Every finding on record at Blue Palms Health and Rehabilitation Center of Day

Based on observations, interviews and record review, the facility failed to follow proper sanitation and food handling practices by failing to ensure the kitchen's ice machine was clean and free of black biofilm. This had the potential to negatively affect all 94 residents currently residing in the facility. The findings include:On 04/19/26 at 9:20 AM, an observation was made of the kitchen's ice machine air filters, which were covered with dust and spider webs. The air filter instructions read: Clean air filter twice a month. (photographic evidence obtained)On 04/20/26 at10:48 AM, another observation was made of the kitchen's ice machine air filters covered with dust and spider webs. (photographic evidence obtained)On 04/21/26 at 4:21 PM, the kitchen's ice machine chute was observed covered with a black biofilm build-up. (photographic evidence obtained) The weekly ice machine cleaning log posted on the wall adjacent to the ice machine noted 07/17/25 (eight months ago) was the last time the ice machine was cleaned. On 04/22/26 at 1:35 PM, another observation was made of the facility's ice machine chute with a black biofilm build-up. (photographic evidence obtained) During an interview with the Certified Dietary Manager (CDM) on 04/22/26 at 1:00 PM, the CDM explained that the maintenance department was made responsible for cleaning the kitchen's ice machine in August of 2025. Prior to maintenance cleaning the kitchen ice machine, kitchen staff cleaned the machine monthly and documented each cleaning on the ice machine's cleaning log. Maintenance did not record cleaning on the ice machine cleaning log. On 04/22/26 at 1:04 PM, an interview was conducted with the Maintenance Director. He explained that the kitchen's ice machine cleaning came up in the facility's electronic work order system once a month. The process for cleaning the ice machine included removing and cleaning the filters, turning off the unit, and flipping the switch to turn on the cleaning mode. On 04/22/26 at 1:35 PM, the Maintenance Director pulled out the dispenser front cover of the kitchen's ice machine, removed the screws and reached the flap. Once the ice chute was in sight, he verified the black biofilm covering the ice chute as well as identifying a biofilm on the interior of a hose above the chute. A review of the facility's work history report for the previous six months revealed that the ice machine was cleaned and disinfected by the maintenance department every three months. Further review of the facility's work history for the previous 12 months noted that the ice machine was cleaned and disinfected by the Maintenance Department on the following dates: 03/31/26, 12/31/25, 09/30/25 and 03/31/25. The task description for ice machine maintenance included: Check filters (if present), clean coil, sanitize interior, and delime as necessary. A review of the facility's policy titled Sanitation Inspection (effective 06/22/24, reviewed/revised 06/21/24), revealed:Page one documented .it is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations.

Based on observation, record review and interviews, the facility failed to implement a care plan for one (Resident #5) of 38 residents in the total survey sample for administration of medications as ordered by the physician. The nursing staff did not adhere to the parameters set by the resident's physician, which could lead to a dangerous cardiovascular event such as severe hypotension (low blood pressure). The findings include:A review Resident #5's active physician's orders and Medication Administration Record (MAR) revealed parameters for Bumetanide (diuretic) 0.5 milligrams (mg) twice a day. The parameters were: Hold if systolic blood pressure is less than 115. Further review of the April 2026 MAR revealed:Bumetanide 0.5, give 1 tablet by mouth every morning and at bedtime for fluid overload. Hold for SBP (systolic blood pressure) of less than 115. On the following dates, the medication was administered without following the parameters:4/1/26 - BP (blood pressure) 112/60 AM and PM with medication administered both times.4/2/26 - BP 106/68 AM and PM with medication administered both times.4/3/26 - BP 107/63 AM and PM (MAR not signed)4/4/26 - BP 108/72 AM and 112/60 PM with medication administered both times.4/5/26 - BP 97/61 AM and 91/62 PM with medication administered both times.4/6/26 - BP 106/62 AM with medication administered.4/11/26 - BP 111/68 PM with medication administered.4/14/26 - BP 104/63 AM with medication administered. 4/15/26 - BP 110/73 AM and 98/57 PM with medication administered both times.4/16/26 - BP 111/62 AM with medication administered.4/19/26 - BP 102/56 AM with medication administered.(photographic evidence obtained)Further review of the resident's medical record revealed diagnoses included chronic obstructive pulmonary disease(COPD), hypertension (HTN), congestive heart failure (CHF), and paroxysmal atrial fibrillation.A review of the Minimum Data Set assessment dated [DATE], revealed a diagnosis of hypertension recorded. A review of the resident's care plan, dated 4/22/26, revealed a focus area for Alteration in Cardiovascular Function with a diagnosis of hypertension. The first approach listed was to administer medications as ordered. (photographic evidence obtained)An interview was conducted with Licensed Practical Nurse (LPN) A on 4/23/26 at 9:25 a.m. She was asked to pull up the MAR for Resident #5 in the electronic medical record. She was asked if a medication was held for any reason, what was noted on the MAR. She reported she did not know. She was asked to scroll down and look at the codes attached to the MAR. She reported 5 should be documented if medications were held for any reason. When she was asked what the check mark and initials represented on the MAR, she replied that they meant the resident received their medications. She was asked about Resident #5's parameters for a systolic blood pressure below 115, and she confirmed that Bumetanide was administered multiple times when the resident's systolic blood pressure was below 115.An interview was conducted with the Director of Nursing (DON) at 11:24 a.m. on 4/23/26. She confirmed that Bumetanide was administered multiple times when the resident's SBP was less than 115. She stated education would be provided, the mistakes would be reported as medication errors, and the resident's physician would be notified.A review of the facility's policy and procedure for Medication Administration (revised 8/7/25), revealed:Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.A review of the facility's policy and procedure for Comprehensive Care Plans (revised 4/5/25), revealed:It is the policy of this facility to develop and implement a comprehensive, person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a residents medical, nursing, and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality.The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented as needed.

Based on interviews and record review, the facility failed to provide documented evidence of having informed each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility's per diem rate. This could have a potentially negative affect on 65 of the 82 residents currently in the facility who actively receive Medicare/Medicaid. The findings include: During the Entrance Conference on [DATE] at 10:37 a.m., the Administrator was asked to provide a list of Medicare beneficiaries who were discharged from a Medicare covered Part A stay with benefit days remaining in the past six months prior to the survey. The instructions were to exclude residents who: Received Medicare Part B benefits only; were covered under Medicare Advantage insurance; who expired during the sample date range and/or who were transferred to an acute care facility or another skilled nursing facility (SNF). On [DATE] at 3:50 p.m., the information provided for review by the facility contained the names of residents who had expired as well as residents who had been discharged to another SNF. The document was returned to the Social Services Director (SSD). She was reminded of the instructions which stated these residents were not to be included in the selection. She stated she would make the corrections. On [DATE] at 8:58 a.m., the list was returned to the survey team. The Administrator was asked to provide Beneficiary Notices for three random residents. On [DATE] at 5:13 p.m., the survey team inquired about the Beneficiary Notices requested the previous day. The Administrator stated she did not recall the request. The Administrator was given a second written request for the same three beneficiary notices. On [DATE] at 9:40 a.m., the SSD returned the notices, which were incomplete. She was advised that the entire form needed to be completed. They were returned to her for correction. On [DATE] at 11:40 a.m., the information was returned to the survey team. The Administrator was advised that the information was still not correct. The documents were incomplete and did not include the notices. On [DATE] at 12:33 p.m., the Beneficiary Notices provided were still not accurate. The SSD was asked who was responsible for providing the information to the residents. She stated the Admissions Office got the information and forwarded it to her, then she completed them. On [DATE] at 2:26 p.m., the SSD was reminded that the requested Beneficiary Notices had not been received. She stated she was still gathering the information. She asked for clarity about what was being requested. The surveyor explained to the SSD what was being requested to meet the requirement. She stated the Beneficiary Notices requested did not meet the requirements. She stated she could provide the documents for three other residents. On [DATE] at 2:54 p.m., the SSD advised the survey team that she was informed the information she previously provided to the survey team was not accurate. She stated she only had partial information. At the time of the survey exit on [DATE] at approximately 3:40 p.m., the facility still had not provided the survey team with the requested information.

