:55 PM, during an interview, the DON confirmed that staff were expected to review and enter all CCO's into the medical record correctly at the time of admission.

Based on record review and interview, the facility failed to provide a written Notice of Medicare Non-Coverage (NOMNC) to 1 (R #16) of 3 (R #16, R #17, and R #18) residents reviewed for beneficiary notices. If residents or their representatives are not provided with the beneficiary notices, then they may not make an informed decision about the services provided to them and could likely result in a decline in health and function. The findings are: A. Record review of R #16's admission Record, no date, revealed R #16 was admitted to the facility on [DATE]. B. On 02/13/26 at 1:22 PM, during an interview, R #16's Power of Attorney (POA, the authority to act for another person in specified or all legal or financial matters) stated she did not receive a NOMNC informing her of when R #16's last day of Medicare Part A (Medicare hospital insurance that covers inpatient hospital stays, skilled nursing facility care, hospice, and limited home health services) coverage was. C. Record review of R #16's End of Part A MDS assessment (an assessment that is required when a resident's Medicare Part A stay ends but they remain in the facility) revealed R #16's end date for her most recent Medicare stay was 01/09/26. D. On 02/13/26 at 2:16 PM, during an interview, the Administrator confirmed the following: 1. Staff did not give R #16 or her POA a NOMNC. 2. Staff were expected to give residents or their representatives a copy of the NOMNC at least three (3) to five (5) days prior to the end of their Medicare Part A coverage so they can make informed decisions regarding the residents' care.

Based on record review and interview, the facility failed to provide the required transfer information in writing for 1 (R #24) of 3 (R #24, R #25 and R #26) residents sampled for hospitalizations when staff failed to: 1. Send a written copy of the Transfer Notice to the Ombudsman (is a government official who investigates and tries to resolve complaints). 2. Ensure resident or their representative received a written notice of the bed hold policy which indicated the duration the bed would be held. These deficient practices could likely result in the residents and/or their representative not knowing the reason for the transfer, the location of the transfer or discharge, their rights to advocate and make informed decisions regarding the residents' healthcare. The findings are: A. Record review of R #24's admission Record revealed he was admitted to the facility on [DATE]. B. Record of R #24's nursing progress note dated 02/14/26 revealed resident was sent to the hospital due to shortness of breath. C. Record review of R #24's Bed Hold Notice Agreement dated 02/14/26, revealed staff did not document the number of days for R #24's bed hold when R #24 was transferred to the hospital on [DATE]. D. On 02/16/26 at 11:14 AM, during an interview, the Social Service Clerk (SSC) stated R #24 was sent to the hospital. SSC stated that she does not send notification to the ombudsman to inform the ombudsman when R #24 was discharged from the facility. E. On 02/16/26 at 12:54 PM, during an interview, RN #27 stated that the process for Discharge/Transfer and bed hold is given to the residents when they are leaving facility. RN #27 stated she puts three days on Bed Hold for residents' and management will change because she doesn't know how many Bed Hold days residents have. F. On 02/16/26 at 1:03 PM, during an interview, the DON stated that nurses initiate the Bed Hold process, and then BOM will follow up with the number of days the residents have. Each nurse has a check list of what needs to get done so that nothing is missed. This will make sure the Discharge/Transfers and Bed Hold process is completed for each resident that goes out. G. On 02/16/26 at 1:46 PM, during an interview, the Business Office Manager (BOM) stated nursing initiates the discharge/transfer for residents. BOM stated Nursing does not know how many days residents have. The BOM completes the Bed Hold process by reaching out to family on how many days are left for the residents. The BOM informs the family and follows up with the Bed Hold process typically the next day. H. On 02/16/26 at 2:07 PM, during an interview, the Administrator stated the Social Service department is the one that sends the notifications of discharges to the Ombudsman. The Administrator stated the Ombudsman told her that monthly notifications were okay to do. The Administrator stated she sent an email notification out on 01/20/26 for the following dates 01/12/26-01/20/26. The Administrator's expectation is that SSC would send out the Ombudsman notification of resident discharges monthly by email. I. Record review of an email from the Ombudsman on 02/16/26 at 3:16 PM, revealed that the Administrator was sending the Ombudsman notifications, however; it was to the incorrect email address. J. Record review of the facility's Transfer and Discharge policy, dated 10/24/22, revealed the facility must ensure documentation is complete, involve the physician in the decision, notify the residents and/or their representative, issue a written notice, and assist with safe and appropriate discharge planning. The policy also stated residents must be informed of their right to appeal, and staff must notify the Ombudsman.

Based on record review and interview, the facility failed to ensure a comprehensive MDS assessment was completed within 14 calendar days after admission for 1 (R #17) of 3 (R #16, R #17, and R #18) residents reviewed for discharge planning. This deficient practice could likely result in residents' needs not being met. The findings are: A. Record review of R #17's admission Record, no date, revealed the following: 1. R #17 was admitted to the facility on [DATE]. 2. R #17 was discharged from the facility on 02/10/26. B. Record review of R #17's medical record, no date, revealed staff did not document a comprehensive MDS assessment during R #17's stay at the facility. C. On 12/13/26 at 1:41 PM, during an interview, the MDS coordinator confirmed the following: 1. R #17 was readmitted to the facility on [DATE]. 2. Staff did not document an admission MDS for R #17. 3. Staff were expected to complete an admission MDS on all residents within 14 days of admission to the facility. 4. Staff should have completed an admission MDS for R #17 by 02/05/26.

Based on record review and interview, the facility failed to complete a Significant Change (major decline or improvement in the patient's health status) MDS assessment within 14 days after the facility determined a significant change in the resident's physical condition had occurred for 1 (R #20) of 2 (R #19 and R #20) residents reviewed for hospice services. This deficient practice could likely result in residents not receiving the appropriate care and services they need. The findings are:A. Record review of R #20's admission record, no date, revealed R #20 was admitted to the facility 11/07/25. B. Record review of R #20's physician's orders, revealed the following: 1. An order dated 01/16/26 to refer R #20 to hospice. 2. An order dated 01/22/26 to admit R #20 to hospice. C. Record review of R #20's Hospice admission Agreement, dated 01/17/26, revealed R #20 was signed by R #20's family member on 01/17/26. D. Record review of R #20's hospice visit note, dated 01/17/26, revealed R #20 was seen by a hospice nurse on 01/17/26 for R #20's start of hospice care. E. Record review of R #20's medical record, no date, revealed staff did not document a change in condition MDS assessment within 14 days after staff identified that R #20 conditioned had declined and he required hospice services. F. On 02/16/26 at 2:21 PM, during an interview, the MDS Coordinator and Regional MDS Coordinator confirmed the following: 1. R #20 was placed on hospice services on 01/17/26. 2. Staff did not document a change in condition MDS assessment for R #20 after his condition declined and he was placed on hospice services. 3. Staff were expected to complete a change in condition MDS assessment within 14 days after staff identified that a resident had a change in condition. 4. Staff should have completed a change in condition MDS assessment within 14 days after R #20 was admitted to hospice services.

Based on record review and interview, the facility failed to complete and transmit a MDS assessment within 14 days of the assessment reference date (ARD; last day of the resident observation period for the MDS assessment) for 1 (R #3) of 3 (R #1, R #2 and R #3) residents reviewed for MDS assessments. This failed practice could lead to the facility not reporting information in a timely manner (within 14 days) to the Centers for Medicare & Medicaid Services (CMS). The findings are: A. Record review of R #3's Quarterly MDS dated [DATE] revealed the following: 1. The ARD was 01/14/26. 2. The RN signed the assessment completion date on 02/10/26. B. On 02/16/26 at 4:50 PM, during an interview, the MDS Coordinator confirmed that R #3's MDS was not completed and transmitted within 14 days.

Based on observation, record review, and interview, the facility failed to provide respiratory care in accordance with professional standards for 1 (R #3) of 2 (R #3 and R #22) resident reviewed for implementation of orders when the facility failed to: 1. Ensure staff entered convalescent care orders (CCO's, physician-signed, temporary, medically necessary orders to admit a patient to a skilled nursing facility) for oxygen use into R #3's medical record. 2. Ensure staff followed R #3's physician's order for oxygen use. These deficient practices are likely to result in residents not receiving enough oxygen and can lead to worsening of their condition. The findings are: A. Record review of R #3's admission Record, no date, revealed R #3 was readmitted to the facility on [DATE]. B. Record review of R #3's CCO's, dated 02/13/26, revealed an order for R #3 to receive oxygen at a rate of 2.5 liters per minute (LPM, flow rate of oxygen). C. Record review of R #3's orders, no date, revealed staff did not document the physician's order for oxygen in R #3's medical record. D. On 12/16/26 at 12:24 PM, during an observation of R #3's room revealed there was not an oxygen concentrator (a medical device that separates nitrogen from the air around you so you can breathe up to 95% pure oxygen) or any oxygen delivery equipment (devices, including nasal cannulas, masks, and catheters, supply supplemental oxygen to individuals with respiratory needs by delivering specific concentrations of oxygen) in her room. E. On 12/16/26 at 12:29 PM, during an observation of R #3 in the dining room, revealed R #3 did not have an oxygen tank (a container with oxygen inside it, used for helping people to breathe) on her wheelchair or a nasal cannula (a lightweight, flexible tube with two prongs inserted into the nostrils to deliver supplemental oxygen) on her face. F. On 02/16/26 at 1:57 PM, during an interview, LPN #16 confirmed the following: 1. R #3 did not have an order for oxygen in the medical record. 2. R #3's convalescent care orders dated 02/13/26 had an order for R #3 to be on 2.5 LPM of oxygen. 3. R #3 had not been placed on oxygen after returning from the hospital on [DATE]. 4. Staff were expected to enter all convalescent care orders into the medical record when a resident returns from the hospital. G. On 02/16/26 at 2:55 PM, during an interview, the DON confirmed the following: 1. Staff were expected to review all convalescent care orders and enter the orders into the resident's medical record. 2. Staff were expected to ensure all orders were implemented.

Based on record review and interview, the facility failed to create a baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) that include all necessary information for providing care for 1 (R #17) of 3 (R #16, R #17 and R #18) residents reviewed for treatment of wounds. This deficient practice could likely result in residents not receiving the appropriate care upon admission and may place residents at risk of an adverse event (undesirable experience, preventable or non-preventable, that caused harm to a resident because of medical care or lack of medical care) or worsening of current condition. The findings are: A. Record review of R #17's admission documents, no date, revealed the following:1. R #17 was admitted to the facility on [DATE].2. R #17 had a diagnosis of a fracture (broken bone) of the left femur (upper leg bone), subsequent encounter for closed fracture with routine healing (refers to a specific phase in fracture recovery, indicating a follow-up visit for routine care like cast checks, X-rays to monitor healing, or medication adjustments after active treatment, not the initial injury or complex complications). B. On 12/29/25 at 11:57 AM, during an interview, R #17 stated the following:1. Staff were completing wound care on her left hip.2. She was going to the doctor that day to remove the staples from her surgical incision (a clean cut or opening made in the body, typically by a surgeon, to access tissues for an operation) and see how her hip was healing. C. Record review of R #17's physician order, dated 12/22/25, revealed an order to clean incision and ensure dressing was in place each shift until staples were removed. D. Record review of R #17's base line care plan, dated 12/20/25, revealed staff did not document that R #17 had a surgical wound or any interventions in place to treat her incision. E. On 12/30/25 at 1:03 PM, during an interview, the DON confirmed the following:1. R #17 had an incision on her left hip that still had staples.2. R #17 had orders for wound care for her incision.3. Staff did not document on R #17's baseline care plan that she had an incision on her left hip that required wound care.4. Staff were expected to document all wounds and interventions in place to treat wounds in resident baseline care plans.

Based on record review and interview, the facility failed to develop an accurate, person-centered comprehensive care plan for 1 (R #16) of 3 (R #16, R #17 and R #18) residents reviewed for treatment of wounds. This deficient practice could likely result in staff being unaware of the current and actual needs of the residents. The findings are: A. Record review of R #16's admission documents, no date, revealed the following:1. R #16 was admitted to the facility on [DATE].2. R #16 had a diagnosis of a fracture (broken bone) of the left fibula (lower leg bone), subsequent encounter for open fracture type 1 or 2 (indicating a small wound with minimal contamination) with routine healing (the fracture is progressing as expected, without complications like delayed healing or nonunion). B. Record review of R #16's physician orders, dated 11/11/25, revealed the following:1. An order for Surgical Incision (surgical cut made in skin) care for R #16's left inner ankle.2. An order for Surgical Incision care for R #16's left knee. C. Record review of R #16's admission MDS assessment, dated 11/12/25, revealed staff documented that R #16 had a surgical wound. D. Record review of R #16's care plan, dated 12/16/25, revealed staff did not document the ordered interventions to treat the wounds on R #16's left leg. E. On 12/30/25 at 12:55 PM, during an interview, the DON confirmed the following: 1. R #16 had wounds on his left shin (front of the leg below the knee) and left ankle. 2. R #16 had orders for wound care to his left knee and left ankle. 3. Staff documented on R #16's care plan that he had wounds on his left knee and left ankle. 4. Staff did not document interventions in place to heal R #16's wounds on his left knee or left ankle. 5. Staff were expected to document all interventions in place to heal wounds on resident care plans.

Based on record review and interview, the facility failed to meet professional standards of practice (established guidelines and expectations that ensure the delivery of high-quality care to residents) for 1 (R #16) of 3 (R #16, R #17 and R #18) residents reviewed for treatment of wounds when staff failed to follow physician's orders. If the facility is not providing care per physician's orders, then residents are likely to experience adverse effects, worsening of their condition, and potential complications from not receiving the care ordered by the physician. The findings are: A. Record review of R #16's admission documents, no date, revealed the following:1. R #16 was admitted to the facility on [DATE].2. R #16 had a diagnosis of a fracture (broken bone) of the left fibula (lower leg bone), subsequent encounter for open fracture type 1 or 2 (indicating a small wound with minimal contamination) with routine healing (the fracture is progressing as expected, without complications like delayed healing or nonunion). B. Record review of R #16's physician order, dated 12/03/25, revealed an order to remove R #16's sutures (sterile threads, also called stitches, used to hold tissues together after injury or surgery) and staples from his left leg. C. Record review of R #16's wound clinic documents (from outside clinic), dated 12/23/25, revealed the wound care clinic removed sutures and staples from R #16's left leg on 12/23/25 (staff had not removed R #16's sutures and staples as ordered on 12/03/25). D. On 12/30/25 at 12:55 PM, during an interview, the DON confirmed the following: 1. R #16 had an order to remove R #16's sutures and staples from his left leg on 12/03/25. 2. Staff had not removed R #16's sutures or staples from his left leg until the wound clinic removed the sutures on 12/23/25. 3. Staff were expected to follow physician's orders. 4. Staff should have removed R #16's sutures and staples.

Based on record review, and interview, the facility failed to ensure medical records were complete and accurate for 1 (R #16) of 3 (R #16, R #17 and R #18) residents reviewed for treatment of wounds when staff failed to accurately document in the resident's medical record. This deficient practice has the potential to negatively impact the care staff provide to meet residents' needs due to inaccurate records. The findings are: A. Record review of R #16's admission documents, no date, revealed the following:1. R #16 was admitted to the facility on [DATE].2. R #16 had a diagnosis of a fracture (broken bone) of the left fibula (lower leg bone), subsequent encounter for open fracture type 1 or 2 (indicating a small wound with minimal contamination) with routine healing (the fracture is progressing as expected, without complications like delayed healing or nonunion). B. Record review of R #16's physician order, dated 12/03/25, revealed an order to remove R #16's sutures (sterile threads, also called stitches, used to hold tissues together after injury or surgery) and staples from his left leg. C. Record review of R #16's Treatment Administration Record (TAR, documentation of treatments that have been provided to residents), dated December 2025, revealed on 12/04/25, staff documented removing R #16's sutures and staples. D. Record review of R #16's wound photographs, dated 12/09/25, revealed the following: 1. Four (4) sutures were visible on R #16's knee. 2. Six (6) staples were visible on R #16's inner left leg near the knee. E. Record review of R #16's wound clinic documents (from outside clinic), dated 12/23/25, revealed the wound care clinic removed sutures and staples from R #16's left leg on 12/23/25 (staff had not removed R #16's sutures and staples as ordered on 12/03/25). D. On 12/30/25 at 12:55 PM, during an interview, the DON confirmed the following: 1. R #16 had an order for staff to remove R #16's sutures and staples from his left leg on 12/03/25. 2. On 12/04/25, staff documented that they had removed R #16's sutures and staples as ordered.3. Staff did not removed R #16's sutures or staples from his left leg. 4. Staff should not have documented that they removed R #16's sutures and staples when they did not remove them.

Based on the record review and interview, the facility failed to ensure RN coverage was provided for 8 consecutive hours a day and for 7 days a week. This failure could potentially affect all 72 residents who lived in the facility (residents were identified by the Resident Matrix provided by the Administrator on 06/23/25. This deficient practice is likely to result in residents not receiving the services they require. The findings are: A. Record review of the Payroll Base Journal (PBJ) Staffing Data Report (report from the database of the federal agency overseeing certification for long term care facilities) dated Quarter #1 (October 1 through December 31) 2025 revealed no RN coverage for at least 8 consecutive hours on 10/06/24 and 12/31/24. B. On 11/21/25 at 2:38 PM during an interview, the administrator confirmed they were unable to provide proof of RN coverage for 10/06/24 and 12/31/24.

Based on record review and interview, the facility failed to ensure residents and/or their representatives were informed in advance of what medications they received and understood the reasons, risks, and benefits of the medications for 1 (R #6) of 5 (R #3, R #5, R #6, R #39, and R #60) residents reviewed for unnecessary medications. If the residents or their representatives are not informed of the risks and benefits of the medication or treatment alternatives, they are not able to make informed decisions regarding residents' care. The findings are: A. Record review of R #6's physician's orders, dated 10/28/25, revealed an order for clonazepam (used to treat seizure disorders and panic disorder) 0.5 mg one time a day for insomnia. B. Record review of R #6's medical record, no date, revealed staff did not document consent for clonazepam. C. On 11/21/25 at 10:19 AM, during an interview, the DON confirmed that there was not a consent for R #6's clonazepam. The DON stated consents should be completed for psychotropic active medications.

Based on record review and interview, the facility failed to ensure residents did not receive psychotropic medications (group of drugs that affect behavior, mood, thoughts, or perception) unless there was adequate monitoring for any adverse consequences resulting from the medication for 3 (R #5, R #6, and R #60) of 5 (R #3, R #5, R #6, R #39, and R #60) residents reviewed for unnecessary medications, when staff failed to: 1. Monitor R #5 for side effects of antidepressant (medication used to treat depression) medication. 2. Perform an AIMS (Abnormal Involuntary Movement Scale test used in medicine to assess side effects of antipsychotic medication) for R #6 and R #60. These deficient practices could likely result in residents receiving medications without a medical reason and being at a higher risk of adverse side effects (unwanted, harmful, or abnormal result). The findings are: R #5 A. Record review of R #5's admission documents, no date, revealed the following: 1. R #5 was admitted to the facility on [DATE]. 2. R #5 had a diagnosis of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). B. Record review of R #5's physician's order, dated 09/16/25, revealed an order for citalopram hydrobromide (antidepressant medication used for the treatment of depression) 20 mg, for depression. C. Record review of R #5's MAR, dated September 2025, revealed R #5 received Citalopram Hydrobromide as ordered from 09/17/25 to 09/30/25. D. Record review of R #5's MAR, dated October 2025, revealed R #5 received Citalopram Hydrobromide as ordered the entire month. E. Record review of R #5's MAR, dated November 2025, revealed R #5 received Citalopram Hydrobromide as ordered from 11/01/25 to 11/21/25. F. Record review of R #5's entire medical record, no date, revealed staff did not document assessing R #5 for side-effects (unwanted undesirable effects that are possibly related to a drug) of antidepressant medication. G. On 11/21/25 at 1:32 PM, during an interview, LPN #16 confirmed the following: 1. R #5 had an order for citalopram hydrobromide. 2. Staff were not monitoring R #5 for side effects of antidepressant medications. 3. Staff were supposed to document monitoring for medication side effects on the Treatment Administration Record (TAR, a comprehensive, organized record of each treatment or monitoring of a patient). H. On 11/21/25 at 1:36 PM, during an interview, the Regional Clinical Nurse (RCN) confirmed the following: 1. R #5 had an order for an antidepressant medication. 2. Staff were expected to monitor for side effects of antidepressants. R#6 I. Record review of R #6's admission record, no date, revealed the following: 1. R #6 was admitted to the facility on [DATE]. 2. R #6 had psychiatric diagnosis of schizophrenia (severe mental disorder characterized by disturbances in thinking, perception, and behavior, including delusions, hallucinations, and disorganized speech). J. Record review of R #6's physician's order dated 11/12/25, revealed an order for thioridazine (antipsychotic medication, historically used for schizophrenia and other psychotic disorders) 10 mg, give 1 tablet by mouth two times daily for schizophrenia. K. Record review of R #6's pharmacy recommendation dated 08/08/25, 09/05/25, and 10/03/25 revealed that R #6's antipsychotic medication can cause tardive dyskinesia (a neurological condition causing involuntary, repetitive body movements, often in the face (grimacing, tongue thrusting, lip-smacking), neck, limbs, or trunk) and other movement disorders and recommends a movement test within 30 days, and then every six months while R #6 is taking an antipsychotic medication. L. Record review of R #6's medical record, no date, revealed the following: 1. No order oder for AIMS, and 2. No AIMS test had not been documented. R #60 M. Record review of R #60's admission record, no date, revealed the following: 1. R #60 was admitted to the facility on [DATE]. 2. R #60 has a diagnosis of unspecified Dementia, unspecified severity, with other behavioral disturbance (is caused by damage to or loss of nerve cells and their connections in the brain with behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety depending on patient). N. Record review of R #60's physician's order dated 10/09/24, revealed an order for Mirtazapine (antidepressant medication, used to treat depression) 45 mg, give 1 tablet by mouth at bedtime for agitation related to restlessness and agitation. O. Record review of R #60's physician's order dated 05/06/25, revealed an order for Risperidone (antipsychotic medication used in elderly patients with dementia-related psychosis) 0.5 mg, give tablet by mouth one time a day for psychosis. P. Record review of R #60's pharmacy recommendation dated 09/01/25, and 09/05/25 revealed R #60's antipsychotic medication can cause tardive dyskinesia and other movement disorders and recommends a movement test within 30 days, and then every six months while R #6 is taking an antipsychotic medication. Q. Record review of R #60's medical record, no date, revealed the following: 1. No order for AIMS, and 2. No AIMS test had not been documented. R. On 11/21/25 at 10:19 AM, during an interview, the DON confirmed that there were pharmacy recommendations for a movement test for R #6 and R #60. RCN confirmed that an AIMS test has not been completed for R #6 and R #60. The DON stated that an AIMS test should have been done initially upon admission and that the recommendation should have been followed.

Based on record review and interview, the facility failed to provide the required discharge or transfer information to the resident and the resident's representatives in writing for 4 (R #16, R #19, R #83, and R #85) of 4 (R #16, R #19, R #83, and R #85) residents sampled for hospitalizations or discharge when staff failed to: 1. Notify the residents and resident representative(s) of the resident's transfer to the hospital in writing and in a language and manner they understand for R #19 and R #85. 2. Send a written copy of the Discharge or Transfer Notices to the Ombudsman for R #16, R #19, R #83, and R #85. 3. Ensure residents or their representative received a written notice of the bed hold policy which indicated the duration the bed would be held for R #19 and R #83. 4. Complete a discharge summary for R #85. These deficient practices could likely result in the resident and/or their representative not knowing the reason for a transfer or discharge, the location of the transfer or discharge, their rights to advocate and make informed decisions regarding the resident's healthcare, the services that the resident received while at the facility, the resident's current health status, or the resident's current medications leading to adverse outcomes for the resident. The findings are: R #16 A. Record review of R #16's admission documents, no date, revealed R #16 was admitted to the facility on [DATE]. B. Record review of R #16's progress note, dated 10/13/25, revealed R #16 fell and was transferred to the hospital for evaluation. C. Record review of R #16's transfer notice, dated 10/13/25, revealed R #16's was transferred to the hospital due to an unwitnessed fall. D. On 11/20/25 at 2:13 PM, during an interview, the social services worker (SSW) stated he did not send a copy of R #16's transfer notice, dated 10/13/25, to the Ombudsman. R #19 E. Record review of R #19's admission documents, no date, revealed she was admitted to the facility on [DATE]. F. On 11/17/25 at 3:44 PM, during an interview, R #19 stated the following: 1. She was sent to the emergency room (ER) on 11/13/25 due to concerns about her surgical incisions. 2. She did not receive a written transfer notice for her transfer to the ER. 3. She did not receive a written bed hold notice. G. Record review of R #19's entire medical record, no date, revealed the following: 1. R #19's medical record did not contain a written transfer notification that included information regarding how the resident or representative could appeal a transfer or how to contact the ombudsman for her transfer to the hospital on [DATE]. 2. R #19's medical record did not contain a written bed hold notification for her transfer to the hospital on [DATE]. H. On 11/20/25 at 2:04 PM, during an interview, the administrator confirmed the following: 1. Staff did not complete a written transfer notification for R #19's transfer to the hospital on [DATE]. 2. Staff did not complete a written bed hold notification. 3. Staff were expected to complete a transfer notice and bed hold notice and give a copy to the resident or resident representative at the time of transfer. 4. Staff were expected to send a copy of the transfer notice to the Ombudsman. R #83 I. Record review of R #83's admission Record (no date) revealed R #83 was admitted to the facility on [DATE]. J. Record review of R #83's electronic medical record (EMR) revealed R #83 was transferred to the hospital on [DATE] due to changes of wound appearance and dehiscence (surgery complication where the incision reopens). K. Record review of R #83's EMR revealed R #83's medical record did not contain a written bed hold notification for the transfer to the hospital on [DATE]. L. On 11/21/25 at 3:13 PM during an interview, the corporate nurse confirmed the following: 1. Staff did not complete a written bed hold notification for R #83. 2. Staff were expected to send a copy of the transfer notices to the Ombudsman. M. On 11/20/25 at 2:09 PM, during an interview, the SSW confirmed he did not send the Ombudsman copies of a written notice of transfers R #85 O. Record review of R #85's medical record, no date, revealed the following: 1. R #85 was admitted to the facility on [DATE]. 2. R #85 was discharged from the facility AMA (Against Medical Advice when a person decides to leave the facility against a provider's advice) on 09/02/25. P. Record review of R #85's progress note, dated 09/02/25, revealed the following: 1. R #85 left the facility AMA with his family. 2. R #85 was not given his medications and discharge paperwork. Q. Record review of R #85's entire medical record, no date, revealed staff did not document the following: 1. A discharge notice for R #85's discharge from the facility on 09/02/25. 2. A discharge summary for R #85 that included the following: a. A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. b. A final summary of the resident's status including an accurate and current description of the clinical status of the resident and sufficiently detailed, individualized care instructions, to ensure that care is coordinated and the resident transitions safely from one setting to another. c. A reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over the counter) R. On 11/20/25 at 11:05 AM during an interview, the Social Service Coordinator confirmed the following: 1. R #85 discharged AMA on 09/02/25 and refused to sign discharge paperwork. 2. R #85's medical record did not contain documentation of a discharge summary, discharge notification, recapitulation of stay, or medication reconciliation. 3. The facility did not send a written copy of a discharge notification for R #85 to the Ombudsman. 4. R #85's medical record did not contain documentation of a report made to APS (Adult Protected Services) for R #85's discharge that Social Service Coordinator confirmed was reported to APS.

During a complaint and CoVID-19 ([MEDICAL CONDITION] infection) investigation the following was discovered: 1) Staff who tested positive for CoVID-19 were working in the facility. 2) A resident who tested positive for CoVID-19 at the local hospital was readmitted to the yellow zone (quarantine zone becasue unsure if positive or not) and place with a roommate. 3) Interviews and observations revealed staff were not compliant with PPE (personal protective equipment) requirements both willing and unknowingly: a) Dietary staff not wearing isolation gown in the yellow zone. b) Direct care staff not changing gowns between residents in the yellow zone. c) Direct care staff not wearing face shield or eye protection while providing care to a resident in both the red (quarantined because of positive test result) and yellow zones. d) Maintenance/Environmental Director not wearing Personal Protective Equipment (PPE) or improperly wearing PPE. 4) Food tray cart entering the red zone on two separate occasions and was not observed to be cleaned after being on the unit. 5) Interviews and observations revealed disinfecting of high touch surface areas (i.e. door knobs, and hand rails) Also, No staff were disinfecting high touch surfaces between the hours of 6:00 PM -6:00 am. 6) Interviews and observations revealed staff were wearing KN95 masks taken off the Food and Drug Administration's (FDA) emergency use authorization list in May 2020. 7) Interviews, observations, and record review revealed staff were not screening for sign and symptoms of CoVID-19 consistently for staff and visitors. This resulted in an Immediate Jeopardy that was called on 02/22/21 at 5:10 PM. A final plan of removal was approved on 02/26/21. The facility was verified to have fully implemented this approved plan on 03/02/21 at 1:30 PM. This resulted in the scope and severity being reduced from a level 4, L to level 2, F. Plan of Removal * Screening of Staff and visitors: Daily rounding audits will be completed by Administrator or designee twice daily to visually observe the screening process in order to ensure all visitors have been appropriately screened. The Administrator and or Designee will do the screening. *Staff not changing gowns between residents: All Nursing Staff will be monitored daily by the Clinical leaders and or Designee until the outbreak is over to ensure that all Gowns are changed upon entering another residents' room and between. *Positive staff working in the Yellow Zone We proactively reviewed all employees for their most recent test results on 2/25/2021 and verify DAILY that no employees working are currently symptomatic. *Staff not changing PPE between zones Staff have been re-educated using CDC Guidelines in conjunction with Good Samaritan policies and procedures on proper infection prevention processes, including donning and doffing of PPE as well as appropriate PPE for each zone and reviewed transitioning between zones. Each zone will be labeled with signage that includes PPE guidelines specific to that zone, including directions on how to don/doff PPE appropriately. The facility will put a trash receptacle by the exit door of the red and yellow zone in order for staff to dispose of PPE and hand sanitizer were placed on the storage bins upon exiting the yellow zone. All staff, including ancillary departments, have been re-educated using CDC Guidelines in conjunction with Good Samaritan policies and procedures on proper infection prevention processes, including donning and doffing of PPE, appropriate PPE for each zone, and appropriate movement between zones. Dietary aide received re-education by the Administrator on 02/23/21. Signs have been placed on the Yellow Zone and Red Zone doors on 02/24/2021 outlining the PPE that must be worn upon entering those Zones (N95 Mask, Gowns, and eye protection). *Cleaning high-touch surfaces High touch surface areas were cleaned on February 25, 2021 and continue to be cleaned according to CDC Guidelines in conjunction with Good Samaritan policies and procedures on proper infection prevention processes. The nightshift C.N.A's as of 2/25/21 are responsible for cleaning the high touch surface area. *Readmission of positive resident: All admissions and nursing staff will be re-educated on the process for accepting admissions based on CoVID Status, verified positives will admit directly to the red zone, all other residents will admit to gray (quarantine) zone for 14 day observation. *Dedicated staff for the Red Zone: Facility has a dedicated C.N.A on both shifts working the Red Zone and One nurse working the Red Zone for both shifts as of 2/24/21. *Use of KN-95s: All unapproved KN95s were removed on 2/23/2021. Based on observation, interview and record review, the facility failed to implement proper infection control practices for CoVID-19, when the facility failed to: 1) To acknowledge positive CoVID -19 test results for staff and residents: a) Ensure staff who tested positive do not return to work unless facility has been approved for crisis staffing or follow CDC guidance for returning to work. b) Readmit a positive resident to the red zone. 3) Ensure staff were knowledgeable of wearing proper PPE and ensure staff were wearing proper PPE; 4) Ensure staff cleaned and disinfected a food tray cart taht was taken into the red zone; 5) Ensure staff were cleaning high touch surface areas and staff were cleaning between 6:00 pm - 6:00 am; 6) Ensure staff were wearing approved KN95 masks for healthcare workers while providing care to residents; 7) Ensure staff were screening for sign and symptoms of CoVID-19 consistently for staff and visitors. This has the potential to affect all 57 residents at the facility (residents were identified by the census list provided by the Administrator on 02/18/21). This deficient practice resulted in 17 residents contracting CoVID-19. The findings are: A. The facility was experiencing an outbreak of CoVID-19: 1. Record review of a list of staff that has tested positive for CoVID-19 provided by the Administrator on 02/18/21 showed 18 staff had tested positive starting on 02/09/21. 2. Upon entry into the facilty on 02/18/21, 17 resident were on the Red Zone after being tested positive for CoVID-19 B. Record review of the Letter of Direction (LOD) sent out by the State Agency (DOH) on 12/23/20 directed the facilities to: 1. Test utilizing either Reverse Transcription-Polymerase Chain Reaction (PCR) or [MEDICATION NAME] (Ag). If the test result is positive for CoVID-19, the person is to be quarantined. If a staff member, they are sent home and asked not to work. If the Ag result is negative, the person is to have a PCR test completed and sent to the laboratory. This person should be treated as if they were positive pending receipt of the PCR test result. 2. If staff or resident recently tested positive, then 100% of staff and residents are tested using PCR. 3. Any staff that fail the screening process should not be allowed in the facility and any staff reporting signs and symptoms of illness cannot report to work. 4. Staff that have had exposure to a known positive individual outside of the facility should not report to work. 5. For staff who are confirmed COVID-19 positive Maintain isolation at home and do not report to work until: 1. At least 10 days have passed since symptoms first appeared; AND, 2. At least 1 day (24 hours) has passed with no fever; AND 3. Symptoms have improved 6. For COVID-19 positive staff without symptoms: Maintain isolation at home and do not report to work until at least 10 days have passed since the date of the first positive test. 7. For staff who had close contact with a COVID-19 positive case Maintain isolation at home and do not report to work until: 1. You have completed your quarantine period of at least 14 days since the date of the last exposure to the confirmed case. 2. Close contacts are encouraged to get tested . Testing should occur toward then of the quarantine period before returning to work. A negative test does not end the quarantine period, the full 14 days of quarantine must be observed. 3. If close contacts develop symptoms they should be tested as soon as possible 4. If test is positive, follow guidance above. CoVID-19 Positive Staff Working C. On 02/19/21 at 1:00 PM, the Administrator was asked for the paperwork for the positive results from the agency that is doing the PCR testing for the facility. She only produced a few and stated that it was difficult for her to sort through the information that the testing agency sends. D. On 02/19/20 at 1:24 pm, during an interview in the yellow zone, RN #2 confirmed that he was working in the both the red zone and the yellow zone. RN #2 was not observed to change his PPE and use sanitizer before going into the Yellow Zone. E. On 02/22/21 at 1:02 PM, during an interview, RN #2 stated that he was assigned to work in the Red Zone/400 unit and also had the 300 unit which is in the Yellow Zone. F. On 02/22/21 at 1:02 PM, during an interview, RN #2 stated that he was notified by the Administrator that he tested positive for CoVID-19 on 02/13/21 from the test on 02/11/21. RN #2 stated that he was asymptomatic (having no symptoms of the disease) and returned to work on 02/15/21, had a rapid (Ag card nasal swab rapid test for CoVID-19 which provides results within 15 minutes) test and the results were negative, so he worked that day. G. On 02/22/21 at 2:51 PM, during an interview, the Administrator confirmed that RN #2 returned to work on 02/15/21. She stated that RN #2 insisted he was negative and asymptomatic, so he was retested with the Ag card and tested negative. He returned to work that day. H. On 02/22/21 at 3:35 PM, during an interview, the Administrator stated that RN #2 was the only positive staff member that returned to work prior to their 10-day quarantine. I. On 02/25/21 at 11:28 am, during an interview with CNA #10 and CNA #11 revealed that they both tested on [DATE] with both returning positive. They both received a phone call from DOH telling them of their positive test results and telling them to quarantine for 10 days. On 02/13/2021 they both were asked to return to work and given a rapid test which came back negative and they were both told by the Administrator that they can work because they were both Asymptomatic. CNA #10 was placed in the red unit until 02/24/21 and CNA #11 remained in the yellow unit after testing positive. J. On 02/25/21 at 11:35 am, during an interview with CNA #10, revealed that 3 members of her house hold tested positive the week prior to her positve result. CNA #10 reported that when she called the facility to report her family was positive, she wastold she st ill needed to report to work. K. Test results of the PCR test results completed by an outside agency completed between 02/11/21 ans 02/13/21 for CNA #10 and CNA #11 were not provided by the facility. The test result provided by the facility was the rapid test dated 02/13/2021. L. Record review of CNA #10 and CNA#11's test results that were provided by the Department of Health (DOH) revealed confirmed positive results for CNA #10 and CNA #12 dated 02/13/21 with a collection date of 02/11/2021. They both received calls from DOH directing them to stay home and quarantine and when they reported this to the facility they were both told they needed to report to work. M. On 03/01/2021 at 2:30 pm, during an interview, CNA #10 revealed that her family that live in the same home as her all tested positive for CoVID-19 the week prior to her positive result and she was told by Administrator that she still needed to report to work. N. On 03/02/21 at 1:15 PM, during an interivew, the Administrator stated she did not read all of the Letters of Direction from that state because they were too many. She stated that she did not know about Crtical Staffing until 02/17/21 and did not know that she has to submit a plan to the state to be approved. She further stated she did not know that once a staff member reeived and positive test, that they were to not to work for 10 days. She thought that once they tested negative, they could return. Findings for R #7 O. Record review of R #7's Progress Notes revealed the following: 1. 02/20/21 at 4:10 pm . Resident complained that he was having difficulty breathing even though he was on supplemental oxygen and ox. (sic) sat. (percentage of hemoglobin binding sites in the bloodstream occupied by oxygen) rate of 93% on 3 L (liters). Resident and (name of family member) agreed that he be sent to ER for evaluation. 2. 02/20/21 at 11:53 pm Resident back via (name of ambulance service) at 2215 (10:15 pm) from (name of local hospital) with a dx (diagnosis) of CoVID but upon arrival he was tested again here and he was negative. Will be checking him in the morning again and letting his family know but for now he is back in his room he was before resting. No fever, no coughing and vitals stable at this time. Will continue to monitor him throughout the night. 3. 02/21/21 at 5:07 am Called (name of family member) and let her know he arrived back last night and that we had done two CoVID test after he arrived and both are negative. No fever, no diarrhea, no vomiting and vitals are stable at this time. P. Record review of R #7's hospital records revealed 02/20/21, [DIAGNOSES REDACTED]-CoV-2 (CoVID-19) PCR Positive. Q. Record review of R #7 medical record revealed the following: 1. R #7 was placed back on the yellow zone on 02/20/21 with his roommate, R #10. 2. R #7's CoVID-19 assessment (the daily screen of residents for signs and symptoms of Covid-19) was last done on 02/19/21 (as of 02/26/21, no documentation of an another CoVID-19 assessment was found). R. Record review of R #10 medical record revealed R #10's CoVID-19 assessment was last done on 02/19/21 (as of 02/26/21, no documentation of an another CoVID-19 assessment was found). S. On 02/23/21 at 9:52 am, during an interview, RN #5 confirmed that R #7 and R #10 CoVID -19 assessments had not been done since the 02/19/21. RN #5 stated that the assessments should be done at least once a day. PPE T. Record review of the Zone Color Document dated 11/30/20 revealed Red Zone (Isolation Zone) Healthcare workers should wear full CoVID-19 level PPE (Gloves, Gown, N-95 mask and face shield) and while providing care the residents in teh yellow zone. U. On 02/19/21 at 1:07 pm, during an interview in the yellow zone, LPN #2 was asked when he needed to change he isolation gown. He stated that he needs to change his gown when he changes hallways on his assignment. V. On 02/19/21 at 1:14 pm, during an observation, CNA #5 went into room [ROOM NUMBER] in the yellow zone. She did not change her gown going into or coming out of room [ROOM NUMBER]. W. On 02/19/21 at 1:16 pm, during an observation, CNA #5 was asked when she needed to change her isolation gown. She stated, We can use the same gown to go into resident's rooms. X. On 02/19/21 at 1:21 pm, during a interview in the yellow zone, CNA #6 was asked when she needed to change her isolation gown. She stated, Only if they are soiled. Y. On 02/22/21 at 11:40 am, during observation it was revealed that there was no hand santiizer available at the entrance or exit of the yellow unit for staff to use. Z. On 02/22/21 at 1:02 pm, during an observation, RN #2 and CNA #2 were sitting at nurse's station in the Red Zone and were not wearing face shields or N95 masks, they only had gowns and unapproved KN95 masks on. AA. On 02/23/21 at 9:42 am, during an observation and interview, Dietary Aide (DA) #1 was not wearing an isolation gown in the yellow zone. DA #1 was asked if she had wear an isolation gown in the yellow zone, she stated she was not sure. CNA #5 told the DA she needed to wear an isolation gown in the yellow zone. DA #1 acknowledged CNA #5 but did not put on an isolation gown. The DA #1 continued walking through the yellow zone to the kitchen. BB. On 02/23/21 at 9:48 am, during an observation of the yellow zone, CNA #7 went into room [ROOM NUMBER] without face shield or eye protection. CC. On 02/23/21 at 9:50 am, during an interview, RN #5 confirmed that CNA #7 should have eye protection and did not. DD.On 02/23/21 at 9:58 am, during an interview, CNA #7 confirmed that she did not have eye protection on when she entered room [ROOM NUMBER]. CNA #7 stated I forgot to put them on. EE. On 02/23/21 at 3:08 pm, during an observation of the yellow zone revealed the Maintenance/Environmental Director (MED) did not put on an isolation gown when he entered the yellow with CNA #5. CNA #5 told the MED to put on an isolation gown as she was putting hers on. The MED stated I'm in a hurry. I got sh** to do. The MED then went back put on the isolation gown. After putting on the isolation the MED, then pushed the isolation gown sleeves up to his elbows exposing his forearms. FF. On 02/23/21 at 3:13 pm, during an observation of the yellow zone revealed the MED not wearing eye protection and wearing only one strap of his N95 mask. GG. On 02/23/21 at 3:16 pm, during an observation of the yellow zone, CNA #8 entered that yellow zone walked from the entrance to the nurses station did not wear an isolation gown. During an interview at that time, CNA #8 was asked if he had to wear an isolation gown in the yellow zone. The stated that he had just gotten off break and puts on the isolation gowns when he gets to his assigned hallway 100 (which is also in the yellow zone). HH. On 02/23/21 at 3:18 pm, during an observation of the yellow zone revealed CNA #7 had ripped one strap of her N95 mask (the N95 mask has two straps to keep a tight seal around nose and mouth), so that the mask only had one strap. During an interview at that time, CNA #7 was asked if she needed to change her mask. CNA #7 stated that she was unsure. RN #5 stated that she needed to change her mask and told her to see the Administrator for a new one. II. On 02/23/21 at 3:23 pm, during an observation of the yellow zone, CNA #7 entered the yellow zone without putting on an isolation gown and wearing the N95 mask with one strap. During an interview at that time, CNA #7 stated the Administrator was in meeting so she could not get a new mask. JJ. On 02/23/21 at 12:20 pm, during an observation of the red zone revealed RN #2 did not have face shield or eye protection in the red zone. KK. On 02/24/21 at 12:24 pm, during an observation of the red zone and interview with the Administrator, she confirmed that RN #2, again, did not have eye protection on in the red zone. LL. On 02/25/21 at 11:45 am, during observation of the Yellow Unit, LPN #12 was observed not wearing his eye protection and gown was not properly secured. MM. On 02/25/21 at 11:45 AM, during an interview, LPN #12 confirmed he was aware that he did not have his eye protection and he reported that it was do to his face sweating. When asked if he should have eye protection and a fastened gown and reported that he was aware. NN. On 03/01/21 at 3:15 pm, during observation in the Yellow Unit, Housekeeper #10 was observed walking onto the Unit and did not do hand hygiene before opening the drawer and getting a clean gown. House Keeper #10 was also observed touching her mask in an attempt to push it up because it was sliding off her nose. When ask if her mask fit properly, she revealed that the reason she keeps touching her mask is because she had a runny nose. Food Cart Tray OO. On 02/23/21 at 12:20 pm, during an observation of the red zone revealed RN #2 taking food out of the food tray cart in the red zone. PP. On 02/24/21 at 12:24 pm, during an observation of the red zone and interview, with the Administrator, she confirmed the food tray cart was in the red zone. The Administrator was asked where the cart should be, She stated they leave the cart outside the door plugged in. They take the drink first and then take the food and the trays do not go into the red zone. QQ. On 02/25/21 at 11:46 am during observation of the red zone revealed that the food tray cart was in the red zone. RR. During observation of the cart coming out of the Red Zone, no staff was observed to clean or disinfect the cart immediately upon leaving the Red Zone. High Touch Surface Areas SS. On 02/22/21 at 1:27 pm, during an interview Maintenance/Environmental Director (MED) was asked who cleans the high touch surface areas. He stated that some of the housekeeping staff were out of the facility. He further stated there was one in the red zone and he was supposed to clean the yellow zone. The MED stated that this include sweeping, moping, throwing the trash, and cleaning of high touch surface areas. The MED was asked if he had cleaned the high touch surface areas, he stated It has not been done today by any staff. TT. On 02/25/21 at 2:15 pm, during an interview, the MED was asked who cleans the high touch surface at night. The MED stated, After 6 pm, no one cleans high touch surface areas. KN95 Masks UU. On 02/23/21 at 10:06 am, during an observation of the facility supply room revealed the facility was using KN95 masks from Fujian Pageone Garments co ltd During an interview with Supply #1 confirmed that the facility was using these KN95 masks. VV. Record review the FDA approved manufacturers list for emergency use authorization list revealed Fujian Pageone Garments co ltd was removed from the list in May 2020. WW. On 03/02/21 at 1:15 PM, during an interview, the Administrator confirmed she did not know to check the FDA emergency use authorization lists to ensure that the KN95 masks that the facility staff were using were still approved for use. Screening for Signs and Symptoms of CoVID-19 XX. Record review of the list of CoVID-19 positive staff, undated list, provided by the Administrator revealed CNA #9 had tested positive for CoVID-19 on 02/11/21. YY. Record review of the staff screened for CoVID-19 for 02/10/21 and 02/11/21 revealed that CNA #9 had not been screened prior to coming into the facility for her shift on these days. ZZ. On 02/22/21 at 2:05 pm, during an interview, the Administrator confirmed that CNA #9 was not on the list for CoVID-19 screening on 02/11/21, but she should have been on there. AB. Upon entry into the facility on [DATE] at 2:15 pm, no facility staff screened the two surveyors for signs and symptoms of CoVID-19. They were led to the conference room shortly after arriving and not screened. AC. On 02/22/21 at 1:02 pm, during an interview, RN #2 stated that he had not been screened prior to entering the building since he tested positive on 02/13/2020. (This is to ensure that RN #2 does not start showing symptoms and infect the residents on the 300 hall (yellow zone).) AD. Record review of the screening history provided by the Administrator revealed no screenings were completed for 02/15/21, on 02/16/21 only the Administrator was screened and there were no screenings for all of the other staff that worked entered for 02/18/21 through 02/21/21. AE. On 03/01/21 at 3:15 pm, CNA #10 revealed that the screening tool was not being used and staff were just writing their name and their temperature after taking their own temperatures. No one was there actually ensuring that the form was being filled out correctly.