Based on observations, staff interview, medical record review, and a review of facility policies, the facility failed to maintain infection prevention and control standards for one (Resident #538) of 31 residents in the total survey sample, by leaving the resident's enteral nutrition line uncapped and open to air when it was not in use. The facility also failed to maintain infection prevention and control standards when one (Licensed Practical Nurse (LPN) A) of six nurses observed during medication administration failed to clean/disinfect a blood pressure cuff between resident uses. This practice could negatively impact any resident having their blood pressure checked by this nurse using this cuff. Written standards, policies, and procedures must include standard and transmission-based precautions to be followed to prevent the spread of infections. Policies must define and explain standard precautions and their application during resident care activities, including routine cleaning and disinfection of resident care equipment including equipment shared among residents (e.g., blood pressure cuffs, etc.). The findings include: On 7/29/24 at 12:50 p.m., Resident #538 was observed lying in bed with his eyes closed. His enteral nutrition bottle, dated 7/29/24, was spiked/open with approximately 100 milliliters (ml) missing from the 1000 ml bottle. The bottle was hanging on the pole but was not connected to the resident. The tubing was also hanging on the pole. The open end of the tubing had no cap or protective device, and was open to air. (Photographic evidence obtained) On 7/30/24 at 9:00 a.m., Resident #538 was observed sitting up in a Geri chair (large, padded, reclining chair). The enteral nutrition bottle was not connected to the resident. The bottle was dated 7/30/24, was spiked/open and half empty. The bottle was hanging on a pole at the resident's bedside. The tubing connected to the enteral nutrition bottle was also hanging on the pole. The open end of the tubing had no cap or protective device, and was open to air. (Photographic evidence obtained) A review of Resident #538's active physician's orders, revealed an order for Nepro (liquid nutrition) 1.8 cal (calorie) by gastric tube at 600 ml per hour, continuous for 24 hours per day. On 8/1/24 at 7:10 a.m., Licensed Practical Nurse (LPN) A was observed coming out of Resident #538's room. She confirmed that she was caring for this resident today. She was asked if the feeding was stopped or held, would the same bottle and tubing be reconnected when it was restarted. She stated, Yes, as long as it's less than 24 hours old. On 8/1/24 at 7:18 a.m., Licensed Practical Nurse (LPN) A was observed while checking a resident's blood pressure. In an interview with LPN A at the time of the observation, she stated she preferred to check her residents' blood pressures herself, as she was responsible for them. She was then observed removing the blood pressure cuff from the resident and placing it back in the case on her medication cart without cleaning it. When she was asked to explain the process for disinfecting the blood pressure cuff, she stated she usually cleaned it once per shift. A review of the facility's policy titled Standard Precautions for Infection Control (revised 4/4/24) revealed: Policy: All staff are to assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Therefore, all staff shall adhere to Standard Precautions to prevent the spread of infection to residents, staff, and visitors. Policy Explanation and Compliance Guideline: 5. Resident Care-Equipment and Instruments/Devices: a. Policies and procedures have been established for containing, transporting, and handling resident-care equipment and instruments that may have been contaminated with blood or bodily fluids. Personnel are trained in the use of these procedures. (No other policy and procedure was provided that addressed how staff were to contain, transport and/or handle resident care equipment and instruments that were potentially contaminated.) A review of the facility's policy titled Care and Treatment of Feeding Tubes (revised 4/4/24) revealed: Policy: It is a policy of this facility to utilize feeding tubes in accordance with the current clinical standards of practice, with interventions to prevent complications to the extent possible. 7. Direction for staff on how to provide the following care will be provided: d. Use of infection control precautions and related techniques to minimize the risk of contamination. (No specifics were included in the facility's policy regarding how to minimize contamination.) On 8/1/24 at 1:30 p.m., during an interview with the Administrator, she was asked for any other Infection Prevention and Control Policies. She stated there were no other policies. According to the National Library of Medicine at https://pubmed.ncbi.nlm.nih.gov/28079411 (accessed on 8/21/24 at 11:00 a.m.): The contamination of enteral feed can often be overlooked as a source of bacterial infection. Enteral feeds can become contaminated in a variety of different ways. Most often infections result in extended lengths of stay in hospital and patients also need additional therapies and treatments in order to resolve these infections. According to the National Library of Medicine at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3086084 (accessed on 8/21/24 at 11:10 a.m.): Failure to place a sterile cap on the end of a reusable intravenous (IV) administration set that has been removed from a primary administration set, saline lock, or IV catheter hub, with the tubing left hanging between uses. Result: The tip of the set is exposed to potential contaminants; this can lead to infection if the non-sterile IV set is reconnected to the patient ' s IV access. Now it appears that many practitioners are not considering the risk of contamination; they are not placing a sterile cap on the exposed tubing. a compatible sterile covering should be aseptically attached after each intermittent use. Capping the tubing end and disinfecting the port should be documented in the institution ' s policies and procedures. The capping procedure should emphasize that a new sterile cap must be used each time the tubing is capped. According to the World Health Organization at https://www.who.int/docs/default-source/documents/health-topics/standard-precautions-in-health-care.pdf?sfvrsn=7c453df0_2 (accessed on 8/21/24 at 11:20 a.m.): Standard precautions are meant to reduce the risk of transmission of bloodborne and other pathogens from both recognized and unrecognized sources. They are the basic level of infection control precautions which are to be used, as a minimum, in the care of all patients. The control of spread of pathogens from the source is key to avoid transmission. Promotion of a safety climate is a cornerstone of prevention of transmission of pathogens in health care. Develop policies which facilitate the implementation of infection control measures. 50369

Based on observations, staff and resident interviews, and medical record review, the facility failed to ensure that three residents who were unable to carry out activities of daily living (Residents #34, #43, and #66) from a total survey sample of 31 residents, received necessary care and services to maintain grooming and personal hygiene. The findings include: 1. On 7/29/24 at 1:00 p.m., Resident #34 was observed lying in bed, awake. His feet were uncovered. His toenails were elongated on both feet with his right great toenail observed to be curled around his toe. The resident was asked if he had toenail care or had been seen by podiatry since arriving at the facility. He replied no. (Photographic evidence obtained) On 7/31/24 at 8:21 a.m., Resident #34 was observed lying in bed, awake. He was asked if anyone had trimmed his toenails. He pulled his bedcovers back and said, Nope! I can't trade my feet. His toenails were observed in the same condition as on 7/29/24 at 1:00 p.m. A review of Resident #34's medical record revealed he was admitted on [DATE]. A review of his physician's orders revealed an order dated 6/15/24: Monitor skin weekly. Further review of the orders revealed no orders for podiatry services. A review of weekly skin checks for the past six weeks revealed the following: 7/27/24: nails cleaned and trimmed? No. 7/20/24: nails cleaned and trimmed? No 7/13/24: nails cleaned and trimmed? No 7/06/24: nails cleaned and trimmed? Yes 6/29/24: nails cleaned and trimmed? Yes 6/22/24: nails cleaned and trimmed? Yes A review of the Quarterly Minimum Data Set (MDS) assessment, dated 5/31/24, revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 possible