Based on observation, interview, and record review, the facility failed to update Care Plans for 5 (R #3, R #5, R #11, R #31, & R #49) of 5 (R #3, R #11, R #12, R #31, & R #49) residents sampled with care plan issues, when they failed to update care plan for: 1) R #11 4 falls that resulted in a fracture of her left fibula, 2) R #31's depression and her change of condition after hospitalization , 3) R #3's anti-depressant, 4) R #49's antibiotic usage for UTI (urinary tract infections), 5) R #5's NPO (nothing by mouth) diet. This deficient practice caused R #11 to ambulate with a wheelchair after she fractured fibula, where before she was using a walker to ambulate. The findings are: R #11 A. Record review of the Incident Report dated 11/27/17 revealed that it was documented that on 11/27/17 at 10:00 pm, Resident was found on floor between her bed & the wall to the restroom. Resident stated that she fell on the way from the restroom . Ensure that staff are aware to leave bed in low position, mat beside bed. Remind resident to call for assistance. B. Record review of the Clinic Referral dated 11/30/17 revealed a request for x-ray due to R #11's left leg pain. Related to fall on 11/28/17 (11/27/17) pain of left leg not able to bear weight on leg. C. Record review of the Final Diagnostic Incident Report dated 12/05/17 revealed the following Three views of the left ankle reveal [MEDICAL CONDITION] fibula. D. Record review of the Incident Report dated 12/02/17 revealed that it was documented that on 12/02/17 at 7:00 am, Resident fell r/t (related to) not waiting for help to transfer weakness from the previous fall (11/27/18) . Low bed, mat beside bed, consult with family re-moving (changing the bed from current position to against the wall) bed beside wall or concave mattress. E. Record review of the Progress Notes dated 01/23/18 revealed that it was documented that on 01/23/18 at 6:00 am Resident (R #11) was found on the floor by CNA's (Name of CNA's #8 and #4) during shift change. They called me (LPN #2) to the room where I assessed saw the resident laying on her back on the floor mat. I asked her how she fell and she couldn't give me an answer. We sat her in the wheelchair and I assessed her, finding no injuries . F. Record review of the Incident Report dated 01/23/18 revealed that it was documented that on 01/23/18 at 4:40 pm Resident couldn't find call light - found lying on floor . Staff will ensure call light in reach (sic), bed in low position, floor mat. G. Record review of the R #11's Care Plan dated 11/14/17 revealed the following: (Name of R #11) is at risk for falls R/T [MEDICAL CONDITION]: Educate (Name of R #11) and family about safety reminders and what to do if a fall occurs. Remind (Name of R #11) not to bend over to pick up dropped items. Encourage use of grabber or to ask for assistance. Encourage (Name of R #11) to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Ensure that (Name of R #11) is wearing appropriate footwear, fully enclosed slip resistant shoes, non-skid socks when ambulating or mobilizing in w/c (wheelchair). No interventions were found to have been updated after any of R #11's 4 falls. H. On 02/14/18 at 10:29 am, during an interview the MDS Coordinator confirmed that R #11's care plan had not been updated after any of her 4 falls. I. On 02/14/18 at 1:33 pm, during an interview CNA #5 was asked about how R #11 ambulates, she stated She (R #11) used to use the walker now the wheel chair and she is extensive 1 person assist. J. On 02/14/18 at 2:16 pm, during an interview the DON confirmed that R #11 had 2 separate falls on 01/23/18. One fall at 6:00 am and the other at 4:30 pm. K. On 02/14/18 at 3:10 pm, during an interview the DON confirmed that R #11's care plan did not have any interventions documented after any of her 4 falls. The DON also confirmed that interventions were document on the incident reports for R #11's falls on 11/27/17, and 12/02/17, but no new interventions for the 2 falls on 01/23/17 were documented. L. On 02/14/18 at 3:25 pm, during an interview with LPN #2 and Physical Therapist revealed that R #11 used to use her walker to ambulate, but since her ankle fracture she uses her wheelchair. Now it is a fear thing (of falling). R #31 M. On 02/12/18 at 2:30 pm during observation, R #31 was laying in her bed asleep. Surveyor attempted to speak with R #31 at 9:20 am, 1:35 pm, 2:30 pm. Resident observed to be sleeping during each attempt. She remained in her gown in bed, no staff observed caring for R #31 during any of these observations. N. On 02/13/18 at 8:23 am, 10:04 am, 12:29 pm, and 4:14 pm during observation of R #31 no staff members were in her room caring for her or checking on her status. R #31 observed to be in her gown and bed each time surveyor entered her room. O. On 02/13/18 at 2:35 pm during an interview with Licensed Practical Nurse (LPN) #2 she said, She (R #31) stays in her room until the afternoon usually, but sometimes all day. She refuses care, food, and activities when they're offered to her. It's her choice, she doesn't really like to be bothered. P. On 02/14/18 at 8:45 am, 11:15 am, and 12:11 pm during observation of R #31 it was revealed that she had not been changed out of her gown or gotten out of bed. Signs and symptoms of depression were evident. Q. Review of Depression Among Women, Centers for Disease Control and Prevention, dated (YEAR), https://www.cdc.gov/reproductivehealth/depression/index.htm revealed: Signs and symptoms of depression include: Loss of interest in hobbies or activities, loss of energy, difficulty falling asleep or sleeping too much, overeating or loss of appetite. R. Record review of RN #2's progress note dated 01/12/18 at 4:15 pm indicated, Resident has had signs of increased depression the last several days. She has refused to get out of bed, refuses to eat and refuses medication. When asked resident if she would like to attend activities she refused and started to become tearful. Fax sent to PCP (Primary Care Provider) to increase antidepressant S. Record review of the Minimum Data Set Coordinator (MDSC) #1's progress note dated 01/10/2018 at 12:53 pm indicated, Resident continues to be depressed, but very pleasant and cooperative. She stays in bed often for the first half of the day by choice. No changes to care plan made. T. Record review of R #31's Care Plan revealed that her depression was first entered in her Care Plan on 07/11/17. Her Care Plan states, The resident has depression E/B (evidenced by) statements of occasional depression, current condition, facility placement, wanting to go home. The resident has little activities 1-3 times a day or no activity involvement R/T (related to) impaired hearing and weakness in her bones. Immobility, Physical limitations. Care Plan interventions were implemented for depression and lack of activity on 07/11/17, but had not been reassessed or revised according to effectiveness since 07/11/17. It was also revealed that R #31's need for behavioral health services had not been addressed. U. On 02/14/18 at 1:35 pm during an interview with MDSC #1 she confirmed that interventions within R #31's Care Plan have not been reassessed and revised according to her symptoms and needs. V. On 02/14/18 at 11:40 am record review of R #31's electronic chart revealed a change of condition was completed on 02/2/18 after resident was transferred to the hospital due to vaginal bleeding. R #31 was diagnosed with [REDACTED]. R #31's hospitalization /change of condition was not reflected in the comprehensive care plan. W. On 2/14/18 at 12:08 pm during an interview with MDSC #1, she confirmed that R #31's care plan was not updated after her hospitalization /change of condition. R #3 X. Record review of the Admission Record, dated 04/27/17, for R #3, revealed: admitted [DATE] with [DIAGNOSES REDACTED]. Y. Record review of the physician orders [REDACTED]. Z. Record review of the care plan for R #3, revised on 10/12/17 revealed: Care planning for depression and no mention of antidepressant use or antidepressant cautions in the interventions. AA. On 02/14/18 at 03:02 pm, during an Interview with MDS (Minimum Data Set Coordinator #1), She (R #3) was not care planned for the [MEDICATION NAME]. She should have been care planned for that. Normally, the nurse on the floor would put it in the care plan when it was ordered. BB. On 02/14/18 at 3:10 pm, during an interview with LPN (Licensed Practical Nurse) #1, when asked how the antidepressant would get care planned after the medication was ordered, she stated, That's a good question, I would guess MDS would do it. CC. On 02/14/18 at 03:17 pm, during an interview with the DON (Director of Nurses), she stated, The antidepressant should have been care planned. R #49 DD. Record review of R #49's Face Sheet dated 05/04/07 revealed [DIAGNOSES REDACTED]. of micturition (urination)); other specified disorders of bladder; overactive bladder; and retention of urine. EE. Record review of R #49's care plan that was revised on 09/13/17 revealed: (Name of resident) has chronic UTI infection due to indwelling urinary catheter use· (Name of resident) will remain free from complications of UTI through the review date Educate (name of resident) regarding side effects and adverse reaction to antibiotics to monitor and report to the nurse.· Monitor vital signs as indicated, temperature, pain, urine color and clarity, intake and output Administer Bactrim DS (antibiotic) once a day for [MEDICATION NAME] (for preventative use) of chronic UTI. FF. Record review of R #49's physician's orders [REDACTED]. 1. 08/05/17 - Bactrim DS 800/160 mg BID (twice a day) for 10 days for UTI. 2. 01/11/17 - [MEDICATION NAME] 250 mg every day for 7 days for UTI 2. 01/25/18 - [MEDICATION NAME] 250 mg every day for 7 days for UTI-sepsis. (Sepsis occurs when chemicals released into the bloodstream to fight the infection (bacteria) trigger [MEDICAL CONDITION] responses throughout the body.) 3. 02/09/18 - [MEDICATION NAME] 100 mg BID for 7 days for UTI. GG. On 02/14/18 at 4:40 pm, during an interview, MDS Coordinator #2 and the DON confirmed that the care plan had not been undated regarding the medications. R #5 HH. Record review of R #5's Medical Chart revealed that R #5 went to the hospital on [DATE] and returned 02/07/18. II Record review of Medication Discharge Report dated 02/07/17 revealed NPO till (sic) appointment with speech therapy. JJ. Record review of R #5's orders revealed no order for NPO in the electronic medical record system (EMRS). KK. Record review of R #5's Care Plan dated 11/23/17 revealed the following: Name of R #5) has nutritional problem R/T: FTT (failure to thrive)/Protein-Calorie Malnutrition, Swallowing Problem, [MEDICAL CONDITION] E/B Mechanically altered diet/internal feedings/wt. loss, Current wt. 128.8 lbs., BMI 18.5, Decline in cognitive ability, Swallowing problem Provide [MEDICATION NAME] 1.5 5 x's a day with 180 ml water flush via peg tube (flexible feeding tube is placed through the abdominal wall and into the stomach). Weigh weekly. (Name of R #5) eats in main dining room at an assist table at meals. Monitor closely/report s/s of chewing/swallowing difficulties, coughing, choking (Regular/Level 3). Provide set up help and assistance as needed at meals. There was no documentation of R #5's NPO diet. LL. On 02/13/18 at 2:25 pm, during an interview LPN #2 was asked about R #5's diet, she stated that R #5 was NPO, so he did not eat anything just enteral feeding. When asked about his order for NPO, LPN #2 confirmed that R #5 did not have an order for [REDACTED].>MM. On 02/13/18 at 2:26 pm, during an interview the Speech Therapist stated that he had not seen R #5 after he came back from the hospital. The Speech Therapist stated that he had seen R #5 before he went to the hospital and there was anything more that speech therapy could for him. NN. On 02/13/18 at 2:33 pm, during an interview the MDS Coordinator confirmed that R #5's was not updated to reflect his NPO diet. OO. On 02/13/18 at 2:42 pm, during an interview the Nurse Manager (NM) stated that she had forgotten to put R #5's NPO order in the EMRS. NM stated that he had seen the Speech Therapist before he left to the hospital. PP. On 02/14/18 at 8:52 am, during an interview the DON confirmed that R #5 had an order for [REDACTED].#5's EMRS and been clarified if speech therapy was not going to see R #5.