points, indicating moderate cognitive impairment. No behaviors were documented. He required supervision for personal hygiene. A review of the resident's person-centered care plan (3/21/24, revised 6/10/24) revealed: Resident requires supervision assistance with some activities of daily living (ADLs) related to a history of cerebral vascular accident (CVA - stroke), anemia, neuropathy, chronic obstructive pulmonary disease (COPD), and shortness of breath upon exertion during ADLs. Goal: Resident will maintain current level of function through the review date. Interventions: Personal Hygiene: Requires staff supervision. A review of the progress notes from 6/4/24 through 8/1/24 revealed no notes regarding toenails, care of toenails, or podiatry services. During an interview with the Director of Nursing (DON) on 7/31/24 at 3:52 p.m., she was asked for the facility's policy for the care of resident fingernails and toenails. She stated, We don't have a policy. She was asked to provide podiatry notes for Resident #34. She was unable to provide any notes. She was asked who provided toenail care for the residents. She stated, We have a podiatrist. She was asked how often the podiatrist came to the facility. She stated, They were here on July 21st. She was asked again how often they came to the facility. She stated, It's supposed to be monthly, but we did have one or two months we were without one. She was asked how residents were added to the schedule to be seen by the podiatrist. She stated, Social Services handles that. She was asked if staff were permitted to trim residents' toenails. She stated, No, only the podiatrist trims toenails. The DON was shown photographs of Resident #34's toenails and was asked if the length, cleanliness, and curving onto the skin of the toes in these photos was an acceptable standard of practice. She agreed that this was not acceptable. She was asked if this resident had been seen by a podiatrist since he had been at the facility. She stated she wasn't sure and would check his medical record. She was not able to provide verification of the resident having been seen by podiatry since his admission to the facility on [DATE]. On 7/31/24 at 4:05 p.m., during an interview with the Social Services Director (SSD), she was asked if she set up podiatry services for the residents. She stated, Yes, we have a service in place that came out to see our first set of people and they'll be back next Saturday. I have asked for the entire building to be seen. I had priority people set to be seen right away. She was asked how long the facility had not had a podiatrist coming out to see the residents. She replied, We had one and asked him to leave, because he only had one set of tools, so we asked that he not come back. We have been without a podiatrist for several months. She was asked how she was made aware of which residents needed to be seen by podiatry. She replied, The nurses let me know and we keep a list. I will send that list over to the podiatrist as to who needs to be seen. She was asked if Resident #34 was on her priority list. She stated, He is on the list to be seen next for the upcoming podiatrist. She was asked when the last time was that Resident #34 had been seen by a podiatrist. She stated, I don't know. My emails don't go that far back; they are set up to auto erase. It's just how they are set up, I'm not sure why. October 2023 was the last time I can see he was seen by podiatry on my email. She was asked to provide the notes for the October 2023 visit. She stated, Yes, I just have to go to my computer to get that. She was asked how often residents should be seen by podiatry. She stated, They should be seen every six weeks. That's what I was always taught. She was asked if there was a facility policy for the frequency of toenail care or for podiatry services. She stated, No, the lady who taught me said it's every six weeks, but no longer than three months. The SSD was unable to provide any podiatry notes for Resident #34. On 7/31/24 at 4:20 p.m., in an interview with the Administrator, she stated the facility had been trying to get a podiatrist in place and had emails to show the attempts, as well as cancellations of visits with their former podiatrist. She was asked if the facility had sought an alternative for residents, such as a policy allowing registered nurses to trim residents toenails. She stated no. 48947 2. On 7/29/24 at 12:57 p.m., Resident #43 was observed with long, jagged fingernails. On 7/31/24 at 10:09 a.m., Resident #43 was observed with long, jagged fingernails. The resident's orders and a copy of the skin check for 7/28/24 were requested from the Director of Nursing (DON). They were not provided during the survey. On 8/1/24 at 9:31 a.m., Resident #43 was again observed with long, jagged fingernails. (Photographic evidence obtained) A review of Resident #43's medical record revealed that he was admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease, protein-calorie malnutrition, dementia without behavior disturbance, psychotic disturbance, mood disturbance, anxiety, and adult failure to thrive. A review of his active physician's orders revealed an order dated 3/20/23 instructed nursing to complete skin observations weekly per schedule. Weekly Skin Checks were reviewed revealing a note dated 7/28/24 documenting that the resident's fingernails were trimmed. (One day before the resident was observed with long, jagged nails) A review of the Quarterly minimum data set (MDS) assessment, dated 5/10/24, revealed a brief interview for mental status (BIMS) assessment had not been conducted with the resident because he was rarely or never understood. The assessment was documented as having been conducted with staff and the resident was noted with moderately impaired cognitive skills for daily decision making. Decisions were poor and cues/supervision were required. There were no behaviors indicated. The resident required supervision or touching assistance for personal hygiene tasks, and he was receiving hospice care. A review of the Care Plan revealed the following Focus Area: Impaired cognitive function and impaired thought processes related to a diagnosis of dementia. Resident has decreased ability to complete and verbalize thought processes, decreased ability to state basic needs, and long/short term memory loss. (initiated 9/1/22, revised 5/20/24). Focus Area: Resident has an ADL (activities of daily living) self-care performance deficit related to altered cognition, decreased physical mobility due to dementia. (initiated 8/28/2022, revised 5/20/2024), and Focus Area: Resident has the potential for impaired skin integrity related to incontinence, altered cognition, decreased physical mobility, and malnutrition. Resident has a history of pressure ulcers and poor safety awareness. (initiated 8/28/2022, revised, 5/20/2024). On 8/1/24 at 10:03 a.m., a telephone interview was conducted with Licensed Practical Nurse (LPN)/Unit Manager H for the North Wing and the Hope Unit. She was asked who was responsible for providing the residents' fingernail care. She stated, The CNAs (certified nursing assistants) cut the nails if the resident is not diabetic; the nurses cut the fingernails for diabetics. A policy for fingernail care was requested, but no policy was provided for review during the survey. 3. A review of Resident #66's medical record revealed that he was admitted on [DATE] with diagnoses including muscle wasting and atrophy of the right lower leg, major depression, non traumatic ischemic infarction of left lower leg, muscle weakness, and dependence on supplemental oxygen. A review of his 5-Day MDS assessment, dated 6/17/24, revealed that he had a brief interview for mental status (BIMS) score of 14 out of 15 possible points, indicating intact cognition. No behaviors were indicated. He required supervision/touching assistance for eating, and was dependent for bed mobility, transfers, toileting, and personal hygiene. A review of Resident #66's Care Plan (dated 6/24/24) revealed the following Focus Area: Risk for Self-Care Deficit: Bathing, Dressing, Feeding. Further review of the medical record revealed no documented evidence of podiatry visits from the resident's admission through 8/1/24. On 7/31/24 at 1:53 p.m., Resident #66 was observed lying in bed. His toenails were elongated. (Photographic evidence obtained) On 8/1/24 at 10:03 a.m., a telephone interview was conducted with LPN/Unit Manager H for the North Wing and the Hope Unit. She stated, The podiatrist cuts all toenails. A policy for toenail care was requested, but no policy was provided for review during the survey.