Based on record review, observation, and interview, the facility failed to ensure proper catheter (is a thin tube that is inserted in the body, in this case, used for the urine bladder) care was provided to avoid Urinary Tract Infections (UTIs) for 1 (R #49) of 1 (R #49) sampled residents for catheter care. The resident has a history of UTIs for which he has received multiple different antibiotics for and needs assistance from the staff to provide catheter care. While providing catheter care, the CNA wiped the catheter towards the resident and she further failed to perform proper hand hygiene. This failed practice led to the resident having multiple UTIs which can further lead [MEDICAL CONDITION]. (Sepsis occurs when chemicals released into the bloodstream to fight the infection (bacteria) trigger [MEDICAL CONDITION] responses throughout the body.) The findings are: A. Record review of R #49's Face Sheet dated 05/04/07 revealed [DIAGNOSES REDACTED]. of micturition (urination)); other specified disorders of bladder; overactive bladder; and retention of urine. B. Record review of R #49's physician's orders [REDACTED]. 1. 08/05/17 - Bactrim DS 800/160 mg BID (twice a day) for 10 days for UTI. 2. 01/11/18 - [MEDICATION NAME] 250 mg every day for 7 days for UTI. 3. 01/25/18 - [MEDICATION NAME] 250 mg every day for 7 days for UTI-sepsis. (Sepsis occurs when chemicals released into the bloodstream to fight the infection (bacteria) trigger [MEDICAL CONDITION] responses throughout the body.) 4. 02/09/18 - [MEDICATION NAME] 100 mg BID for 7 days for UTI. C. Record review of the Care Plan reviewed on 10/17/17 revealed: (Name of resident) has a suprapubic Catheter (urinary catheter which has been placed through the skin and directly in to the bladder) R/T (related to) [MEDICAL CONDITION] bladder, [MEDICAL CONDITION] (enlarged prostate) E/B (as evidenced by) inability to empty bladder without catheter. *(Name of resident) will show no s/s (signs or symptoms) of urinary infection through review date. **(Name of resident) has suprapubic catheter (urinary catheter which has been placed through the skin and directly in to the bladder) which is required to be emptied after each meal and PRN (as needed). Catheter bag is to be emptied at or before every 6 hours. He has a suprapubic catheter, 24 french (measurement to size a catheter), 20 cc balloon . D. On 02/15/18 at 12:00 pm, during observation of CNA #3 performing catheter care on R #49, CNA #3 washed her hands, filled a basin with water and disposable towels from R #49's restroom and carried it to the bedside tray table. CNA #3 put on gloves, touched R #49's bed, bed controller, blankets, and opened the side of R #49's disposable briefs. CNA #3 did not change her gloves and perform hand hygiene before she touched R #49 and cleaned R #49's catheter tubing and insertion site. Further, CNA #3 wiped the catheter tubing upward and toward the insertion site rather than downward and away from insertion site. E. On 02/15/18 at 12:09 pm, while observing and during an interview, CNA #3 was asked, When performing catheter care, do you think you should clean the catheter tubing away from the insertion site or toward the insertion site? CNA #3 shrugged her shoulders and said, I don't know, away? F. On 02/15/18 at 12:14 pm, during an interview after the observation, CNA #3 confirmed that she did not change her gloves and perform hand hygiene before touching the resident or his catheter tubing and insertion site. When asked, CNA #3 confirmed she usually provides care to R #49 and this was how she usually did the catheter care. G. On 02/15/18 at 12:22 pm, during an interview, the DON confirmed that the CNA should have changed changed her gloves and performed hand hygiene before touching the resident and his catheter. She also confirmed that catheter tubing should be wiped away from catheter insertion site. H. Record review of the facility's Hand Hygiene and Handwashing Clinical Skills Checklist dated (MONTH) (YEAR) revealed, 2. If hands are not visibly soiled or contaminated with blood or body fluids, use an alcohol-based hand rub for routinely cleaning hands: a. Before having contact with residents, patients, and children b. After having direct contact with another person's skin. c. After having contact with body fluids, wounds or broken skin. d. After touching equipment or furniture near the resident/patient. e. After removing gloves. I. Record review of the facility's Catheter Care Procedure, revised on (MONTH) (YEAR), revealed, Procedure: 3 . Then cleanse for four inches down the catheter (moving away from the person).

Based on interview and record review, the facility failed to keep residents free from accidents for 1 (R #11) of 1 (R #11) residents sampled for accidents, when 1) R #11 fell on [DATE] and fractured her left fibula, 2) R #11 fell three times after her fracture. This deficient practice caused R #11 to ambulate with a wheelchair after she fractured her fibula, where before she was using a walker to ambulate. The findings are: A. Record review of the Incident Report dated 11/27/17 revealed that it was documented that on 11/27/17 at 10:00 pm, Resident was found on floor between her bed & the wall to the restroom. Resident stated that she fell on the way from the restroom . Ensure that staff are aware to leave bed in low position, mat beside bed. Remind resident to call for assistance. B. Record review of the Clinic Referral dated 11/30/17 revealed a request for x-ray due to R #11's left leg pain. Related to fall on 11/28/17 (11/27/17) pain of left leg not able to bear weight on leg. C. Record review of the Final Diagnostic Incident Report dated 12/05/17 revealed the following Three views of the left ankle reveal [MEDICAL CONDITION] fibula. D. Record review of the Incident Report dated 12/02/17 revealed that it was documented that on 12/02/17 at 7:00 am, Resident fell r/t (related to) not waiting for help to transfer weakness from the previous fall (11/27/18) . Low bed, mat beside bed, consult with family re-moving (changing the bed from current position to against the wall) bed beside wall or concave mattress. E. Record review of the Progress Notes dated 01/23/18 revealed that it was documented that on 01/23/18 at 6:00 am Resident (R #11) was found on the floor by CNA's (Name of CNA's #8 and #4) during shift change. They called me (LPN #2) to the room where I assessed saw the resident laying on her back on the floor mat. I asked her how she fell and she couldn't give me an answer. We sat her in the wheelchair and I assessed her, finding no injuries . F. Record review of the Incident Report dated 01/23/18 revealed that it was documented that on 01/23/18 at 4:40 pm Resident couldn't find call light - found lying on floor . Staff will ensure call light in reach (sic), bed in low position, floor mat. G. Record review of the R #11's Care Plan dated 11/14/17 revealed the following: (Name of R #11) is at risk for falls R/T [MEDICAL CONDITION]: Educate (Name of R #11) and family about safety reminders and what to do if a fall occurs. Remind (Name of R #11) not to bend over to pick up dropped items. Encourage use of grabber or to ask for assistance. Encourage (Name of R #11) to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Ensure that (Name of R #11) is wearing appropriate footwear, fully enclosed slip resistant shoes, non-skid socks when ambulating or mobilizing in w/c (wheelchair). No interventions were found to have been updated after any of R #11's 4 falls. H. On 02/14/18 at 10:29 am, during an interview the MDS Coordinator confirmed that R #11's care plan had not been updated after any of her 4 falls. I. On 02/14/18 at 1:33 pm, during an interview CNA #5 was asked about how R #11 ambulates, she stated She (R #11) used to use the walker now the wheel chair and she is extensive 1 person assist. J. On 02/14/18 at 2:16 pm, during an interview the DON confirmed that R #11 had 2 separate falls on 01/23/18. One fall at 6:00 am and the other at 4:30 pm. K. On 02/14/18 at 3:10 pm, during an interview the DON confirmed that R #11's care plan did not have any interventions documented after any of her 4 falls. The DON also confirmed that interventions were document on the incident reports for R #11's falls on 11/27/17, and 12/02/17, but no new interventions for the 2 falls on 01/23/17 were documented. L. On 02/14/18 at 3:25 pm, during an interview with LPN #2 and Physical Therapist revealed that R #11 used to use her walker to ambulate, but since her ankle fracture she uses her wheelchair. Now it is a fear thing (of falling).

Based on observation, interview, and record review, the facility failed to ensure proper infection control practices were followed when 1) performing catheter care for 1 (R #49) of 1 (R #49) resident sampled for catheter care and 2) there was lack of hand hygiene during dining observation for 2 (R #20 and R #29) of 2 (R #20 and R #29) residents randomly sampled for dining. This deficient practice contributed to multiple urinary tract infections for a R #49. This same deficient practice could lead to other residents with indwelling catheters getting infections. The findings are: R #49 A. On 02/15/18 at 12:00 pm during observation of Certified Nursing Assistant (CNA) #3 performing catheter care on R #49, CNA #3 washed her hands, filled a basin with water and disposable towels from R #49's restroom and carried it to the bedside tray table. CNA #3 put on gloves, touched R #49's bed, bed controller, blankets, and opened the side of R #49's disposable briefs. CNA #3 did not change her gloves and perform hand hygiene before she touched R #49 and cleaned R #49's catheter tubing and insertion site. CNA #3 wiped the catheter tubing upward and toward the insertion site rather than downward and away from insertion site. B. On 02/15/18 at 12:14 pm during an interview with CNA #3, she confirmed that she did not change her gloves and perform hand hygiene before touching the resident or his catheter tubing and insertion site. C. On 02/15/18 at 12:09 pm, while observing and during an interview, CNA #3 was asked, Is this how you would normally perform catheter care? CNA #3 replied, Yes, I always do it that way. CNA #3 was then asked, When performing catheter care, do you think you should clean the catheter tubing away from the insertion site or toward the insertion site? CNA #3 shrugged her shoulders and said, I don't know, away? D. On 02/15/18 at 12:22 pm, during an interview, the DON confirmed that CNA #3 should have changed her gloves and performed hand hygiene before touching the resident and his catheter. She also confirmed that catheter tubing should be wiped away from catheter insertion site. E. Record review of R #49's Face Sheet dated 05/04/07 revealed [DIAGNOSES REDACTED]. of micturition (urination)); other specified disorders of bladder; overactive bladder; and retention of urine. F. Record review of R #49's physician's orders [REDACTED]. 1. 08/05/17 - Bactrim DS 800/160 mg BID (twice a day) for 10 days for UTI. 2. 01/11/18 - [MEDICATION NAME] 250 mg every day for 7 days for UTI. 3. 01/25/18 - [MEDICATION NAME] 250 mg every day for 7 days for UTI-sepsis. (Sepsis occurs when chemicals released into the bloodstream to fight the infection (bacteria) trigger [MEDICAL CONDITION] responses throughout the body.) 4. 02/09/18 - [MEDICATION NAME] 100 mg BID for 7 days for UTI. G. Record review of the Care Plan reviewed on 10/17/17 revealed: (Name of resident) has a suprapubic Catheter (urinary catheter which has been placed through the skin and directly in to the bladder) R/T (related to) [MEDICAL CONDITION] bladder, [MEDICAL CONDITION] (enlarged prostate) E/B (as evidenced by) inability to empty bladder without catheter. *(Name of resident) will show no s/s (signs or symptoms) of urinary infection through review date. **(Name of resident) has suprapubic catheter (urinary catheter which has been placed through the skin and directly in to the bladder) which is required to be emptied after each meal and PRN (as needed). Catheter bag is to be emptied at or before every 6 hours. He has a suprapubic catheter, 24 french (measurement to size a catheter), 20 cc balloon . R #20 and R #29 H. On 02/12/18 at 11:33 am, during dining observation, CNA (Certified Nursing Assistant) #7, was sitting between R #20 and R #29 in the dining room. CNA # 7 was feeding Resident # 29 coaching her and feeding her holding R #29's jaw with one hand to stabilize the jaw and feeding her with the other hand. CNA #7 periodically turned to R # 20, moving her a slumped position, applying her napkin, cutting her food and sometimes feeding her. CNA #7 was touching and patting R #20 in reassuring manner. No hand hygiene was observed by CNA #7 between caring for both residents. At 11:37 am, CNA #7 went to the drink cart and poured a drink, handling the pitcher handle, CNA #7 returned to the table and gave R #20 a drink, then continued to feed R # 29. No hand hygiene was performed. I. On 02/16/18 at 11:00 am, during an interview, the DON affirmed the staff should be doing hand hygiene between residents, including between helping residents in the dining room. J. Review of the facility's Hand Hygiene and Handwashing Clinical Skills Checklist dated (MONTH) (YEAR) revealed, 2. If hands are not visibly soiled or contaminated with blood or body fluids, use an alcohol-based hand rub for routinely cleaning hands: a. Before having contact with residents, patients, and children b. After having direct contact with another person's skin. c. After having contact with body fluids, wounds or broken skin. d. After touching equipment or furniture near the resident/patient. e. After removing gloves.

Based on record review, observation, and interview, the facility failed to ensure a CNA (Certified Nursing Assistant) had demonstrated current competencies and skills to meet resident needs for catheter (is a thin tube that is inserted in the body, in this case, used for the urine bladder) care for 1 (CNA #3) of 1 (CNA #3) observed for catheter care. This deficient practice resulted in a CNA's performing incorrect catheter care increasing the risk of urinary tract infection that can result in debility, illness, and death. The findings are: A. Record review of R #49's Face Sheet dated 05/04/07 revealed [DIAGNOSES REDACTED]. of micturition (urination)); other specified disorders of bladder; overactive bladder; and retention of urine. B. Record review of R #49's physician's orders [REDACTED]. 1. 08/05/17 - Bactrim DS 800/160 mg BID (twice a day) for 10 days for UTI. 2. 01/11/18 - [MEDICATION NAME] 250 mg every day for 7 days for UTI. 3. 01/25/18 - [MEDICATION NAME] 250 mg every day for 7 days for UTI-sepsis. (Sepsis occurs when chemicals released into the bloodstream to fight the infection (bacteria) trigger [MEDICAL CONDITION] responses throughout the body.) 4. 02/09/18 - [MEDICATION NAME] 100 mg BID for 7 days for UTI. C. Care plan for R #49, revised on 10/17/17, revealed; Focus: (Name of R #49) has a suprapubic catheter (a tube used to drain the bladder that has been surgically inserted through the abdomen) Goal: Will show no signs or symptoms of urinary infection through review date. Revised on 02/15/17 Interventions: Clean suprapubic exit site (area in abdomen through which the catheter was inserted) every shift and protect skin with drain sponge. Clean drainage tube with alcohol swab. D. On 02/15/18 at 12:00 pm, during observation of CNA #3 performing catheter care on R #49, CNA #3 washed her hands, filled a basin with water and disposable towels from R #49's restroom and carried it to the bedside tray table. CNA #3 put on gloves, touched R #49's bed, bed controller, blankets, and opened the side of R #49's disposable briefs. CNA #3 did not change her gloves and perform hand hygiene before she touched R #49 and cleaned his catheter tubing and insertion site. CNA #3 wiped the catheter tubing upward and toward the insertion site rather than downward and away from insertion site. E. On 02/15/18 at 12:09 pm, while observing and interview, CNA #3 was asked, Is this how you would normally perform catheter care? CNA #3 said, Yes I always do it that way. When she was asked, When performing catheter care, do you think you should clean the catheter tubing away from the insertion site or toward the insertion site? CNA #3 shrugged her shoulders and said, I don't know, away? F. On 02/15/18 at 12:14 pm, during an interview, CNA #3 confirmed that she did not change her gloves and perform hand hygiene before touching the resident or his catheter tubing and insertion site. G. On 02/15/18 at 12:22 pm, during an interview, the DON confirmed that CNA #3 should have changed her gloves and performed hand hygiene before touching the resident and his catheter. She also confirmed that catheter tubing should be wiped away from catheter insertion site. H. On 02/16/18 at 11:30 am, during an interview, the DON stated, We just do competencies on orientation, when the employee starts. I. Record review of the Competency Verification Checklist for CNA #3 was dated 10-28-15 revealed: 3. Provides pericare and catheter care, handling & placing tubing appropriately to minimize infection. The rating code is 4 and is described in the legend as skilled and able to work independently. There is no signature of supervisor/trainer nor date reviewed by supervisor or trainer.

Based on record review and staff interview, the facility failed to monitor the blood level of [MEDICATION NAME] (an anticoagulant used to treat or prevent blood clots) for 1 (R #64) of 4 (R #53, R #64, R #85, and R #116) residents reviewed for [MEDICATION NAME] treatment. R #64 had an order for [REDACTED]. The findings are: A. Record review of R #64's Medication Administration Record [REDACTED]. B. Record review of the physician's orders [REDACTED]. Record review of the R #64's clinical record revealed no results for this test was found. C. Record review of the resident's Progress Notes revealed the following: 1. 01/04/17 at 4:19 pm and 4:24 pm revealed R #64 was bleeding from his nose and the doctor ordered that he be sent to the hospital. 2. 01/04/17 at 11:24 pm revealed R #64 had Critical INR greater than 10. The doctor was called and gave the order for him to return to the ER. (Target range for [MEDICATION NAME] treatment is 2.0 to 3.0.) 3. 01/05/17 at 9:06 am revealed the doctor gave an order to hold the [MEDICATION NAME] for 3 days. 4. 01/05/17 at 10:11 am and 10:48 am revealed R #64 continued to have a bloody nose even after several attempts to stop the bleeding and also has blood coming from his left eye. The doctor was notified and gave the order to send him back to the ER. 5. 01/05/17 at 4:40 pm, notes written by the former DON, revealed R #64, Went to the ER for a nosebleed and was returned to the Center (the facility) without lab draws or treatment other than pressure to stop the bleeding. After returning to the center, a PT/INR was drawn at (the facility). Results were called to the physician and the resident was taken to the ER for treatment of [REDACTED]. D. On 03/08/17 at 10:45 am, during an interview, LPN #1 stated that when she got R #64 up after lunch on 01/04/17, there was some blood on his pillow case, but he was not actively bleeding. At about 4:00 pm, his nose started bleeding and it would not stop. She noted the lab order dated 12/20/16 but could not find the results. She called the doctor and the doctor would not order another lab, but ordered R #64 to be sent to the ER. When R #64 had returned from the ER without the PT/INR being done, she called the doctor again and obtained the order for another PT/INR. She stated that the on-coming nurse drew the blood and she took it to the hospital lab to be processed. E. On 03/08/17 at 11:15 am, during an interview, the DON stated that when R #64 was at the hospital for the second time on 01/04/17 and then again on 01/05/17, he received Vitamin K treatments (a vitamin to help with the clotting of blood) each time that he went. G. Record review of R #64's Progress Notes dated 01/19/17 revealed the following: 1. 11:55 am revealed that he was found unresponsive sitting in his wheel chair with labored breathing. 2. 12:42 pm revealed R #64 had passed away before the Emergency Medical Services had arrived. H. On 03/08/17, the Administrator and DON provided the correction the facility made because of the incident with R #64. The following is a summary of what was completed: 1. An Anticoagulant Procedure was created that makes the nurse responsible for documenting the order and drawing the blood work. 2. This is also put into a [MEDICATION NAME] log and the results are also documented in the same log. 3. The nurses were in-serviced on the procedure. 4. A Root-Cause Analysis (RCA) was completed for the incident and a Performance Improvement Plan was implemented based on the RCA by the facility Quality Assessment/ Performance Improvement committee.

Based on record review and staff interview, the facility failed to obtain labs services as ordered by a physician for 1 (R #64) of 4 (R #53, R #64, R #85, and R #116) residents reviewed for [MEDICATION NAME] treatment. R #64 had and order for blood monitoring dated [DATE] that was not followed, and on [DATE] he had bloody nose and was sent to the ER. This deficient practice could have led to his death on [DATE]. The findings are: A. Record review of the physician's orders [REDACTED]. Record review of the R #64's clinical record revealed no results for this test was found. B. Record review of the resident's Progress Notes revealed the following: 1. [DATE] at 4:19 pm and 4:24 pm revealed R #64 was bleeding from his nose and the doctor ordered that he be sent to the hospital. 2. [DATE] at 11:24 pm revealed R #64 had Critical INR greater than 10. The doctor was called and gave the order for him to return to the ER. (Target range for [MEDICATION NAME] treatment is 2.0 to 3.0.) 3. [DATE] at 9:06 am revealed the doctor gave an order to hold the [MEDICATION NAME] for 3 days. 4. [DATE] at 10:11 am and 10:48 am revealed R #64 continued to have a bloody nose even after several attempts to stop and also has bleeding coming from his left eye and the doctor was notified and gave the order to send him back to the ER. 5. [DATE] at 4:40 pm, note written by the former DON revealed R #64, Went to the ER for a nosebleed and was returned to the Center (the facility) without lab draws or treatment other than pressure to stop the bleeding. After returning to the center, a PT/INR was drawn at (the facility). Results were called to the physician and the resident was taken to the ER for treatment of [REDACTED]. C. Record review of the physician's orders [REDACTED]. D. On [DATE] at 10:45 am, during an interview, LPN #1 stated that when she got R #64 up after lunch on [DATE], there was some blood on his pillow case, but he was not actively bleeding. At about 4:00 pm, his nose started bleeding and it would not stop. She noted the lab order dated [DATE], but could not find the results. She called the doctor and the doctor would not order another lab, but ordered R #64 to be sent to the ER. When R #64 had returned from the ER without the PT/INR being done, she called the doctor again and obtained the order for another PT/INR. When asked if she documented the order obtained that day, LPN #1 stated she forgot to document the new order. E. On [DATE], the Administrator and DON provided the correction the facility made because of the incident with R #64. The following is a summary of what was completed: 1. An Anticoagulant Procedure was created that makes the nurse responsible for documenting the order and drawing the blood work. 2. This is also put into a [MEDICATION NAME] log and the results are also documented in the same log. 3. The nurses were in-serviced on the procedure. 4. A Root-Cause Analysis (RCA) was completed for the incident and a Performance Improvement Plan was implemented based on the RCA by the facility Quality Assessment/ Performance Improvement committee.

Based on observation, interview and record review, the facility failed to promote healing for residents having pressure ulcers for 1 (R #3) of 4 (R #1, R #2, R #3, and R #4) residents sampled for pressure ulcers. The facility failed to properly reposition R #3 every 2 hours after returning from the hospital with [MEDICAL CONDITION] and a hamstring tear. This changed R#2's condition, limiting her time out of bed. This deficient practice likely resulted R #3's pressure ulcer worsening. The findings are: A. Record review of the Wound Data Collection dated 03/16/16, revealed R #3 had a pressure ulcer to coccyx (tailbone). The identification comments stated healed. B. Record review of the Wound Data Collection dated 03/22/16, revealed pressure ulcer on coccyx with no measurements for length, width, and depth. Also there were no identification comments. C. Record review of the Wound Data Collection dated 03/23/16, revealed R #3 had a pressure ulcer on the coccyx with no measurements for length, width, and depth. The Identification comments revealed wound closed. D. Record review of the Wound Data Collection dated 03/29/16, revealed R #3 had a pressure ulcer to the coccyx length 12 cm (centimeters), width 12 cm, depth 0.1 cm. The identification comments revealed 4.5 X (by) 3 cm coccyx pressure wound . E. Record review of Wound RN assessment dated [DATE] revealed R #3 had a pressure ulcer stage 2 (The topmost layer of skin (epidermis) is broken, creating a shallow open sore). F. Record review of R #3's Care Plan dated 03/04/16 revealed The resident has stage II coccyx pressure ulcer . Assist to turn/reposition at least every 2 hours G. Record review of the Documentation Survey Report Type Turning & Repositioning for March 2016 revealed the following: 1. Assist to turn and/reposition at least every 2 hours: 03/05/16 it was documented that the 6:00 am and the 8:00 am repositioning were both done at 8:18 am. The 11:00 am repositioning was done at 12:07 pm. The 8:00 pm and 10:00 pm repositioning were done at 1:11 am. 2. On 03/06/16 it was documented that the 2:00 am and 4:00 am repositioning were done at 4:37 am and 4:38 am. The 6:00 am, 8:00 am, 10:00 am, 12:00 pm, 2:00 pm, and the 4:00 pm repositioning was done at 4:07 pm, 4:08 pm, 4:09 pm, 4:10 pm and 4:11 pm. The 6:00 pm was blank. The 8:00 pm and 10:00 pm repositioning were done at 1:08 am. 3. On 03/07/16 it was document that the 12:00 am and 2:00 am repositioning was done at 3:34 am and 3:35 am. The 4:00 am repositioning was done at 5:20 am. The 6:00 am, 8:00 am, and 10:00 am repositioning were done at 11:50 am, 11:51 am, and 11:51 am. The 8:00 pm repositioning was done at 10:17 pm. 4. On 03/08/16 it was documented that the 12:00 am repositioning was done at 2:15 am. The 4:00 am repositioning was done at 3:05 am. The 6:00 am repositioning was done at 8:28 am. The 12:00 pm repositioning was done at 2:42 pm. The 4:00 pm repositioning was done at 3:09 pm. The 6:00 pm repositioning done at 8:14 pm. The 8:00 pm and 10:00 pm repositioning was blank. 5. On 03/09/16 it was documented that the 12:00 am repositioning was done at 1:07 am. The 2:00 am and the 4:00 am repositioning were done at 5:25 am. The 6:00 am and the 8:00 am repositioning were done at 7:45 am and 7:46 am. The 2:00 pm repositioning was done at 4:46 pm. The 6:00 pm repositioning was blank. The 8:00 pm and 10:00 pm was done at 1:07 am. 6. On 03/10/16 it was documented that the 12:00 am repositioning was done at 2:14 am. The 4:00 am repositioning was done at 5:27 am. The 6:00 am, 8:00 am, and 10:00 am repositioning was done at 9:36 am. The 12:00 pm and 2:00 pm repositioning was done at 1:43 pm and 1:44 pm. The 4:00 pm repositioning was done at 5:07 pm. 7. On 03/11/16 it was documented that the 12:00 am repositioning was blank. The 6:00 am repositioning was done at 8:57 am. The 10:00 am repositioning was done at 9:00 am. The 12:00 pm and the 2:00 pm repositioning was done at 1:02 pm and 1:04 pm. The 6:00 pm repositioning was done at 7:28 pm. The 8:00 pm repositioning was done at 10:14 pm. 8. On 03/12/16 it was documented that the 2:00 am repositioning was done at 4:10 am. The 6:00 am repositioning was done at 8:33 am. The 10:00 am repositioning was done at 9:24 am. The 2:00 pm and the 4:00 pm repositioning was done at 3:11 pm and 3:12 pm. 9. On 03/13/16 it was documented that the 12:00 am was blank. The 6:00 am and the 8:00 am repositioning was done at 9:21 am. The 6:00 pm and the 8:00 pm repositioning was done at 7:42 pm. 10. On 03/14/16 it was documented that the 12:00 pm was done at 1:36 am. The 2:00 am repositioning was done at 3:37 am. The 6:00 am and 8:00 am repositioning was done at 3:39 pm. The 10:00 am, the 12:00 pm, 2:00 pm and the 4:00 pm repositioning were blank. The 10:00 pm repositioning was done at 11:35 pm. 11. On 03/15/16 it was documented that the 12:00 am, 2:00 am, and the 4:00 am repositioning was done at 5:05 am. The 6:00 am and 8:00 am repositioning was done at 10:51 am. The 12:00 pm repositioning was done at 2:54 pm. The 6:00 pm repositioning was done at 7:58 pm. The 8:00 pm repositioning was done at 10:36 pm. 12. On 03/16/16 it was documented that the 12:00 am, 2:00 am, and 4:00 am repositioning was done at 5:04 am. The 6:00 am repositioning was done at 8:53 am. The 6:00 pm, 8:00 pm, and 10:00 pm repositioning were blank. 13. On 03/17/16 it was documented that the 2:00 am repositioning was done at 3:06 am. The 4:00 am repositioning was blank. The 6:00 am and 8:00 am repositioning was done at 9:02 am and 9:03 am. The 10:00 am repositioning was done at 12:35 pm. The 2:00 pm repositioning was done at 3:04 pm. The 6:00 pm, 8:00 pm, and 10:00 pm repositioning were blank. 14. On 03/18/16 it was documented that the 12:00 am and 2:00 am repositioning was done at 4:40 am. The 6:00 am, 8:00 am, 10:00 am, and 12:00 pm repositioning was done at 2:40 pm and 2:41 pm. The 6:00 pm, 8:00 pm, 10:00 pm repositioning was done at 4:40 am. 15. On 03/19/16 it was documented that the 2:00 am, and 4:00 am repositioning was done at 5:17 am. The 6:00 am and 8:00 am repositioning was done at 10:15 am. The 6:00 pm and 8:00 pm repositioning was done at 9:17 pm. The 10:00 pm repositioning was done at 12:52 am. 16. On 03/20/16 it was documented that the 12:00 am repositioning was done at 2:15 am. The 6:00 am repositioning was done at 8:53 am. The 6:00 pm and 8:00 pm repositioning was done at 7:34 pm and 7:35 pm. 17. On 03/21/16 it was documented that the 2:00 am and 4:00 am repositioning was done at 3:20 am. The 6:00 pm, 8:00 pm, and 10:00 pm repositioning were blank. 18. On 03/22/16 it was documented that the 12:00 am, 2:00 am, and 4:00 am repositioning was done at 3:40 am. The 6:00 am, 8:00 am, and 10:00 am repositioning was done at 9:18 am. 19. On 03/23/16 it was documented that the 12:00 am repositioning was blank. The 6:00 am, 8:00 am, and 10:00 pm repositioning was done at 9:29 am and 9:30 am. The 12:00 pm repositioning was done at 1:57 pm. The 6:00 pm and 8:00 pm repositioning was done at 10:12 pm. 20. On 03/24/16 it was documented that the 12:00 am, 2:00 am, and 4:00 am repositioning was done at 5:40 am. The 6:00 am repositioning was done at 8:50 am. The 12:00 pm, 2:00 pm, and 4:00 pm repositioning was done at 5:49 pm and 5:50 pm. The 6:00 pm repositioning was done at 7:38 pm. 21. On 03/25/16 it was documented that the 12:00 am, 2:00 am, and 4:00 am repositioning was done at 5:02 am. The 6:00 pm and 8:00 pm repositioning was done at 10:02 am. The 12:00 pm, and the 2:00 pm repositioning was done at 1:39 pm. The 6:00 pm repositioning was done at 8:07 pm. 22. On 03/26/16 it was documented that the 12:00 am and 2:00 am repositioning was done at 4:09 am. The 6:00 am repositioning was done at 8:40 am. The 12:00 pm and 2:00 pm repositioning was done at 4:56 pm. The 10:00 pm repositioning was blank. 23. On 03/27/16 it was documented that the 12:00 am repositioning was done at 2:20 am. The 4:00 am repositioning was blank. The 6:00 am and 8:00 am repositioning was done at 10:28 am. The 2:00 pm and 4:00 pm repositioning was done at 5:50 pm. The 6:00 pm repositioning was done at 8:35 pm. 24. On 03/28/16 it was documented that the 12:00 am repositioning was done at 1:30 am. The 2:00 am and 4:00 am repositioning were blank. The 6:00 am and 8:00 am repositioning was done at 9:44 am. The 12:00 pm, 2:00 pm, and 4:00 pm repositioning was done at 3:13 pm and 3:14 pm. 25. On 03/29/16 it was documented that the 6:00 am and 8:00 am repositioning was done at 7:41 am. The 10:00 am repositioning was done at 12:55 pm. The 6:00 pm and 8:00 pm repositioning was done at 7:50 pm. The 10:00 pm repositioning was blank. 26. On 03/30/16 it was documented that the 6:00 am and 8:00 am repositioning was done at 10:09 am. H. Record review of the Progress Note dated 03/23/16 by RN #5 revealed Resident admitted with stage 2 (pressure ulcer), the wound has [MEDICATION NAME] (to form a covering of [MEDICATION NAME] (skin) cells over, as a wound). At this time, resident will probably (sic) less mobile due to recent increase of pain. Wound not resolved at this time. I. Record review of the Progress Note dated 03/23/16 by LPN #3 revealed Resident stayed in bed this morning. She is very sleepy and out of it from pain medication (R #3 had returned from hospital with [MEDICAL CONDITION] hamstring tear) . J. Record review of the Progress Note dated 03/29/16 by RN #4 She (R #3) has a now stage II pressure ulcer on her coccyx in the shape of a butterfly, about 6 x 6 inches with the first layer of skin off . L. On 03/28/16 at 10:28 am, during an interview RN #3 stated R #3 came to the facility with a pressure ulcer, she had been doing well. Then she went to the hospital and her condition had changed. Now, R #3 stays in bed more, and the pressure ulcer got worse. It was almost healed. M. On 03/29/16 at 12:55 pm, during an interview the Unit Manager (UM) was asked why R #3's pressure ulcer had gotten worse. UM stated I do not think we were turning her like we should have.

Based on record review, interview and observation, the facility failed to ensure adequate supervision to prevent accidents for 2 ( #1 and 2) of 4 (#1, 2, 3 and 4) residents. Resident #1 took a drink of a laxative concoction and spit the drink out onto her chest. She received a reddened area measuring 8 X (by)10 centimeters (cm) that blistered. The Certified Occupational Therapy Assistant (COTA) gave the resident a cup containing a hot liquid and did not check the temperature. Resident #2 spilled coffee onto her upper thigh. The reddened area measured 1.0 cm X 12.0 cm and another area next to that measured approximately 1.0 cm x 4.0 cm. The activity staff did not assist the resident to sit upright in her chair . This failed practice likely caused the residents to be burned by the hot beverages. The findings are: Resident #1 A. Review of a facility Incident Report dated 02/06/13 revealed resident #1 received a burn from hot liquid. In the section D. Contributing Factors: Comments: "COTA gave resident heated cocktail (prune juice, applesauce & (and) butter) that CNA (Certified Nursing Assistant #3) had prepared. Resident took a drink then spit out drink onto chest, stating 'too hot'. Res. (resident) now has reddened area to chest & (sic) lip. Section F . Type of alleged Injury burns is marked " Chest 8 cm (centimeter) X (by) 10 cm. Lower lip - skin just under lip." B. Review of a hand written statement given by the COTA dated 02/06/13 revealed "I (name) COTA handed patient a cocktail that the CNA made for patient. I let patient know that it was just out of the microwave and warm and to be careful. Patient chugged 'cocktail' spit it out on to chest and stated 'it was hot.' Assistant (sic) helped patient to wipe 'cocktail' off chest with a washcloth ..." C. Review of a Health Facilities Licensing and Certification (HFL&C) Incident Report dated 02/07/13 revealed the resident drank warm liquid and spit it out sustaining a reddened area on her chest. D. Review of the Admission Record dated 02/28/13 for resident #1 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. E. Review of the Care Plan dated 12/31/12 for resident #1 revealed under Focus: Resident has an ADL (Activity of Daily Living) self care performance deficit related to immobility, stroke with right sided paralysis of her dominant side, incontinence, obesity, lack of desire or motivation evidenced by requires extensive assist with ADL's. Description: resident requires set up with limited assist. F. Review of the 30-day scheduled assessment Minimum Data Set ((MDS) dated [DATE] revealed in Section G Functional Status H. that the resident requires supervision and set up for eating. Section G Functional status also indicates the resident has impairment on one side of her body to include the shoulder, elbow, wrist and hand. G. On 02/27/13 at 4:54 pm, during an interview with RN #12, she stated "I have documentation to reflect I saw it on 02/06/13. I measured it as 4 X 6 cm below the notch on the upper chest. Center skin was loosening. Slight blistery looking on left side of the area looked like skin loosening ..." H. On 02/27/13 at 5:45 pm, during an interview with RN #14, he stated "...Someone told me about the burn and I went to the room and looked at it. It looked like a red crescent paisley (droplet shaped) mark. It was not raised at that point in time, it was moderately red. Stage 1 burn ...As I treated it over time there were several raised areas turned from red to reddish brown, blistering on inside of wound ..." I. On 02/28/13 at 9:15 am, during an interview with the COTA, she stated, "The CNA made her prune juice, applesauce and butter. I was asked to give it to her. I took it into the room and said "Here's the cocktail" (sic) and explained it was warm. I told her it was just warm, just out of (sic) microwave. She chugged the drink. A 8 ounce glass, ? full. She put her head back and drank the juice, put her head forward and spit it on her chest ... It was just a red mark off center of chest on the right side. (Name of CNA) put the drink in the microwave and started the microwave. The temp. (temperature) of the cup was lukewarm to my hands ...I was not aware of a policy on drink temps before the incident. It says don't serve anything over 105 degrees. I don't know what 105 degrees feel (sic) like ..." J. On 02/28/13 at 11:31 am, during an interview with RN #25, she stated "I saw the burn right after it happened within 12 hours. It was 2 X 6 cm, on upper chest, bright red and a couple of areas appeared they may blister. First degree ...Prune juice, applesauce and butter. The brown bomb." K. On 02/28/13 at 11:35 am, during an interview with RN #24, she stated "It got too hot in the micro (microwave) and they took it to her before it cooled." L. On 02/28/13 at 2:00 pm, during an interview with CNA #23, she stated "The day she got the burn she wanted one of those cocktails. I asked (name of COTA) if she would take it to her ...I usually put it in for 30 seconds and again until the butter melts. I don't know if (name of COTA) warmed it. 30 seconds is not long enough to melt butter. Usually takes about 1 minute. I put it in a 12 ounce cup. I usually fill to the 8 ounce mark ...I saw the burn, looked like red with a blister in the center of upper chest." M. On 03/01/13 at 8:25 am, during an interview with resident #1, she stated "The girl neglected to tell me it was hot. They just took it out of the microwave and it was too hot. It was scalding. It had just come out of the microwave. (Name of COTA) brought the drink. Someone here suggested I drink it, don't remember who. I had not heard of the drink before. I took a big gulp and it got on my chest. I spilled it on me. Burned my chest and a little on my chin but mostly on my chest. It blistered up and everything." Resident #2 N. Review of the Admission Record 02/28/13 for resident #2 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. O. Review of a facility Incident Report dated 02/06/13 revealed the resident spilled coffee on her leg while in the activity room. In Section D. Comments: "While in activities, spilled coffee down her R (right) leg. Reddened area approximately 1.0 cm X 12.0 cm and another area next to that area approx. (approximately) 1.0 cm x 4.0 cm..." The Incident Report continues with General Information under "6. Summerize factors that may have contributed to the incident." There is a hand written entry under the statement, "Resident slouches back in wheelchair constantly..." P. Review of the Interdisciplinary Progress Notes did not reveal an entry for 02/06/13. Q. Review of a FAX Communication to Physician dated 02/06/13 revealed "While in activities, spilled coffee down her R (right) leg. Red area approximately 1.0 cm X 12.0 cm and another area right next to it measuring approximately 1.0 X 4.0 cm ..." R. Review of the Quarterly MDS dated [DATE] revealed in Section G. Functional Status H. Eating the resident requires supervision. S. On 03/05/13 at 10:15 am, during an interview with Activity Volunteer #29, she stated "I remember the incident happened in the dining room. I took her to the nurses station. A CNA told me she burned herself with coffee. She started to complain that 'It burns, it burns' so I took her down to the nurses station. She's not supposed to have coffee." T. On 03/05/13 at 10:15 am, during an observation, resident #2 was sitting in her wheel chair in the activity room. She was observed sitting in her chair with her head resting on the back of the wheel chair and her buttocks at the edge of the seat. The resident was not sitting up straight and there was a space between her back and the back of the wheelchair. U. On 03/05/13 at 12:53 pm, during an interview with CNA #30, she stated "I was standing at the nursing station and the activity person reported she had spilled hot coffee on herself. I then took her to her room to change clothes and lifting skirt and noticed burn mark on leg (sic) right leg. It was about 7 inches long and 1 inch wide, red in color ...She normally spills coffee on herself at least once a day. I told (name) the nurse. (Name of nurse #33) went in and did assessment told me to keep an eye and to check and told me to tell her if worse ...We tell her not to fill her cup . Dietary has told her." V. On 03/06/13 at 10:30 am, during an interview with RN #33, she stated "I was working the floor and one of the activity people told me she spilled coffee down her front and it was pretty hot. Not the first time. I got an aide and went to her room. We looked at the area. It looked like she had been in hot water, a little red ...It was on her right leg thigh upper inner. She said it was hot when she spilled it ..." W. On 03/06/13 at 6:10 pm, the temperature of the coffee in the main dining room was 150 degrees Fahrenheit. X. Review of the facility Policy and Procedure for Safety Hot Beverages dated March 2009 revealed under Procedure: 3. When serving hot beverages to residents with behavior or medical conditions that put them at risk for spills: * Evaluate the ability of the resident to manage hot beverages independently and provide assistance as needed. * Encourage resident to consume cold beverages. * Allow hot beverages to cool before serving. * Add ice to hot beverages before serving, if resident agrees.