Based on observations, interviews, record review, and a review of facility policy, the facility failed to report to the State Agency, injuries of unknown origin for one (Resident #43) of 31 residents in the total survey sample. The findings include: A review of Resident #43's medical record revealed an admitted [DATE] with diagnoses including atherosclerotic heart disease, protein-calorie malnutrition, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and adult failure to thrive. Further review of the record revealed a progress note dated 7/18/24 at 5:25 a.m., which documented that facility staff observed a left elbow hematoma and left lower leg hematomas with dried blood. The note indicated that the resident had some confusion and was unable to explain what happened. No additional notes mentioning these injuries were found between 7/18/24 and 8/1/24. A review of the active physician's orders revealed an order dated 3/20/23 instructed nursing to complete skin observations weekly per the schedule. No orders for care of the resident's shins were located in the record. On 7/29/24 at 12:57 p.m., Resident #43 was observed with several skin tears and bruises on both of his shins. On 7/31/24 at 10:09 a.m., Resident #43 was observed with several bruises and skin tears on both of his shins. The resident's care orders for these areas and a copy of the skin check from 7/28/24 were requested from the Director of Nursing (DON). They were not received during the survey. On 8/1/24 at 9:31 a.m., the same bruises and open areas/skin tears were again observed on both of the resident's shins. (Photographic evidence obtained) A review of the Weekly Skin Checks for 6/21/24, 6/28/24, 7/5/24, 7/14/24, 7/21/24, and 7/28/24, revealed that none noted multiple bruises/hematomas or open areas to the right or left shin. A review of the Quarterly minimum data set (MDS) assessment, dated 5/10/24, revealed a brief interview for mental status (BIMS) assessment had not been conducted with the resident because he was rarely or never understood. The assessment was documented as having been conducted with staff and the resident was noted with moderately impaired cognitive skills for daily decision making. Decisions were poor and cues/supervision were required. There were no behaviors indicated. The resident required supervision or touching assistance for personal hygiene tasks, and he was receiving hospice care. A review of the resident's Care Plan revealed the following Focus Area: Resident has the potential for impaired skin integrity related to incontinence, altered cognition, decreased physical mobility, and malnutrition. Resident had a history of pressure ulcers and poor safety awareness. (initiated 8/28/2022, revised, 5/20/2024). On 8/1/24 at 10:03 a.m., a telephone interview was conducted with Licensed Practical Nurse (LPN)/Unit Manager H for the North Wing and the Hope Unit. She was asked to explain the facility's process for weekly skin checks. She stated, The skin is checked during showers. Any nurse can go in and observe the skin and document the skin check. She was asked about the most recent skin check that she documented on 7/28/24, and why the documentation did not match the current condition of the resident's skin. She stated, The nurse that works the 11-7 shift had already written a note in the medical record on 7/18/24, and he had already reported to me that the staff observed the resident's legs, so I didn't include it on the skin check report. When I did the skin check, the areas looked like they were not new. She was asked if the facility was ever able to determine how the resident acquired the injuries. She replied, No, we never found out. LPN H was asked if these injuries of unknown origin were investigated. She replied, I don't want to say that it was investigated, but I don't really know. She was asked how the facility addressed injuries of unknown origin. She stated, We notify the doctor and the family, and whatever orders we receive, we put them in and carry them out. The nurses usually treat skin tears. On 8/1/24 at 1:12 p.m., a telephone interview was conducted with Hospice Registered Nurse (RN) J. She stated, I was out to see him (Resident #43) yesterday. He was in a social setting, so honestly, I didn't disrobe him or try to take him to his room. She was asked if the facility notified her of the condition of his lower legs, specifically, an open area and several skin tears. She stated she couldn't recall being notified of that, but she was aware that he had some scratches. She stated, I was just out there yesterday and he seemed fine, but I can come back tomorrow and address the issue. On 7/31/24 at 1:17 p.m., an interview was conducted with the DON. She was asked to describe the facility's process for a circumstance in which a resident was observed with an injury of unknown origin. She stated, We ask the resident what happened first. If they can't tell us how the injury occurred, we start an investigation. We talk to the staff about the resident's behaviors , any habits that may have contributed to the injury, and any redirection issues that the resident may have. We start abuse and neglect training and continue to monitor. We also contact family and the doctor. The unit managers usually make the contact. If we cannot figure out how the resident was injured, we report it to DCF (Department of Children and Families) and ACHA (Agency for Health Care Administration. The DON was asked who was responsible for the reporting. She stated, [Administrator] keeps track of that, and the incident is documented in the medical record under incidents. She was asked what tools the facility had for making the staff aware of resident injuries of unknown origin. She stated, We typically discuss any incidents in the morning meeting. A review of facility's policy for Incidents and Accidents (implemented 4/4/24, revised: 4/4/24), revealed an accident refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident. Policy Explanation: The purpose of incident reporting can include: Meeting regulatory requirements for analysis and reporting of incidents and accidents. Compliance Guidelines: 4. Incidents that rise to the level of abuse, misappropriation, or neglect, will be managed and reported according to the facility's abuse prevention policy and will be reported accordingly. The following incidents/accidents require an incident/accident report but are not limited to: unobserved injuries.