The facility failed to follow physician orders [REDACTED]. Residents #1 and 38 were each prescribed thickened fluids. During meal observations, Resident #1 was served thickened water in which the thickener had settled prior to service, leaving thin fluid visible at the top of the glass, while Resident #38 was served thin fluids. Further investigation revealed that the fluids had not been thickened to manufacturer guidelines, resulting in fluids being delivered that were thinner than prescribed. These deficient practices resulted in an Immediate Jeopardy (IJ) being identified at the facility on 10/23/12 at 3:30 pm. The facility Administrator and Director of Nursing (DON) were notified on 10/23/12 at 3:30 pm. The facility took corrective action by providing an acceptable Plan of Removal. Based on the plan, interventions included retraining of all kitchen staff and Certified Nursing Assistants (CNAs) in provision of thickened fluids and the implementation of a monitoring system to ensure that fluids were being thickened as prescribed. Based on the Plan of Removal and the information provided, the IJ was lifted on 10/25/12 at 3:30 pm. This resulted in the scope and severity being reduced from a scope and severity of K to Level 2, Scope E. Based on observation, interview and record review, the facility failed to follow physician orders [REDACTED].#1, 17, 38, 48 and 78) of 5 (#1, 17, 38, 48 and 78) sampled residents with physician's orders [REDACTED]. Resident #78 was prescribed thickened fluids but was observed independently obtaining thin fluids from a fluid dispenser in the dining room; no staff were present to supervise the dispenser, nor was thickener available at the dispenser for the residents' use, nor did the resident's care plan make allowance for independent access to thin fluids. Further investigation revealed that the fluids had not been thickened to manufacturer guidelines, resulting in fluids that were thinner than prescribed for all residents served thickened fluids (#1, 17, 38, 48 and 78). This deficient practice had the potential to expose the 5 residents with orders for thickened fluids to the risk of aspiration, a condition in which the individual inadvertently takes fluids into the lungs. The findings are: A. On 10/23/12, observation of the main dining room revealed the following: 1. At 11:40 am, resident #1 was sitting at a table with a glass of thickened water; the water had separated, with a layer of thin fluid at the top 2. At 11:30 am resident #38 had two different drinks in front of her. One cup was filled with unthickened water, and another cup was filled with unthickened orange liquid. During the course of the lunch, the resident was assisted with eating and drinking. Observed the Certified Nursing assistant bring the resident another glass filled with unthickened fluid. B. Review of Resident #1's record revealed the following: 1. A Face Sheet dated 09/20/12 documenting an admission date of [DATE] with admitting [DIAGNOSES REDACTED]. 2. physician's orders [REDACTED]. 3. A Nutrition assessment dated [DATE] documenting a diet of "Reg. (regular), level 4 nectar thx (thickened) liquids." 4. A Comprehensive Care Plan dated 07/24/12, revealed the resident is care planned for risk of altered nutrition due to [MEDICAL CONDITION], anxiety, immobility, constipation, [MEDICAL CONDITION] and swallowing. On the Comprehensive Care Plan, the approaches related to fluids are listed as, "Diet per physician's orders [REDACTED]. C. Review of Resident #17's record revealed the following: 1. A Face Sheet dated 06/08/11 records an admission date of [DATE], with an admitting [DIAGNOSES REDACTED]. 2. physician's orders [REDACTED]." 3. A Nutrition assessment dated [DATE] documented, "level 4 diet to allow regular breads per request, but mainly eats puree" 4. A Comprehensive Care Plan dated 09/11/12, reveals the resident is at risk for alteration in nutrition due to GERD, depression, anxiety, poor vision, chewing and swallowing. On the Comprehensive Care Plan the approaches related to fluids are listed as, "Offer nectar thick fluids at room temperature per resident choice to encourage fluid intake." D. Review of Resident #38's record revealed the following: 1. A Face Sheet dated 09/23/12, recorded an admission date of [DATE] with admitting [DIAGNOSES REDACTED]. 2. physician's orders [REDACTED]." E. Review of Resident #48's record revealed the following: 1. A Face Sheet dated 09/05/12 recorded the resident was admitted on [DATE] with an admitting [DIAGNOSES REDACTED]. 2. physician's orders [REDACTED]. F. On 10/23/12 at 12:29 pm, during an interview, Dietary Assistant #1 was interviewed about provision of thickened fluids. She identified herself as the staff responsible for thickening fluids. When asked at what time she had prepared the thickened fluids, she stated, "I usually serve the drinks while they're sitting at the table." When asked about the thickened liquids separating, she stated, "I stirred it real good, but when it sits for a while it'll go down, and we have to stir it again." When asked to show how she had prepared the thickened fluids, she picked up a standard commercial sugar dispenser containing powdered thickener, then began pouring it into a cup; she stated, "I usually go 30 seconds in my head, and when I see that it's thick enough, then I stop." 1. On 10/23/12 at 12:35 pm, Dietary Assistant #1 was asked to prepare a cup of thickened water according to the process she had reported, using one cup with 12 ounces of water and one empty cup to measure the quantity of thickening powder used. She poured powdered thickener into each cup for the same amount of time; measure by stopwatch revealed she had poured for 20 seconds. The powder in the empty cup was measured with a measuring spoon; there was 1/2 ounce of powder. 2. Dietary Assistant #1 was asked to provide the original container used to fill the dispenser she had used. She provided a container of Resource Thicken-up Instant Food and Drink Thickener. Review of the manufacturer label on the original container revealed a serving guide instructing use of 1 tablespoon plus 1 teaspoon of powdered thickener per 4 ounces of water. Based on the manufacturer's guidelines, the recommended volume of thickener for 12 ounces of water was two ounces of powdered thickener. 3. Observation of the cup of thickened water prepared by Dietary Assistant #1 over the next 15 minutes revealed that the fluid started separating immediately, showing 1/4 inch of thin fluid at the top of the cup after 5 minutes. After 10 minutes, there was 1/2 inch of thin fluid at the top. 4. The manufacturer-recommended quantity of thickener powder was measured into a small cup and compared visually with the amount poured by Dietary Assistant #1. When asked if she had poured the correct amount of thickening powder based on the comparison, she stated, "No." 5. On 10/23/12 at 1:00 pm, in the presence of the Dietary Manager, 12 ounces of thickened water were prepared according to manufacturer's guidelines for comparison with the 12 ounces of thickened water prepared by Dietary Assistant earlier at 12:35 pm. When asked if they were the same thickness, the Dietary Manager stated, "No." G. On 10/24/12 at 4:37 pm, during an observation in the facility dining room, Resident #78 was observed sitting in his wheelchair in front of the beverage dispenser filling a glass half full with unthickened orange juice, then proceeding to take 4 large swallows. After finishing the orange juice, the resident proceeded to place one coffee creamer in another cup and fill it with hot liquid from the dispenser marked, "coffee". No staff were present and the resident did not add thickener to his drinks. No thickener container was observed at the beverage dispenser. H. Review of Resident #78's record revealed physician orders [REDACTED]. Review further revealed a care plan dated 09/18/12 documenting, "Alteration in oral mucous membrane, r/t (related to) dentures, swallowing problems m/b (manifested by) open sores, [MEDICAL CONDITION] in mouth, mechanically altered diet, thickened liquids." Under Plan and Approaches the care plan documented, "Offer choice of nectar thick fluids to encourage intake... Resident likes orange juice." No provision for independent access to fluids was documented. Based on record review and interview, the facility failed to ensure that 2 (#8, 41) of 8 (#8, 10, 12, 24, 41, 63, 75 and 107) residents received the ordered dosage per the physician for the prescribed medication. Resident #8 was administered [MEDICATION NAME] 70 milligrams (mg) by mouth once daily for 8 days from 10/01/12 through 10/09/12, instead of once weekly. Resident #41 was administered 20 units of Humalog, a quick acting insulin, instead of 20 units of [MEDICATION NAME] on 09/13/12 at 8:30 am. These errors jeopardized the residents' health and safety: resident #8 was taken to the emergency room for emergency diagnostic assessment for signs of hypoglcemia (low blood sugar), a condition which can trigger [MEDICAL CONDITION] in extreme cases; resident #41 was at risk of injury or death due to extreme low blood sugar and required emergency administration of an intramuscular hormone and other interventions to counteract the insulin, as well as enduring 16 finger-stick blood glucose checks (involving sticking the fingertip with a lancet to obtain a drop of blood) over a period of two hours and 40 minutes. This failed pratice likely cause the residents to receive the wrong dosage of prescribed medication and could place in an emergent situation. The findings are: Resident #8 A. Review of the record of resident #8 revealed a Face Sheet dated 07/18/11, documenting admission on 07/14/10 with [DIAGNOSES REDACTED]. B. Review of the Incident Details dated 10/09/12 revealed under comments, "[MEDICATION NAME] was to be given once per week. Orders were transcribed incorrectly to once a day and resident received wrong amount." C. Review of the Fax Communication to Physician, dated 10/09/12, revealed under Concern: "This resident has received 70 mg of [MEDICATION NAME] on a daily basis for 9 days in lieu of once a week." D. Review of Interdisciplinary Progress notes dated 10/09/12 at 5:45 pm revealed, "Resident transferred to (name of hospital) per instructions per Physician for evaluation following discovery that [MEDICATION NAME] had been administered more frequently than originally ordered... " E. During an interview with the Director of Nursing (DON) on 10/25/12 at 10:25 am, he stated,"It was given weekly until they transferred the medication to the new Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]." F. During an interview with RN (Register Nurse) #1 on 10/30/12 at 2:00 pm, she stated regarding the [MEDICATION NAME] order, "I saw the MAR, it said give 5 days a week. I assumed the MAR indicated [REDACTED]. The DON interviewed me and informed me of the error." G. On 10/30/12 at 2:17 pm, during an interview with RN # 2, she stated that she gave [MEDICATION NAME] one time on October 6th or 7th. She stated, "The MAR indicated [REDACTED]. I did not become aware of this problem until the DON informed me on [DATE]th." H. Review of the Incident Details for 10/09/12 at 8:00 am for Resident #8, revealed under Comments: "[MEDICATION NAME] was to be given once per week. Orders were transcribed incorrectly to once a day and resident received wrong amount." I. Review of the 2013 Nursing Drug Handbook revealed, for [MEDICATION NAME], overdose indications including [DIAGNOSES REDACTED]. Review of the Merck Manual of [DIAGNOSES REDACTED].<7 mg/100 ml) may cause laryngospasm (a spasm of the vocal cords that can interfere with breathing) and generalized convulsions." Resident #41 J. Review of the record of resident #41 revealed a Face Sheet dated 11/15/11, documenting admission on 12/15/09 with [DIAGNOSES REDACTED]. Further review revealed a physician's orders [REDACTED]. K. Review of record of resident #41 revealed a Fax Communication to Physician dated 09/13/12. The record documented, "Concern: Res.(Resident) administered 20 u (units) Humalog this am instead of [MEDICATION NAME]" The communication documented emergency interventions including finger-stick blood glucose checks every 5 to 15 minutes, intramuscular injection of [MEDICATION NAME] (a hormone that raises the level of glucose in the blood), and oral administration of a tube of glucose paste and high-sugar foods to counteract the insulin. A follow up Fax Communication with the same date documented 16 finger-stick blood glucose checks between 11:30 am and 2:07 pm. L. During an interview on 10/25/12 at 3:05 pm with Register Nurse (RN)#1, she stated, "I was precepting (teaching) (name of RN #3), when I was drawing up insulin for (name of Resident #41), her 8:00 am dose of [MEDICATION NAME]. I drew up 20 units of what I thought was [MEDICATION NAME] but it was Humalog. I did not check or look at the bottle, was just in a hurry. I had given her Humalog 2 to 4 units at 7:30 am. I had placed the Humalog bottle in the [MEDICATION NAME] box and [MEDICATION NAME] bottle in the Humalog box. The [MEDICATION NAME] bottle is taller. When I noticed the error, I told (name of DIrector of Nursing). I brought the resident into the DON office. Her blood sugar (BS) was 59..." M. During review of the procedure, Insulin Administration, revised 1/20/12, the record instructed, "Procedure, 1. Check label on vial carefully to ensure correct type of insulin and date vial was opened." During record review of the procedure, Administration of Medication, revised 1/20/09, the record instructed, "Using the specific center's medication system, administer medications to the resident according to the 'Five Rights': right drug, right dose, right route, right time, right resident."

The facility failed to follow physician orders [REDACTED]. Residents #1 and 38 were each prescribed thickened fluids. During meal observations, resident #1 was served thickened water in which the thickener had settled prior to service, leaving thin fluid visible at the top of the glass, while resident #38 was served thin fluids. Further investigation revealed that the fluids had not been thickened to manufacturer guidelines, resulting in fluids being delivered that were thinner than prescribed. These deficient practices resulted in an Immediate Jeopardy (IJ) being identified at the facility on 10/23/12 at 3:30 pm. The facility Administrator and Director of Nursing (DON) were notified on 10/23/12 at 3:30 pm. The facility took corrective action by providing an acceptable Plan of Removal. Based on the plan, interventions included retraining of all kitchen staff and Certified Nursing Assistants (CNAs) in provision of thickened fluids and the implementation of a monitoring system to ensure that fluids were being thickened as prescribed. Based on the Plan of Removal and the information provided, the IJ was lifted on 10/25/12 at 3:30 pm. This resulted in the scope and severity being reduced from a scope and severity of K to Level 2, Scope E. Based on observation, interview and record review, the facility failed to provide fluids thickened to the consistency prescribed by the residents' physicians to prevent aspiration for 5 (#1, 17, 38, 48 and 78) of 5 (#1, 17, 38, 48 and 78) sampled residents with physician's orders [REDACTED]. Resident #78 was prescribed thickened fluids but was observed independently obtaining thin fluids from a fluid dispenser in the dining room; no staff were present to supervise the dispenser, nor was thickener available at the dispenser for the residents' use, nor did the resident's care plan make allowance for independent access to thin fluids. Further investigation revealed that the fluids had not been thickened to manufacturer guidelines, resulting in fluids that were thinner than prescribed for all residents served thickened fluids (#1, 17, 38, 48 and 78). This deficient practice had the potential to expose the 5 residents with orders for thickened fluids to the risk of aspiration, a condition in which the individual inadvertently takes fluids into the lungs. The findings are: A. On 10/23/12, observation of the main dining room revealed the following: 1. At 11:30 am resident #38 had two different drinks in front of her. One cup was filled with unthickened water, and another cup was filled with unthickened orange liquid. During the course of the lunch, the resident was assisted with eating and drinking. Observed the Certified Nursing assistant bring the resident another glass filled with unthickened fluid. 2. At 11:40 am, resident #1 was sitting at a table with a glass of thickened water; the water had separated, with a layer of thin fluid at the top. B. Review of resident #1's record revealed the following: 1. A Face Sheet dated 09/20/12 documenting an admission date of [DATE] with admitting [DIAGNOSES REDACTED]. 2. physician's orders [REDACTED]. 3. A Nutrition assessment dated [DATE] documenting a diet of "Reg. (regular), level 4 nectar thx (thickened) liquids." 4. A Comprehensive Care Plan dated 07/24/12, revealed the resident is care planned for risk of altered nutrition due to seizures, anxiety, immobility, constipation, [DIAGNOSES REDACTED] and swallowing. On the Comprehensive Care Plan, the approaches related to fluids are listed as, "Diet per physician's orders [REDACTED]. C. Review of resident #17's record revealed the following: 1. A Face Sheet dated 06/08/11 records an admission date of [DATE], with an admitting [DIAGNOSES REDACTED]. 2. physician's orders [REDACTED]." 3. A Nutrition assessment dated [DATE] documented, "level 4 diet to allow regular breads per request, but mainly eats puree" 4. A Comprehensive Care Plan dated 09/11/12, reveals the resident is at risk for alteration in nutrition due to GERD, depression, anxiety, poor vision, chewing and swallowing. On the Comprehensive Care Plan the approaches related to fluids are listed as, "Offer nectar thick fluids at room temperature per resident choice to encourage fluid intake." D. Review of resident #38's record revealed the following: 1. A Face Sheet dated 09/23/12, recorded an admission date of [DATE] with admitting [DIAGNOSES REDACTED]. 2. physician's orders [REDACTED]." E. Review of resident #48's record revealed the following: 1. A Face Sheet dated 09/05/12 recorded the resident was admitted on [DATE] with an admitting [DIAGNOSES REDACTED]. 2. physician's orders [REDACTED]. F. On 10/23/12 at 12:29 pm, during an interview, Dietary Assistant #1 was interviewed about provision of thickened fluids. She identified herself as the staff responsible for thickening fluids. When asked at what time she had prepared the thickened fluids, she stated, "I usually serve the drinks while they're sitting at the table." When asked about the thickened liquids separating, she stated, "I stirred it real good, but when it sits for a while it'll go down, and we have to stir it again." When asked to show how she had prepared the thickened fluids, she picked up a standard commercial sugar dispenser containing powdered thickener, then began pouring it into a cup; she stated, "I usually go 30 seconds in my head, and when I see that it's thick enough, then I stop." 1. On 10/23/12 at 12:35 pm, Dietary Assistant #1 was asked to prepare a cup of thickened water according to the process she had reported, using one cup with 12 ounces of water and one empty cup to measure the quantity of thickening powder used. She poured powdered thickener into each cup for the same amount of time; measure by stopwatch revealed she had poured for 20 seconds. The powder in the empty cup was measured with a measuring spoon; there was 1/2 ounce of powder. 2. Dietary Assistant #1 was asked to provide the original container used to fill the dispenser she had used. She provided a container of Resource Thicken-up Instant Food and Drink Thickener. Review of the manufacturer label on the original container revealed a serving guide instructing use of 1 tablespoon plus 1 teaspoon of powdered thickener per 4 ounces of water. Based on the manufacturer's guidelines, the recommended volume of thickener for 12 ounces of water was two ounces of powdered thickener. 3. Observation of the cup of thickened water prepared by Dietary Assistant #1 over the next 15 minutes revealed that the fluid started separating immediately, showing 1/4 inch of thin fluid at the top of the cup after 5 minutes. After 10 minutes, there was 1/2 inch of thin fluid at the top. 4. The manufacturer-recommended quantity of thickener powder was measured into a small cup and compared visually with the amount poured by Dietary Assistant #1. When asked if she had poured the correct amount of thickening powder based on the comparison, she stated, "No." 5. On 10/23/12 at 1:00 pm, in the presence of the Dietary Manager, 12 ounces of thickened water were prepared according to manufacturer's guidelines for comparison with the 12 ounces of thickened water prepared by Dietary Assistant earlier at 12:35 pm. When asked if they were the same thickness, the Dietary Manager stated, "No." G. On 10/24/12 at 4:37 pm, during an observation in the facility dining room, resident #78 was observed sitting in his wheelchair in front of the beverage dispenser filling a glass half full with unthickened orange juice, then proceeding to take 4 large swallows. After finishing the orange juice, the resident proceeded to place one coffee creamer in another cup and fill it with hot liquid from the dispenser marked, "coffee". No staff were present and the resident did not add thickener to his drinks. No thickener container was observed at the beverage dispenser. H. Review of resident #78's record revealed physician orders [REDACTED]. Review further revealed a care plan dated 09/18/12 documenting, "Alteration in oral mucous membrane, r/t (related to) dentures, swallowing problems m/b (manifested by) open sores, lesions in mouth, mechanically altered diet, thickened liquids." Under Plan and Approaches the care plan documented, "Offer choice of nectar thick fluids to encourage intake... Resident likes orange juice." No provision for independent access to fluids was documented. Based on observation, interview and record review, the facility failed to ensure that hot beverages were provided at a safe temperature for 1 (#52) of 8 (#1, 2, 17, 38, 48, 52, 78 and 65) sampled residents evaluated for accident prevention. Residents #52 was diagnosed with [REDACTED]. Resident #52 was given a cup of hot coffee to drink and left unattended, spilling the coffee and sustaining burns while staff was away addressing a call bell. The serving staff had made no effort to cool the coffee before service. Further investigation revealed that the 400-unit dining room had a resident-accessible coffee maker with coffee pots containing coffee at 160 degrees Fahrenheit (F); the coffee maker did not have and could not be provided with the safety equipment mandated under the facility's policy, placing any resident who used it at risk for burns from an accidental spill. This deficient practice caused burns to resident #52 and had the potential to result in accidental burn injuries to any resident of the 400-unit. The findings are: A. Review of the record of resident #52 revealed a Face Sheet dated 08/17/12 documenting admission to the facility on [DATE] with [DIAGNOSES REDACTED]. B. Review of the record of resident #52 further revealed documentation of a burn sustained from hot coffee on 09/27/12: 1. An Incident Detail dated 09/27/12 documented, "res. spilled coffee on self." Under Comments, the report documented, "Aide (name of CNA #4) reported to me that resident spilled coffee on himself at the table in dining room. (name of CNA #4) promptly removed/changed residents clothes (in room). Bright red, blanchable areas noted on upper thighs and abdomen." 2. An Incident Detail dated 10/01/12 documented under Comments, "Blisters from burn on 9-27-12 were noticed on 9-28-12." Under Type of Alleged Injury, the report documented burns of size, "8 cm x 6 cm to L groin, 4 cm x 4 cm to head of glans penis." 3. physician's orders [REDACTED]. thigh - covered c adhesive ... no evidence of infection at this time. ..." 4. physician's orders [REDACTED]...1st-2nd degree burn on groin area. ..." C. On 10/30/12 at 4:25 pm, observation in the facility 400-unit dining area revealed a resident-accessible coffee making machine with a clear glass coffee pot containing hot coffee. The coffee pot was a standard pot with a standard loose cover. No protective shield or other protective measures were evident. Test of the coffe in coffee pot revealed a temperature of 160 degrees Fahrenheit (F). D. On 10/30/12 at 4:26 pm, during an interview, CNA #3 was asked about resident #52's need for assistance during eating and drinking. When asked what assistance she provided, she stated, " I fed him, I spoon fed." When asked if the resident was able to hold a cup, she stated, "Yeah, he did one time, he was holding the cup for just a little bit, but I had to help him put the cup on the table." When asked if the resident was able to pick up a cup, she stated, "No. He'd just hold the cup for a little bit, and he'd try to sip, but I'd have to hold the bottom of the cup so he could have a drink." When asked if the resident was able to get his own coffee from the coffee pot on the unit, she stated, "No." E. On 10/31/12 at 9:40 am, RN #8 was asked about the burn sustained by resident #52. When asked if she had been present when it happened, she stated, "I was here, I did not see it happen. It was right at shift change: I was giving report, and it was reported to me." When asked who had reported it, she identified CNA #4. When asked what CNA #4 had reported, she stated, "She said that he had been seated at the table and he had spilled his coffee on his lap, and she had immediately taken him to his room and changed his clothes and his brief, and then she brought him back out and reported to me." When asked if CNA #4 had told her how the resident had spilled his coffee, she stated, "He would often drink independently. He would prefer to hold the cup himself, and with his tremor, he was prone to spilling." When asked if he had been using a special cup for drinking, she stated, "I believe he was using a regular cup, like styrofoam." When asked how the resident had sustained a burn to the glans of his penis through his incontinent brief, she stated, "That is an interesting question. I assessed him (after the spill). I observed reddened areas on his thighs and on the upper abdomen. Per the aide, she didn't see anything unusual in the groin area at the time. I also offered him an ice pack, which he refused. It wasn't till two days later that we started noticing injury to the glans of the penis. The only thing we can figure is it came in through the side of the brief. Per (name of CNA #4), she said the brief was not wet with coffee when she changed him." F. On 10/31/12 at 10:25 am, observation of the 400 unit coffee machine revealed 3 pots of liquid. A pot of coffee was on a heating element immediately beneath the machine, and a pot of coffee and a pot of water were on heating elements attached to one side of the machine. Test of the temperatures in the presence of )Registered Nurse (RN) #8 revealed the following temperatures: 1. Test of a cup of coffee poured from the pot in the machine revealed a temperature of 160 degrees F. 2. Test of a cup of coffee poured from the pot on the heating element beside the machine also revealed a temperature of 160 degrees F. 3. Test of a cup of water poured from the pot of water on the heating element beside the machine also revealed a temperature of 160 degrees F. G. On 10/31/12 at 10:33 am, during an interview, CNA #4 was asked about resident #52's general condition prior to the spill. She stated, "I don't know, a little unsettled; up, down, like out of bed, in bed. His Parkinson's kicked in a lot so he shook a lot. Most of the time he was calm and with it, he just had bad days sometimes." When asked how much assistance the resident needed, she stated, "Some days it was limited, but some days it was extensive; it varied. Sometimes I just had to stand by him and help him, and sometimes I had to get a second person to help me." When asked about assistance with dining, she stated, "Some days you had to feed him. Usually his wife came in in the morning and cued him or fed him." When asked about his burn, she stated, "It was after lunch. He wanted to lay down, and then he wanted to get up about 30 minutes later. I asked him what he wanted to do, and he said he wanted coffee. So I took him to the table and gave him a cup of coffee. I don't know what it was, if it was a call light or something, but I had to leave him for a minute, and when I came back, I noticed that the coffee was in his lap, so I took him to his room, and I stripped him and called the nurse." When asked if he had been more independent or more dependent at that time, she stated, "He was more independent; I barely had to help him get into his chair." When asked about his handling of beverages, she stated, "Whenever his Parkinson's is not real bad, he can hold them, he has good hand-to-mouth, its just when his Parkinson's is bad, he can't really do it." When asked how he was handling beverages at the time of the spill, she stated, "It (his Parkinson's tremor) was pretty calm. I wouldn't have expected him to drop it. He was doing OK that day." When asked to describe how she had served him, she stated, "I put int in the styrofoam cup, because that's the cup he can hold better, and I gave it to him." When asked if she had added anything, she stated, "Two of the powdered creamers, and no sugar." When asked if she had added cold water to the coffee, she stated, "No, I didn't." When asked if she had added ice to the coffee, she stated, "No." When asked if there had been any delay between pouring the coffee from the pot and giving it to him, she stated, "No, I think I took it straight over to him." When asked if she had received any instructions to stay and monitor him during coffee or meals, she stated, "No." When asked if she had received any instructions about how to serve coffee prior to the spill, she stated, "No. After? Yeah, they wanted us to start putting ice in it." H. Review of the facility safety policy, Hot Beverages, issued March 2009, revealed the statement, "Hot beverages are prepared or brewed at high temperatures to maximize flavor and quality ... Serving temperatures for all hot beverages range from 155 to 175 degrees F. However, full thickness skin burns can occur at temperatures just above 120 degrees F depending on the duration of contact between the skin and the hot beverage ... Skin on arms and legs are less sensitive than the mouth ... Elderly residents, especially those who are weelchair bound, are even more prone to burns from hot beverages, and the morbidity and mortality rates are greater than in young adults." Under Procedures, instructions included: 1. "When self-service of hot beverages ... is available in the dining room: Supervise the area ... use only carafes with safety or screw-top lids rather than loose covers ... Prepour beverages whenever possible into drinking cups with lids ... Use china cups or ceramic mugs, as they allow for a more rapid cooling when compared to ... Styrofoam cups ..." 2. "When serving hot beverages to residents with behavioral or medical conditions that put them at risk for spills: Evaluate the ability of the resident to manage hot beverages independently and provide assistance as needed ... Allow hot beverages to cool before serving ... Add ice to hot beverages before serving, if resident agrees." 3. "Coffee: ... Coffee should be served at temperatures hot enough to meet the psychosocial and physiological expectations of the coffee drinker. However, for the safety of our residents, holding temperatures for coffee are recommended to be between 145 - 155 degrees F. ... Maintain the safety of the residents by having staff pour the coffee and supervise the residents who are at risk for spilling ... Place protective shield around the coffee equipment ... Use toggle covers to reduce risk of accidental dispensing ..." I. On 10/31/12 at 2:50 pm, during an interview, the Diet Manager was interviewed about the 400-unit coffee maker. When asked about the protective shield, she stated, "There isn't one. There isn't a way to put a shield around that that would let the residents have access to the pot." When asked how the coffee maker arrangement prevented a resident in a wheelchair from spilling the full pot into his or her lap, she stated, "It doesn't. It'll have to be moved." A repeat test was conducted in the presence of the Diet Manager of the temperature of the coffee in the coffee pot under the 400-unit coffee maker; the test revealed a temperature of 160 degrees F. When asked if there was any way to control the temperature of the coffee maker, she stated, "Not on that unit. There's no way." Based on observation, record review and interview, the facility failed to ensure that dispensed medications were not left at the bedside unattended for 1 (#12) of 8 residents (#8, 10, 12, 24, 41, 63, 75, and 107) observed during medication admininstration. This deficient practice has the potential to lead to another resident taking the medications that were not prescribed to them, jeopardizing their health and safety. The findings are: A. On 10/25/12 at 7:15 am, during a medication pass observation, Register Nurse (RN) #1 was observed setting medications that she had drawn up for resident #12 on the bedside table, then leaving the resident's room to attend to another resident. Medications left unattended at the resident's bedside included Macrobid 100 milligrams (mg), Prednisone 5 mg, Verapamil 20 mg, Vasotec 2.5 mg, Zoloft 2.5 mg, Colace 10 milliliters (ml), Potasium Chloride 10 milliequivalent (meq), and Carafate 1 gram. On 10/25/12 at 7:24 am, RN #1 returned to resident #12's room and administered the poured medications sitting on the nightstand. B. On 10/29/12 at 3:20 pm, during an interview with RN #1 regarding medications left at resident #12's bedside, she stated, "That's a no-no; I should have disposed of the medications. It is our policy to never leave medication by the bedside." C. On 10/29/12 at 3:32 pm, during an interview with the Director of Nursing (DON), he stated, "She should have given medications before leaving room or should have disposed of the medications. It is facility policy not to leave medication at the bedside." D. On 10/29/12, review of the facility procedure, "Administration of Medication, Function," issued November 2002, revised 10/09, revealed the instruction, "Please ensure that medications are administered without unnecessary interruption."

Based on record review and interview, the facility failed to prevent neglect by failing to ensure that nurses follow procedures to ensure delivery of the correct medication to 2 (#24 and #41) of 8 (#8, 10, 12, 24, 41, 63, 75 and 107) residents evaluated for medication administration. Resident #41 was administered 20 units of Humalog, a quick acting insulin, instead of 20 units of [MEDICATION NAME] as a result of the failure of Registered Nurse (RN) #1 to check the label on the bottle before drawing up and administering the insulin. This failure placed resident #41 at risk of injury or death due to extreme low blood sugar; the resident required emergency administration of an intramuscular hormone and other interventions to counteract the insulin, as well as enduring 16 finger-stick blood glucose checks (involving sticking the fingertip with a lancet (device used to obtain a drop of blood for testing blood glucose)) over a period of two hours and 40 minutes. RN #9 and RN #2 administered [MEDICATION NAME] instead of [MEDICATION NAME], an augmented version of [MEDICATION NAME] with a chemical added to reduce antibiotic resistance, to resident #24; this error had the potential to prolong the resident's infection. The findings are: Resident #41 A. Review of the record of resident #41 revealed a Face Sheet dated 11/15/11, documenting admission on 12/15/09 with [DIAGNOSES REDACTED]. Further review revealed a Medication Record dated 09/01/12 documenting orders for Humalog (a fast acting insulin) by sliding scale (various amount of insulin administered based on an individuals blood glucose level) four times daily and [MEDICATION NAME] (a long acting insulin) 20 units in the morning and 15 units in the evening. B. Review of record of resident #41 revealed a Fax Communication to Physician dated 09/13/12. The record documented, "Concern: Res.(Resident) administered 20 u (units) Humalog this am instead of [MEDICATION NAME]" The communication documented emergency interventions including finger-stick blood glucose checks every 5 to 15 minutes, intramuscular injection of [MEDICATION NAME] (a hormone that raises the level of glucose in the blood), and oral administration of a tube of glucose paste and high-sugar foods to counteract the insulin. A follow up Fax Communication with the same date documented 16 finger-stick blood glucose checks between 11:30 am and 2:07 pm. C. During an interview on 10/25/12 at 3:05 pm with Registered Nurse (RN) #1, she stated, "I was precepting (teaching) (name of RN #3), when I was drawing up insulin for (name of resident #41), her 8:00 am dose of [MEDICATION NAME]. I drew up 20 units of what I thought was [MEDICATION NAME] but it was Humalog. I did not check or look at the bottle, was just in a hurry. I had given her Humalog 2 to 4 units at 7:30 am. I had placed the Humalog bottle in the [MEDICATION NAME] box and [MEDICATION NAME] bottle in the Humalog box. The [MEDICATION NAME] bottle is taller. When I noticed the error, I told (name of Director of Nursing (DON)). I brought the resident into the DON office. Her blood sugar (BS) was 59..." D. During review of the procedure, Insulin Administration, revised 01/20/12, the record instructed, "Procedure, 1. Check label on vial carefully to ensure correct type of insulin and date vial was opened." During record review of the procedure, Administration of Medication, revised 01/20/09, the record instructed, "Using the specific center's medication system, administer medications to the resident according to the 'Five Rights': right drug, right dose, right route, right time, right resident." Resident #24 E. Review of the Face Sheet for resident #24 revealed that she was admitted on [DATE] with [DIAGNOSES REDACTED]. F. Review of resident #24's medication order dated 10/09/12 revealed a medication order to "Restart [MEDICATION NAME] 500 mg, one tablet (by mouth) three times a day (TID) x (for) 7 days for UTI (urinary tract infection)." G. During an interview on 10/30/12 at 1:19 pm, RN #3 stated that she was on her way to the medication room to retrieve another medication when asked to pull [MEDICATION NAME] 500 for another RN, RN #9. RN #3 stated she pulled the wrong medication and gave the wrong medication to RN #9, which RN #9 then administered. RN #3 stated she later looked up [MEDICATION NAME] and [MEDICATION NAME], stating that they were, "The same thing. I assumed they were the same drug. I gave the [MEDICATION NAME] to (name of RN #9). I did not tell (name of RN #9) I was giving her [MEDICATION NAME] because I was under the impression I got the right one. The medication was still in the package, two 250 mg [MEDICATION NAME] capsules." RN #2 stated she was also involved with giving the [MEDICATION NAME] instead of [MEDICATION NAME]: "I went to pull medication from the e-kit (emergency kit) and pulled [MEDICATION NAME]. ... I saw it had been pulled earlier and I pulled [MEDICATION NAME] again. ... [MEDICATION NAME] was not in my cart." H. Review of the 2013 Nursing Drug Handbook revealed that [MEDICATION NAME] is a mixture of [MEDICATION NAME] and clavulanate potassium. The handbook documents that clavulanate potassium, "increases [MEDICATION NAME]'s effectiveness by inactivating beta-lactamases (enzymes produced by some bacteria), which destroy [MEDICATION NAME]." I. During record review of the procedure, Administration of Medication, revised 01/2009, the record instructed, "Using the specific center's medication system, administer medications to the resident according to the 'Five Rights': right drug, right dose, right route, right time, right resident." J. Review of the Facility policy, Abuse Definitions, issued 11/1999 and last revised 01/2011 revealed that neglect was defined as, "Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness."

Based on record review and interview, the facility failed to submit a report of the results of investigations (follow-up report) to the State survey and certification agency within 5 working days of submitting a facility report of incidents of possible neglect for 3 of 3 (#8, 24, and 41) residents. The facility submitted two reports of medication errors constituting possible neglect: one on 09/08/12 involving resident #41, and one on 10/09/12 involving residents #8 and #24. As of 10/23/12, the state survey and certification agency Intake Coordinator reported receiving no follow-up report from the facility on either initial report. Failure to inform the State survey and certification agency of the results of investigations had the potential to leave the three residents at continued risk of neglect due to incomplete investigation. The findings are: A. Review of the records of the state Licensing Authority revealed facility self-reports of significant medication errors constituting potential neglect involving three residents: 1. On 09/13/12, the facility Director of Nursing (DON) reported one medication error to the Licensing Authority as possible neglect. No details regarding the incident were provided other than that resident #41 was diagnosed with [REDACTED]. As of 09/21/12, no follow-up report to the incidents had been received by the Licensing Authority. 2. On 10/09/12, the facility DON reported two separate medication errors to the Licensing Authority as possible neglect. No details regarding the first incident were provided other than that the physician had been notified, Poison Control contacted, resident #8 taken to the emergency room for evaluation, and an inservice started to remind nurses about medication rights. In the second incident, resident #24 was given an antibiotic other than the one ordered by the physician. As of 10/24/12, no follow-up report to either incident had been received by the Licensing Authority. B. Review of the record and interview with staff regarding the incident involving resident #41 revealed the following: 1. Review of the record of resident #41 revealed a Face Sheet dated 11/15/11, documenting admission on 12/15/09 with [DIAGNOSES REDACTED]. Further review revealed a Medication Record dated 09/01/12 documenting orders for Humalog (a fast acting insulin) by sliding scale (various amount of insulin administered based on an individuals blood glucose level) four times daily and [MEDICATION NAME] (a long acting insulin) 20 units in the morning and 15 units in the evening. 2. Review of record of resident #41 revealed a "Fax Communication to Physician,"dated 09/13/12. The record documented, "Concern: Res.(Resident) administered 20 u (units) Humalog this am instead of [MEDICATION NAME]" 3. During an interview on 10/25/12 at 3:05 pm with Registered Nurse (RN) #1, she stated, "I was precepting (teaching) (name of RN #3), when I was drawing up insulin for (name of resident #41), her 8:00 am dose of [MEDICATION NAME]. I drew up 20 units of what I thought was [MEDICATION NAME] but it was Humalog. I did not check or look at the bottle, was just in a hurry. I had given her Humalog 2 to 4 units at 7:30 am. I had placed the Humalog bottle in the [MEDICATION NAME] box and [MEDICATION NAME] bottle in the Humalog box. The [MEDICATION NAME] bottle is taller. When I noticed the error, I told (name of DON). I brought the resident into the DON office. Her blood sugar (BS) was 59..." C. Review of the record and interview with staff regarding the incident involving resident #8 revealed the following: 1. Review of the record of resident #8 revealed a Face Sheet dated 07/18/11, documenting admission on 07/14/10 with [DIAGNOSES REDACTED]. 2. Review of the Incident Details dated 10/09/12 revealed, under Comments, "[MEDICATION NAME] was to be given once per week. Orders were transcribed incorrectly to once a day and resident received wrong amount." D. Review of the record and interview with staff regarding the incident involving resident #24 revealed the following: 1. Review of the Face Sheet for resident #24 revealed that she was admitted on [DATE] with [DIAGNOSES REDACTED]. 2. Review of resident #24's medication order dated 10/09/12 revealed a medication order to, "Restart [MEDICATION NAME] 500 mg, one tablet (by mouth) three times a day (TID) x (for) 7 days for UTI (urinary tract infection)." 3. During an interview on 10/30/12 at 1:19 pm, RN #3 stated that she was on her way to the medication room to retrieve another medication when asked to pull [MEDICATION NAME] 500 for another RN, RN #9. RN #3 stated she pulled the wrong medication and gave the wrong medication to RN #9, which RN #9 then administered. RN #3 stated she later looked up [MEDICATION NAME] and [MEDICATION NAME], stating that they were, "The same thing. I assumed they were the same drug. I gave the [MEDICATION NAME] to (name of RN #9). I did not tell (name of RN #9) I was giving her [MEDICATION NAME] because I was under the impression I got the right one. The medication was still in the package, two 250 mg [MEDICATION NAME] capsules." RN #2 stated she was also involved with giving the [MEDICATION NAME] instead of [MEDICATION NAME]: "I went to pull medication from the e-kit (emergency kit) and pulled [MEDICATION NAME]. ... I saw it had been pulled earlier and I pulled [MEDICATION NAME] again. ... [MEDICATION NAME] was not in my cart." E. On 10/23/12 at 2:50 pm, during an interview, the State survey and certification agency Complaint Intake Coordinator reported, "I cannot find any follow-ups on the three residents requested (#8, 24, and 41)." F. On 10/23/12 at 3:00 pm, during an interview, the DON stated that he did not follow up on the incident investigations for resident #8, 24,and 41.