Based on observations, interviews, record review, and a review of facility policy, the facility failed to ensure that a resident who required oxygen therapy received such therapy per the physician's orders for one (Resident #38) of one resident reviewed for oxygen therapy, from 31 residents in the total survey sample. The findings include: On 7/29/24 at 12:49 p.m., Resident #38 was observed lying in bed receiving oxygen via nasal cannula. The oxygen flow rate was set at 2.5 L/min (liters per minute). (Photographic evidence obtained) On 7/30/24 at 9:40 a.m., Resident #38 was observed sitting up on the side of his bed receiving oxygen via nasal cannula. The oxygen flow rate was set at 2.5 L/min. (Photographic evidence obtained) A review of Resident #38's medical record revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and cognitive/communicative deficit. A review of the resident's physician's orders revealed a 9/3/23 order for Oxygen at 2 liters per nasal cannula continuous via concentrator/tank. A review of the Quarterly minimum data set (MDS) assessment, dated 6/13/24, revealed a brief interview for mental status (BIMS) score of 11 out of 15 possible points, indicating moderately impaired cognition. No behaviors were indicated. He was documented with shortness of breath on exertion, when at rest, or when lying flat, and oxygen therapy was indicated. A review of the Quarterly minimum data set (MDS) assessment, dated 3/13/24, revealed a brief interview for mental status (BIMS) score of 12 out of 15 possible points, indicating moderately impaired cognition. No behaviors were indicated. He was documented with shortness of breath when lying flat, and oxygen therapy was indicated. A review of the Quarterly minimum data set (MDS) assessment, dated 9/11/23, revealed a brief interview for mental status (BIMS) score of 12 out of 15 possible points, indicating moderately impaired cognition. No behaviors were indicated. He was documented with shortness of breath with exertion and when lying flat. Oxygen therapy was indicated. A review of the resident's Care Plan (completed 6/24/24), revealed the following Focus Areas: Resident has oxygen therapy related to shortness of breath upon exertion and while lying flat, and Resident has a diagnosis of COPD, and he has shortness of breath upon exertion and when lying flat. A review of the resident's Progress Notes revealed no behavioral issues or non-compliance with oxygen therapy. On 8/1/24 at 1:29 p.m., an interview was conducted with Licensed Practical Nurse (LPN) I. She was asked to review Resident #38's oxygen orders. She opened the electronic medical record (EMR) and stated, He has an order for 2 liters via nasal cannula, continuous for (COPD) chronic obstructive pulmonary disease. She was asked to accompany this surveyor to the resident's room to check the current flow rate against the physician's order. The flow rate was set at 2.5 L/min. The nurse stated, When he comes in from smoking he turns that oxygen up, and I told him that he is doing himself more harm than good. She adjusted the flow to the appropriate rate. A review of the facility's policy titled Oxygen Administration (implemented 4/4/24, reviewed 4/4/2024), revealed: Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under orders of a physician, except in the case of an emergency.

Based on observations, medical record review, staff and resident interviews, and facility policy review, the facility failed to ensure that one (Resident #44) in a sample of 25 residents was provided respiratory care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Resident #44 was administered oxygen at a flow rate which exceeded his physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The findings include: On 7/18/22 at 12:25 PM, Resident #44 was observed lying in bed with his oxygen (O2) concentrator set at 5 liters per minute (LPM). His nasal cannula was observed in his hands. The resident then placed the prongs of the nasal cannula in his mouth. On 7/18/22 at 3:00 PM, Resident #44 was observed lying in bed, awake, with no nasal cannula in place. His oxygen concentrator was running and the flow rate was set at 5 LPM. (Photographic evidence obtained) On 7/19/22 at 10:20 AM, Resident #44 was observed lying in bed, awake. His O2 concentrator flow rate was set at 5 LPM (Photographic evidence obtained) His nasal cannula tubing was in his mouth. He was asked if he knew what his oxygen flow rate was supposed to be set at. He stated, I think 2 or 3? He was asked if he ever changed the oxygen flow rate on the concentrator by his bed. He stated, No, I don't touch that. The nurses do that. On 7/19/22 at 2:40 PM, Resident #44 was observed lying in bed, awake. His O2 nasal cannula prongs were in his mouth. The O2 concentrator flow rate was set at 5 LPM. The resident was asked why his oxygen tubing was in his mouth. He stated, It annoys me. It hurts my nose. On 7/20/22 at 10:15 AM, Resident #44 was observed lying in bed, awake. His O2 nasal cannula prongs were in his mouth. His oxygen concentrator flow rate was set at 5 LPM. (Photographic evidence obtained) A review of the resident's medical record, revealed that he was diagnosed with [CONDITION(S)] ([CONDITION(S)]). His physician' orders read: 9/22/20: Oxygen at 2 LPM per nasal cannula via O2 concentrator and/or tank PRN for SOB (shortness of breath) 9/22/20: O2 sats: pulse oximetry every shift and PRN. A care plan review for Resident #44 revealed the following focus, goal, and interventions created on 12/27/21 (revised 6/3/22): Focus: Resident has altered respiratory status/difficulty breathing r/t [CONDITION(S)] and takes [MEDICATION(S)] routinely. Goal: Resident will have no s/sx (signs or symptoms) of poor oxygen absorption through the next review date. (revision 5/4/22) Interventions: Oxygen therapy as ordered. Focus, goal, and intervention created 10/20/20: Focus: The resident has [CONDITION(S)]/[CONDITION(S)] related to hx (history) of smoking. Goal: The resident will display optimal breathing pattern daily through review date. Interventions: Oxygen therapy as ordered. In an interview with Certified Nursing Assistant (CNA) J on 7/20/22 at 4:15 PM, she was asked if she monitored the rate of oxygen for Resident #44. She stated, The nurses monitor the rate but he's mostly at 2 LPM. The nurses tell us what the rate should be. She was asked if she reported to the nurse if the oxygen concentrator is not set at 2 LPM. She stated, I would tell the nurse but I haven't had to. She was asked if she had ever seen Resident #44 change the oxygen flow rate on his oxygen concentrator. She stated, No, I haven't seen him. I don't think he would change it. In an interview with Registered Nurse (RN) I on 7/20/22 at 4:30 PM, she was asked if she was caring for Resident #44 today. She stated yes. She was asked what his oxygen order was and she stated, He's at 2 liters per minute continuously by nasal cannula. She was asked if he kept his nasal cannula in place. She stated, Sometimes he takes it off and will then put it back on, The doctors is aware of that. I check his sat (oxygen saturation) often and it's always good, always above 90%. She was asked how often she checked the flow rate on his oxygen concentrator. She stated, Three or four times on my shift. She was asked if the rate ever needed to be adjusted and she stated, No, it's ordered for 2 LPM and he doesn't need that changed. She was asked if he ever changed the rate on his oxygen concentrator himself. She stated, No, he wouldn't do that. She was asked how often she checked the nasal cannula to ensure it was in place and she replied, I check that three or four times a shift when I check his rate and his oxygen sat. She was asked if she had seen Resident #44 put the nasal cannula prongs in his mouth. She stated, No, I haven't seen that. A review of the facility's policy titled Oxygen Administration, Safety, Mask Types (Reviewed/revised: 6/29/22) revealed: Purpose: To administer and store oxygen in a safe manner. To keep oxygen equipment clean and maintained in good condition. To administer various levels of oxygen concentration and/or humidity in a safe manner. Oxygen Concentrator: 8. Turn flow rate control slowly clockwise until center of ball in flow rate indicator moves up to the number of liters per minute as ordered by the physician (usually one to two LPM). 10. Place cannula on resident as follows: Fit outlet prongs into nares and place elastic band around head behind ears. Tape can be applied to make cannula stay in place if necessary and cheekbones and ears can be padded to prevent irritation. The curve of the nasal prongs should point down so that they follow the anatomy of the nasal passages. According to the National Library of Medicine at https://www.ncbi.nlm.nih.gov/books/NBK 3 (Accessed on 7/21/22 at 8:10 p.m.), Oxygen is vital to sustaining life. However, breathing oxygen at higher than normal partial pressure leads to hyperoxia and can cause oxygen toxicity or oxygen poisoning. Those at particular risk for oxygen toxicity include . patients exposed to prolonged high levels of oxygen. Extended exposure to above-normal oxygen partial pressures, or shorter exposures to very high partial pressures, can cause oxidative damage to cell membranes leading to the collapse of the alveoli in the lungs.

Based on observation, interview and record review, the facility failed to ensure residents who were allowed to smoke at the facility did not store lighters and other smoke materials in the resident room for two (Residents #4 and #5) of nine residents sampled. This failure placed the residents at risk for an accidental fire through the lack of supervision of smoking materials. The findings include: 1. An observation of Resident #4 was made on 7/28/2021 at 9:00 AM. There was a pack of cigarettes and a lighter inside the pack on the resident's over-the-bed table. Resident #4 was observed with a nasal cannula in his nose and an oxygen concentrator running at 2 liters per minute. A record review was conducted of the quarterly Minimum Data Set (MDS), dated [DATE] which revealed Resident #4 has a Brief Interview of Mental Status score (BIMS) of 12, which indicated Resident #4 had moderately impaired cognition. Resident #4 was not care planned for smoking. Resident #4 had orders for oxygen at 2 liters per minute (lpm) via nasal cannula as needed for shortness of breath, and the order was dated 9/22/2020. 2. Resident #5 was observed on 7/28/2021 at 9:15 AM. Resident #5 had pack of cigarettes and a lighter inside the pack on the dresser. A record review was conducted of the quarterly MDS for Resident #5, dated 7/7/2021. It revealed a BIMS score of 15, which indicated this resident was cognitively intact. A review of the care plan for Resident #5 revealed the resident had impaired cognitive function related to dementia. Resident #5 was not care planned for smoking. 3. On 7/28/21 at 09:10 AM, an interview was conducted with Employee A, Certified Nursing Assistant (CNA). Employee A stated lighters and cigarettes were locked in the medication room. When the residents have assigned times to smoke, the residents are provided cigarettes and lighters. When asked if residents were allowed to keep cigarettes and lighters in their rooms, Employee A stated, No. On 7/28/21 at 11:00 AM, an interview was conducted with the Administrator which revealed that when residents are admitted , residents are asked about smoking preferences. If the resident smokes, the nurse would conduct a Tobacco Use Assessment which determined how to meet the smokers' needs. On 7/28/21 at 2:40 PM, a follow-up interview was conducted with the Administrator. The Administrator stated both wings have locked boxes for the cigarettes and lighters. It is the expectation if smoke materials are found in the resident rooms, the staff must collect the items and secure them. On 7/28/21 at 11:45 AM, an interview was conducted with Employee C, Licensed Practical Nurse (LPN). The nurse was asked if residents were allowed to keep cigarettes and lighters in their rooms. Employee C stated he would check with the manager. He was not sure what the smoking policy allowed. He was asked how residents who smoked were assessed. He stated an assessment is completed. He was asked where residents' cigarettes and lighters were kept and he stated there is a toolbox with the smoking materials in the box. On 7/28/21 at 2:15 PM, an interview was conducted with Employee D, Registered Nurse (RN), Minimum Data Set (MDS) coordinator. When asked how she created a care plan, she stated that she looked at documentation and assessments in the medical record, and conducted interviews with staff and residents. She confirmed that care plan meetings also provided information needed to complete an MDS and care plan. She confirmed Resident #4 and Resident #5 did not have a care plan related to their smoking habits. A record review was conducted of the facility policy, Smoking and Tobacco Use, revised 4/17. The policy did not indicate storage of residents cigarettes or lighters.

Based on record review and interviews, the facility failed to ensure as needed antipsychotic medication was limited to 14 days, or had documented rational and an indicated duration by the attending physician or prescribing practitioner for one (Resident #62) of five residents with a medication review, from a total of 31 residents in the sample. The findings include: A record review for Resident #62 found she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the resident's electronic medical record found that she had current physician's orders [REDACTED]. The order did not have an end date. A review of the resident's January 2021 Medication Administration Record [REDACTED]. During an interview with the Acting Director of Nursing (DON) on 1/27/2021 at 1:00 PM, she was asked for evidence that the as needed ABH gel was reviewed every 14 days. During further interview with the Acting DON on 1/27/2021 at 1:58 PM, she stated she spoke to the Pharmacist and he informed her that the as needed ABH gel should have a stop date. She added that the Pharmacist informed her that because Resident #62 was a hospice patient, it was difficult for the facility to get a stop date. She stated she was aware the medication should only be written for 14 days, and the hospice doctor or facility doctor should assess the resident and determine if the medication order should continue. During an interview with Resident #62's nurse (Employee G) on 01/27/2021 at 1:50 PM, she stated the hospice nurse came to the facility all the time and reassessed Resident #62's medication. She stated all of the paperwork would be in the facility's computer program. She was asked who was responsible for writing the orders for Resident #62's medication. She stated, Resident #62's hospice provider had a physician, and the facility had a physician that both oversaw her medications. She was asked who prescribed the as needed ABH gel and she replied that she did not know. During further interview with the Acting DON on 1/27/2021 at 2:59 PM, she stated she called Resident #62's hospice provider and they were not able to provide any evidence of having re-evaluated Resident #62 for the ABH gel. She stated the Pharmacist had identified the as needed ABH gel was limited to 14 days and hospice wrote back that they wanted the resident to no longer be reviewed by psychiatric services. She stated the previous DON was not doing her job with the pharmacy review and the Unit Manager was not aware the medication should only have been written for 14 days. During another interview with the Acting DON on 1/28/2021 at 11:41 AM, she was asked who was responsible for ensuring the accuracy of medication in the facility. She stated the individual responsible for writing the prescription would have been the physician that saw the resident in the facility. She stated the Unit Managers had the responsibility of ensuring the medication was accurately entered into the electronic medical record with an end date. During an interview on 1/28/2021 at 12:00 PM with the Unit Manager (Employee A) for the unit Resident #62 resided on, she stated she was the Unit Manager in December of 2020. She was asked who was responsible for writing the orders for the as needed ABH gel for Resident #62. She stated the hospice doctor wrote all of the resident's orders. She stated that the Psychiatrist discontinued Resident #62's ABH gel but hospice restarted it. She stated the hospice doctor wrote the orders and the resident's facility doctor signed off on all of the orders. She stated she could not recall if she checked Resident #62's medication orders. She stated she was aware the as needed ABH gel should have had a stop date and should not be for more than 14 days. She could not recall if the order was for 14 days when it was received in December and she stated she would check it. During an interview with the facility's Pharmacy Consultant on 1/28/21 at 12:15 PM, he stated the as needed ABH gel should have been written for 14 days unless it had an earlier hard stop end date. He stated he did tell the DON and supervisors about the medications that needed stop dates and it did not get addressed. He stated he completed narcotic destruction the last day the previous DON was working at the facility and he addressed his concern with her. During a telephone interview on 1/28/2021 at 1:05 PM with the Nurse Practitioner for Resident #62's physician, she stated the last prescription they wrote for ABH gel was on 9/15/2020 and it was scheduled every 4 hours. She stated any changes made after 9/15/2020 to the medication were done by the hospice physician. She stated the hospice physician should have known to write the order for 14 days so it was probable an oversight. During an additional interview with the Acting DON on 1/28/2021 at 1:47 PM, she provided an order from the hospice physician dated 11/4/2020 with the following instructions, Do not change psych order. She also provided the 12/22/2020 hospice physician's orders [REDACTED]. There was no end date given. At the time the Acting DON presented the information she stated she had checked again and the facility had no other record past the 12/22/2020 order addressing Resident #62's continued need for the medication.