Based on record review and interview, the facility failed to implement policies to prevent neglect by failing to ensure that nurses follow procedures to ensure delivery of the correct medication to 2 (#24 and #41) of 8 (#8, 10, 12, 24, 41, 63, 75 and 107) residents evaluated for medication administration. Resident #41 was administered 20 units of Humalog, a quick acting insulin, instead of 20 units of [MEDICATION NAME] as a result of the failure of Registered Nurse (RN) #1 to check the label on the bottle before drawing up and administering the insulin. This failure placed resident #41 at risk of injury or death due to extreme low blood sugar; the resident required emergency administration of an intramuscular hormone and other interventions to counteract the insulin, as well as enduring 16 finger-stick blood glucose checks (involving sticking the fingertip with a lancet(Device used to obtain a drop of blood for testing blood glucose) . to obtain a drop of blood) over a period of two hours and 40 minutes. RN #9 and RN #2 administered [MEDICATION NAME] instead of [MEDICATION NAME], an augmented version of [MEDICATION NAME] with a chemical added to reduce antibiotic resistance, to resident #24; this error had the potential to prolong the resident's infection. The findings are: Resident #41 A. Review of the record of resident #41 revealed a Face Sheet dated 11/15/11, documenting admission on 12/15/09 with [DIAGNOSES REDACTED]. Further review revealed a Medication Record dated 09/01/12 documenting orders for Humalog (a fast acting insulin) by sliding scale (various amount of insulin administered based on an individuals blood glucose level) four times daily and [MEDICATION NAME] (a long acting insulin) 20 units in the morning and 15 units in the evening. B. Review of record of resident #41 revealed a Fax Communication to Physician dated 09/13/12. The record documented, "Concern: Res.(Resident) administered 20 u (units) Humalog this am instead of [MEDICATION NAME]" The communication documented emergency interventions including finger-stick blood glucose checks every 5 to 15 minutes, intramuscular injection of [MEDICATION NAME] (a hormone that raises the level of glucose in the blood), and oral administration of a tube of glucose paste and high-sugar foods to counteract the insulin. A follow up Fax Communication with the same date documented 16 finger-stick blood glucose checks between 11:30 am and 2:07 pm. C. During an interview on 10/25/12 at 3:05 pm with Registered Nurse (RN) #1, she stated, "I was precepting (teaching) (name of RN #3), when I was drawing up insulin for (name of resident #41), her 8:00 am dose of [MEDICATION NAME]. I drew up 20 units of what I thought was [MEDICATION NAME] but it was Humalog. I did not check or look at the bottle, was just in a hurry. I had given her Humalog 2 to 4 units at 7:30 am. I had placed the Humalog bottle in the [MEDICATION NAME] box and [MEDICATION NAME] bottle in the Humalog box. The [MEDICATION NAME] bottle is taller. When I noticed the error, I told (name of Director of Nursing (DON)). I brought the resident into the DON office. Her blood sugar (BS) was 59..." D. During review of the procedure, Insulin Administration, revised 01/2012, the record instructed, "Procedure, 1. Check label on vial carefully to ensure correct type of insulin and date vial was opened." During record review of the procedure, Administration of Medication, revised 01/20/09, the record instructed, "Using the specific center's medication system, administer medications to the resident according to the 'Five Rights': right drug, right dose, right route, right time, right resident." Resident #24 E. Review of the Face Sheet for resident #24 revealed that she was admitted on [DATE] with [DIAGNOSES REDACTED]. F. Review of resident #24's medication order dated 10/09/12 revealed a medication order to "Restart [MEDICATION NAME] 500 mg, one tablet (by mouth) three times a day (TID) x (for) 7 days for UTI (urinary tract infection)." G. During an interview on 10/30/12 at 1:19 pm, RN #3 stated that she was on her way to the medication room to retrieve another medication when asked to pull [MEDICATION NAME] 500 for another RN, RN #9. RN #3 stated she pulled the wrong medication and gave the wrong medication to RN #9, which RN #9 then administered. RN #3 stated she later looked up [MEDICATION NAME] and [MEDICATION NAME], stating that they were, "The same thing. I assumed they were the same drug. I gave the [MEDICATION NAME] to (name of RN #9). I did not tell (name of RN #9) I was giving her [MEDICATION NAME] because I was under the impression I got the right one. The medication was still in the package, two 250 mg [MEDICATION NAME] capsules." RN #2 stated she was also involved with giving the [MEDICATION NAME] instead of [MEDICATION NAME]: "I went to pull medication from the e-kit (emergency kit) and pulled [MEDICATION NAME]. ... I saw it had been pulled earlier and I pulled [MEDICATION NAME] again. ... [MEDICATION NAME] was not in my cart." H. Review of the 2013 Nursing Drug Handbook revealed that [MEDICATION NAME] is a mixture of [MEDICATION NAME] and clavulanate potassium. The handbook documents that clavulanate potassium, "increases [MEDICATION NAME]'s effectiveness by inactivating beta-lactamases (enzymes produced by some bacteria), which destroy [MEDICATION NAME]." I. During record review of the procedure, Administration of Medication, revised 01/2009, the record instructed, "Using the specific center's medication system, administer medications to the resident according to the 'Five Rights': right drug, right dose, right route, right time, right resident." J. Review of the Facility policy, Abuse Definitions, issued 11/1999 and last revised 01/2011, revealed that neglect was defined as, "Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness."

Based on observation, record review and interview, the facility failed to ensure care was provided for for a recurring skin condition, a scab to the nose, for 1 (#48) of 37 (#1, 2, 8, 9, 10, 12, 13, 14, 17, 18, 20, 24, 38, 41, 44, 46, 48, 49, 52, 55, 59, 60, 61, 62, 63, 65, 67, 68, 69, 71, 74, 75, 78, 88, 98, 102, and 107) sampled residents evaluated for provision of care. Resident #48 was observed with a scab to the nose on 10/24/12. During investigation, one nurse reported the scab had been there since the resident's admission on 02/15/11, occasionally falling off and coming back. A second nurse reported she had first noticed the scab on 11/08/12, though the scab had been present since at least 10/24/12. This failed practiced had the potential to result in improper or inadequate care for Resident #48's skin condition. The findings include: A. Observations of Resident #48 revealed the following: 1. On 10/24/12 at 10:23 am, the resident was observed with a small scrape to the bridge of her nose. 2. On 11/07/12 at 11:14 am, the resident was in the dining room; a scab to the left side of the bridge of her nose was observed. 3. On 11/08/12 at 9:45 am, the resident was observed sitting in the hallway; a scab to the left side bridge of her nose was observed. B. On 11/07/12 at 1:08 pm, during an interview, Certified Nursing Assistant (CNA) #1 was asked about the scab on the bridge of resident #48's nose. She said, "... it'll go away and come back; we see it fall off, and she doesn't scratch. I don't know what it's from." During a second interview on 11/08/12 at 10:00 am, CNA #1 was asked what instructions she'd been given regarding the scab. She stated, "They never said anything since I've been here, no." When asked how long the resident had the scab, she stated, "Since I've been here, and I've been here 6 or 7 months now. The son was concerned the last time he was here." C. On 11/07/12 at 1:09 pm, during an interview, CNA #2 was asked about the scab on the bridge of resident #48's nose. She stated, "She doesn't scratch herself, it's just there. She's always had it since I've been here." D. On 11/07/12 at 1:44 pm, during an interview, RN #2 was asked if she knew how resident #48 got the scab on her nose. She said, "Ever since (name of resident #48) has come in some years ago it's been there, and sometimes it'll kind of come off and then it'll grow back again. I've told (name of resident #48's physician) about it, and she said just to watch it, if it changes shape then to let her know. It's not a scab, it's a skin growth of some kind, and it just grows on then falls off." When asked how long it had been there, she said "It's probably been a year or more." When asked if it was assessed when Resident #48 was first admitted , she flipped through Resident #48's chart and reported that it was recorded as a scab on the initial assessment; she then said, "I can see why they'd note it as a scab on the assessment, because it kind of looks like a scab." E. On 11/08/12 at 10:10 am during an interview, RN #6 was asked if she knew what the scab was on Resident #48's nose. She said, "No, I don't know what it is. I just saw that this morning." When asked if Resident #48 has always had it, she said, "uh uh. (No)" When asked if this was the first time she had noticed it, she said, "Yes, I noticed it today." When asked about the facility's procedure when finding something like that, she said, "I fax the doctor, and I like to call because you get a better chance of getting an order quicker, but I'm going to let (name of resident #48's physician) know to set up a routine to monitor and assess." F. On 11/08/12 at 10:19 am during a second interview with RN #2, when asked what the procedure was for a resident that has a skin issue, she said, "It's addressed by the nurse or wound care nurse, and they could evaluate and see what the proper treatment is for the skin. Fax the doctor, requesting treatment for [REDACTED].#48's sore, she said, "I keep an eye on it, but I didn't ever document it, and I should have." When asked what instructions she had given to CNAs regarding the care, she said, "To keep it clean and dry, and if it gets knocked off to tell the nurse." When asked if she had any documentation for skin checks for that, she said, "No, I don't. I ain't going to lie ..." When asked what the facility policy was regarding documentation of skin issues, she said, "Probably in the wound care chart is usually where I put it down and measure it and note the color, and get it done on a routine basis, and get it done once or twice a week, whatever her routine would be, and get documentation on it." G. Review of Resident #48's records revealed the following: 1. A Face Sheet dated 09/05/12 recorded the resident was admitted on [DATE] with admitting [DIAGNOSES REDACTED]. 2. A Physical Nursing Data Collection Tool dated 10/24/11 recorded a scab to the resident's nose. 3. A Comprehensive Care Plan dated 10/16/12 recorded the resident was at risk for impaired skin integrity due to immobility, rib fracture, and a history of [MEDICAL CONDITION]. No mention of a "scab" to Resident #48's nose was noted, nor was there any care plan instructing staff on a recurring nose wound.

Based on record review and interview, the facility failed to ensure that 1 (#14) of 3 (#14, #98 and #102) residents that were admitted into the facility without pressure ulcers did not avoid the development of pressure ulcers while in the facility. Resident #14 was admitted into the facility and assessed as having no pressure ulcer. She developed an avoidable Stage 2 pressure ulcer on her coccyx (bone at the base of the spine) during her stay at the facility. This failed practice likely caused the resident to develop the pressure ulcer during her stay at the facility. The findings are: A. Record review of the residents medical chart revealed a face sheet dated 10/09/12 documenting the resident was admitted to the facility on [DATE]. Resident #14 had the following [DIAGNOSES REDACTED]. Resident #14 was discharged from the facility on 09/26/12. 1. The initial Interdisciplinary Data Collection Tool dated 07/05/12 indicated there were no wounds on the diagrams and stated, "see IDP (Interdisciplinary Progress Notes) notes." 2. The Interdisciplinary Progress Notes (IDP) dated for 07/05/12 revealed, "7/5/12 @ (at) 2130 (9:30 pm) ... coccyx /Buttocks intact/pink & (and) Blanchable (checking integrity of blood flow) old scar on coccyx..." 3. The Braden Scale for Predicting Pressure Sore Risk dated 07/05/12 score was 14 which indicated a moderate risk. B. Review of the Daily Skilled Note dated 09/03/12 at 11:30 am revealed, "(Name of Nurse), LPN (Licensed Practical Nurse) reported to me that res (resident) has wound on lower sacrum (tail bone) measuring 1 cm (centimeter) X (by) 0.25 cm area around wound is reddened and hot, blanchable per (Name of Nurse) ... wound nurse notified." 1. The wound care nurse notes for 09/04/12, on the Wound Flow Sheet, documented that the wound is a pressure ulcer at stage 2 on the sacrum. The form has a question whether the wound was present on admission/readmission and the answer checked off is, "No". The length of the wound is 1.2 cm, the width is 0.6 cm, depth is 0.1 cm. It is noted that there is 100% granulation (Fleshy projections formed on the surface of a gaping wound that is not healing by first intention or indirect union). 2. Review of the Daily Skilled Note dated 09/10/12, "2100 (9:00 pm) Res (resident) A (alert) + (and) confused. returned (sic) back from hospital...varius (sic) bruises + nodules along c (with) coccyx (see admit sheet)..." 3. The Initial Interdisciplinary Data Collection Tool, undated, revealed a diagram with a circle on the coccyx area with a line leading to the words, "decub wound." 4. Review of the Treatment Administration Record for 09/2012 revealed a treatment order, "Pressure ulcer- sacrum cleanse c wound cleanser, cover c Ultec Pro change q (every) QOD (every other day) & (and) PRN (as needed) until resolved." The administration of treatments initialed off were not done every other day. 5. Review of the Wound Flow Sheet dated 09/12/12 indicated that the resident had a Stage III pressure ulcer on the sacrum that measured 1.4 cm in length and 0.5 cm in width with 100% slough (dead matter or necrosed tissue separated from living tissue or an ulceration) and had a minimum amount of serous (thin and watery) drainage. The Wound Flow Sheet dated 09/26/12 documented that the wound measured 2.0 cm in length and 2.0 cm in width with serous drainage. C. On 11/08/12 at 4:00 pm, during an interview, the Wound Care Nurse was asked if she remember resident #14 and that she developed a pressure ulcer. She stated yes and stated that the resident was, "a little person," who came in with no pressure sores and developed a Stage 2. She stated that the resident had developed a Stage II and then went to the hospital, and when she came back it was a Stage 3. She was asked about the treatment being ordered for every other day and asked to look through the chart to find where the treatments were done according to the orders. The Wound care Nurse stated, "There is one place she didn't according to the papers. According to the papers, she didn't get changed every other day." She stated that she usually documents on a, "brown sheet," (Wound Flow Sheet Attachment) and an IDP note, adding, "I see that I did not document thoroughly before she left to the hospital or when she came back." The Wound Care Nurse was asked if this was an avoidable pressure ulcer. She stated, "Probably, honest opinion, yes." D. On 11/13/12 at 3:10 pm, during an interview, the Director of Nursing (DON) was asked if this was an avoidable pressure ulcer for resident #14. He stated, "Yes. It was avoidable. If she came in with a healed wound it should not have gone to a Stage 2."

Based on record review and interview, the facility failed to ensure that 2 (#8, 41) of 8 (#8, 10, 12, 24, 41, 63, 75 and 107) residents evaluated for medication administration remained free of significant errors. Resident #8 was administered [MEDICATION NAME] 70 milligrams (mg) by mouth once daily for 8 days from 10/01/12 through 10/09/12, instead of once weekly. Resident #41 was administered 20 units of Humalog, a quick acting insulin, instead of 20 units of [MEDICATION NAME] on 09/13/12 at 8:30 am. These errors jeopardized the residents' health and safety: resident #8 was taken to the emergency room for emergency diagnostic assessment for signs of hypoglcemia (low blood sugar), a condition which can trigger [MEDICAL CONDITION] in extreme cases; resident #41 was at risk of injury or death due to extreme low blood sugar and required emergency administration of an intramuscular hormone and other interventions to counteract the insulin, as well as enduring 16 finger-stick blood glucose checks (involving sticking the fingertip with a lancet to obtain a drop of blood) over a period of two hours and 40 minutes. This failed pratice likely cause the residents to receive the wrong dosage and medication that could place in an emergent situation. The findings are: Resident #8 A. Review of the record of resident #8 revealed a Face Sheet dated 07/18/11, documenting admission on 07/14/10 with [DIAGNOSES REDACTED]. B. Review of the Incident Details dated 10/09/12 revealed under comments, "[MEDICATION NAME] was to be given once per week. Orders were transcribed incorrectly to once a day and resident received wrong amount." C. Review of the Fax Communication to Physician, dated 10/09/12, revealed under Concern: "This resident has received 70 mg of [MEDICATION NAME] on a daily basis for 9 days in lieu of once a week." D. Review of Interdisciplinary Progress notes dated 10/09/12 at 5:45 pm revealed, "Resident transferred to (name of hospital) per instructions per Physician for evaluation following discovery that [MEDICATION NAME] had been administered more frequently than originally ordered... " E. During an interview with the Director of Nursing (DON) on 10/25/12 at 10:25 am, he stated,"It was given weekly until they transferred the medication to the new Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]." F. During an interview with RN (Register Nurse) #1 on 10/30/12 at 2:00 pm, she stated regarding the [MEDICATION NAME] order, "I saw the MAR, it said give 5 days a week. I assumed the MAR indicated [REDACTED]. The DON interviewed me and informed me of the error." G. On 10/30/12 at 2:17 pm, during an interview with RN # 2, she stated that she gave [MEDICATION NAME] one time on October 6th or 7th. She stated, "The MAR indicated [REDACTED]. I did not become aware of this problem until the DON informed me on [DATE]th." H. Review of the Incident Details for 10/09/12 at 8:00 am for Resident #8, revealed under Comments: "[MEDICATION NAME] was to be given once per week. Orders were transcribed incorrectly to once a day and resident received wrong amount." I. Review of the 2013 Nursing Drug Handbook revealed, for [MEDICATION NAME], overdose indications including [DIAGNOSES REDACTED]. Review of the Merck Manual of [DIAGNOSES REDACTED].<7 mg/100 ml) may cause laryngospasm (a spasm of the vocal cords that can interfere with breathing) and generalized convulsions." Resident #41 J. Review of the record of resident #41 revealed a Face Sheet dated 11/15/11, documenting admission on 12/15/09 with [DIAGNOSES REDACTED]. Further review revealed a physician's orders [REDACTED]. K. Review of record of resident #41 revealed a Fax Communication to Physician dated 09/13/12. The record documented, "Concern: Res.(Resident) administered 20 u (units) Humalog this am instead of [MEDICATION NAME]" The communication documented emergency interventions including finger-stick blood glucose checks every 5 to 15 minutes, intramuscular injection of [MEDICATION NAME] (a hormone that raises the level of glucose in the blood), and oral administration of a tube of glucose paste and high-sugar foods to counteract the insulin. A follow up Fax Communication with the same date documented 16 finger-stick blood glucose checks between 11:30 am and 2:07 pm. L. During an interview on 10/25/12 at 3:05 pm with Register Nurse (RN)#1, she stated, "I was precepting (teaching) (name of RN #3), when I was drawing up insulin for (name of Resident #41), her 8:00 am dose of [MEDICATION NAME]. I drew up 20 units of what I thought was [MEDICATION NAME] but it was Humalog. I did not check or look at the bottle, was just in a hurry. I had given her Humalog 2 to 4 units at 7:30 am. I had placed the Humalog bottle in the [MEDICATION NAME] box and [MEDICATION NAME] bottle in the Humalog box. The [MEDICATION NAME] bottle is taller. When I noticed the error, I told (name of DIrector of Nursing). I brought the resident into the DON office. Her blood sugar (BS) was 59..." M. During review of the procedure, Insulin Administration, revised 1/20/12, the record instructed, "Procedure, 1. Check label on vial carefully to ensure correct type of insulin and date vial was opened." During record review of the procedure, Administration of Medication, revised 1/20/09, the record instructed, "Using the specific center's medication system, administer medications to the resident according to the 'Five Rights': right drug, right dose, right route, right time, right resident."