Based on observations, interviews and record review, the facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one (Resident #34) of one resident sampled for a review of range of motion services from a total of 31 sampled residents. The findings include: On 01/24/21 at 2:09 PM, Resident #34 was observed lying in bed in Semi-Fowlers position (lying on her back with her head and torso raised between 15 and 45 degrees). Her left hand was contracted and was placed close to her chin. When Resident #34 was asked to open her hand, she stated she could not open it. The middle, ring and 5th fingers were firmly squeezed in the palm of her hand. A hand splint was observed on the nightstand beside the resident's bed. (Photographic evidence obtained) On 01/25/21 at 10:33 AM, Resident #34 was observed in the dining room participating in an activity. Her left hand was held close to her chest. She was not wearing a splint. On 01/27/21 at 2:39 PM, Resident #34 was observed lying in bed on her back. When she was asked to open her left hand, she stated, It hurts. Red fingernail marks were observed on the palm of her hand where the contracted fingers were pressing. A hand splint was observed on the nightstand at the resident's bedside. A review of Resident #34's medical record revealed that she was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. A review of her quarterly minimum data set (MDS) assessment, dated 11/28/20, revealed the resident had a brief interview for mental status (BIMS) score of 99, indicating that she was unable to complete the interview. She also required extensive assistance with bed mobility and transfers. She required supervision with eating and she was totally dependent on staff for toileting. Resident #34 was assessed with [REDACTED]. Further review of the record revealed physician's orders for the therapy department to assist with the resident's restorative program. A review of the resident's care plan revealed the following focus area: Resident has a need for restorative intervention to maintain wearing schedule of soft palm guard to decrease risk of skin breakdown with intervention for restorative nursing to ensure skin is clean, intact and dry. Provide gentle PROM (passive range of motion) to the left digits during hand hygiene. Apply soft palm guard as resident allows and tolerates. Remove soft palm guard on evening shift. On 01/27/21 at 10:00 AM, Employee B, Certified Nursing Assistant (CNA)/Restorative Aide, confirmed that Resident #34 had not been wearing the hand splint. She stated the resident had been refusing to wear the splint for the last three months due to a complaint of pain. She added that the facility's policy was to discontinue restorative interventions if the resident refused services on three consecutive attempts. When asked why the services for Resident #34 were not then discontinued, she reported that her restorative nurse was no longer working at the facility, and she was not sure who to report to. When asked if she had any documentation of the resident having refused care/splinting, she stated she had none. On 01/27/21 at 10:58 AM during an interview with Employee A, Licensed Practical Nurse (LPN)/Unit Manager, she confirmed that Resident #34 was still on restorative therapy and was to wear a soft hand splint every morning shift and have it removed during the evening shift. When asked whether the resident refused treatment/splinting, Employee A stated she is not aware. She checked the restorative notes and stated there was only one day (01/27/21) that the resident was documented as having refused. She added that if the resident refused treatment, it should be discontinued. She also mentioned that if the order was not discontinued, it should be carried out and documented. When asked to whom the restorative aide reported, Employee A stated she was in charge of her unit as the restorative nurse had resigned a week ago. A review of the facility policy and procedure titled,Restorative: Nursing Care Implementation and Screening- Rehab/Skilled, Therapy & Rehab (revised 12/28/2020), revealed: . To provide appropriate restorative nursing care to each resident . To provide appropriate treatment for [REDACTED]. - Each resident will receive restorative nursing care to the extent possible, based on individual strengths, needs and problems as identified in nursing assessments. The restorative care will be outlined in the resident's nursing care plan. Care includes safe measures to prevent complications and contractures, maintain strength and self- care abilities including eating and dressing, promote mobility and feeling of well being. Activities of daily living - Residents are provided appropriate treatment and services to attain/ maintain functional abilities in activities of daily living. Any resident who is unable to carry out independent activities of daily living will receive necessary services to prevent further diminishing of independent abilities in bathing dressing/undressing, grooming, transfer, ambulation, toileting, eating and use of speech, language or other functional systems. - Based on the resident's comprehensive assessment, the location ensures that the resident's ability in activities of daily living does not decline except when unavoidable for reasons of disease progression, deterioration of physical condition associated with disability or refusal of care/treatment by the resident or legal representative. Evidence of any of these reasons will be reflected in the clinical record -The goal of restorative nursing acre is to attain and maintain the maximum possible independence and/or prevent rapid declines through the interventions for each resident.

Based on observations, interviews, and record reviews, the facility failed to provide Activities of Daily Living (ADL) care according to the residents' needs and as care planned for one (Resident #122) of two residents reviewed for ADL care, and failed to follow the care plan intervention of [MEDICAL CONDITION]-[MEDICAL CONDITION] Deterrent (TED) hose/stockings for one (Resident #30) of one resident reviewed with TED hose from a total sample of 31 residents. The findings include: 1. On 1/26/2021 at 8:41 AM, the door to Resident #122's room was observed to be closed. Upon knocking on the door, Employee F, Certified Nursing Assistant (CNA), announced she was providing resident care. Upon entry to the room, Employee F was observed changing Resident #122's brief and providing incontinent care that included application of a white barrier cream. Employee F was the only caregiver in the room at the time of the observation. A record review for Resident #122, found she was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the 1/18/2021 quarterly Minimun Data Set (MDS) assessment for Resident #122 in Section G, the resident was assessed as totally dependent on two plus physical assist from staff members, and for transfers and personal hygiene she was totally dependent of two plus persons physical assist. A review of the care plan for Activities of Daily Living (ADL)/Self-care deficit related to status [REDACTED]. A review of the inventions listed, revealed the intervention of a two-person assist with all ADL care. During an interview with Resident #122's nurse (Employee H) on 1/26/2021 at 12:49 PM, she stated Resident #122 needed two people to do her care because she was totally dependent on staff for care. During an interview with Resident #122's CNA, Employee F, on 01/26/21 at 1:09 PM, she was asked what kind of care was she providing to Resident #122 in the morning. She stated she was providing full care. She stated Resident #122 was a total assist. She was bathing her and cleaning her up for the day, and stated she had changed the resident's brief. She was asked how she knew what kind and how much assistance the resident required and how many care givers were needed. She stated the Kardex (brief summary of resident care needs for each individual resident) provided the information about how many people were needed to complete the resident's care. She was asked to review the Kardex for Resident #122. The information in the Kardex was reviewed with the CNA, and it documented that Resident #122 required a two-person assist for all ADL care. Employee F was asked if there was another staff member assisting her with care this morning and she stated no. 2. A record review was conducted for Resident #30, which reported an admission date of [DATE] with [DIAGNOSES REDACTED]. A review of the current physician's orders [REDACTED]. The current care plan was reviewed, which noted under a focus for Activities of Daily Living (ADL) self care performance deficit related to cardiac issues, an intervention for TED stockings to BLE daily, on in AM and off in PM with an initiation date of 10/2/20. The current Treatment Administration Record (TAR) was reviewed, which did not note any TED stockings being applied or taken off. (Photographic evidence obtained) Resident #30 was observed on 1/24/21 at 12:11 PM, in his room sitting in a wheelchair. He was wearing shorts with no TED hose observed. Resident #30 was observed on 1/25/21 at 2:42 PM, in his motorized wheelchair in the hall with no TED hose on his lower extremities. Resident #30 was observed on 1/26/21 at 9:30 AM, in his room in a wheelchair with no TED hose on his lower extremities. An interview was conducted with the resident at the time of the observation, and he reported he had never had or worn TED stockings. He stated if he had them, he would wear them. An interview was conducted with Employee E, Licensed Practical Nurse (LPN), on 1/26/21 at 9:39 AM concerning Resident #30's TED stockings. The LPN reported working at the facility for the past two months, and had never seen the resident wearing TED stockings. Employee E checked the treatment Administration Record (TAR) and reported that the use of TED stockings was not listed. She was asked to check the physician's orders [REDACTED]. Employee E entered Resident #30's room and confirmed that the resident was not wearing TED hose/stockings. The LPN stated she would get him TED stockings. The LPN confirmed the resident did have an order for [REDACTED].

Based on interviews and record reviews, the facility failed to ensure one (Resident #122) of three alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than two hours after the allegation is made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. The findings include: A record review of the facility grievance log found that Resident #122's husband filed a grievance on 1/5/2021 due to the resident having a cut on her eye that he was not notified about. He wanted to know what happened and what would be done about it. The resolution on the concern form was to continue nail audits and it had audits attached of fingernails for facility staff members. There was no other information attached. A record review for Resident #122 found she was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A record review of the 1/18/2021 quarterly minimum data set (MDS) assessment, found Resident #122's Brief Interview for Mental Status (BIMS) indicated she could not be assessed using the tool. A review of Section G found Resident #122 was assessed for bed mobility as totally dependent/two plus person/physical assist, transfer as total dependence/two plus persons physical assist, dressing as total dependence/two plus persons physical assist, and personal hygiene as total dependence of two plus person/physical assist. During an interview with the Administrator on 01/27/21 at 10:07 AM, she was asked to provide the three most resent investigations of abuse. The Administrator stated while reviewing the files yesterday she found a report that Resident #122 had an injury of unknown origin due to a scratch over her eye that she reported on 1/26/2021. A review of the report with the Administrator found that on 12/29/2020, the facility learned of the scratch from the resident's husband during his visit that day. The nurse described the wound as a scratch over the top of the residents left eye. The Director of Nursing (DON) wrote that she entered the building on 12/29/2020 to Resident #122's husband stating he wanted to speak with the DON regarding a scratch over the resident's left eye. Resident #122's husband had been outside on the screen porch area having a scheduled visit with the resident at the time. The report documented that the DON, Advanced Registered Nurse practitioner (ARNP), MDS Coordinator and Floor Nurse witnessed the conversation. The resident's eye was reddened. The Administrator was asked why the 12/29/2020 eye injury was not reported as an abuse allegation. She stated she was on vacation at the time and the DON said based on the statements and the investigation, she felt it was a scratch. All staff were interviewed. The ARNP ordered an X-ray of the resident's face at the request of the DON. When they did the X-ray there was nothing there. The Administrator stated the reason she reported the incident last night was because based on her perspective it was an injury of unknown origin. During an interview with the Social Service Director (SSD) on 1/28/2021 at 8:43 AM, the SSD was asked about the complaint Resident #122's husband made on 1/5/2021 about the cut on his wife's eye. The SSD stated she was not in the building at the time. When she came back, Resident #122's husband asked her about his wife's eye. She stated she took it to the team and it was an injury of unknown origin. They thought it was a result of employees nails and they did an audit for nail care for employees. A review of the facility's Abuse policy (page 4 of 6 under a.) found, If there is an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown sources, misappropriation of resident property and/or there is bodily injury, than it will be reported not later than 2 hours after the allegation is made to the administrator and other officials (including the state survey agency and adult protective services where state law provides for jurisdiction in long term care centers) in accordance in state law.

Based on observation, record review and interview, the facility failed to ensure that residents who required [MEDICAL TREATMENT] received such services and associated care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #40) of one resident receiving peritoneal [MEDICAL TREATMENT], from a total of 31 residents the sample. The findings include: A medical record review for Resident #40 revealed that he was admitted to the facility on [DATE] with a re-entry on 11/30/20. His [DIAGNOSES REDACTED]. A review of the admission minimum data set (MDS) assessment, dated 12/06/20, revealed the resident was assessed as having a brief interview for mental status (BIMS) score of 15 out of a 15 possible points, indicating intact cognition. He was independent for all functions of daily living such as bed mobility, transferring and toileting. A review of the current physician's orders [REDACTED]. Sevelamer HCL tablet (lowers blood phosphorus levels of [MEDICAL TREATMENT] patients), 800 milligrams (mg), give 2 tablets with meals for [MEDICAL TREATMENT]. Peritoneal [MEDICAL TREATMENT] to run in 6 phases different [MEDICATION NAME] strength. Call ([MEDICAL TREATMENT] center) with numbers and directions 386 258 7719 weight and vital signs [MEDICATION NAME] 1000 units/ml (units per milliliter), infuse 6 ml in the peritoneal cavity in the afternoon every Monday for [MEDICATION NAME] in solution/insert in heater bag related to dependence on [MEDICAL TREATMENT] [MEDICATION NAME] 0.1%, apply to peritoneal catheter site topically one time a day for [MEDICAL TREATMENT] Eliquis 5 mg two times a day (BID) for blood clots Aspirin 81 mg everyday (QD) for blood clots Resident to be monitored every hour while connected to peritoneal [MEDICAL TREATMENT]. Check tubing placement and ensure it is not wrapped around the foot pedals and wheels of he bed every evening and night. Exit site care - remove old dressing, cleanse with cleaning agent (except) inner to outer, pat dry, apply [MEDICATION NAME] on a split 2X2, cover with sterile 4X4, window frame with tape Full set of vital signs after disconnected [MEDICAL TREATMENT] (0800 need blood pressure, pulse, temperature and pain) Immediately report swelling, warmth or redness around the site, pus/drainage from the site. Chill or fever more than 100 degrees. Dizziness/[MEDICAL CONDITION] when standing up or shortness of breath (SOB) Rena- vite B complex folic acid QD (daily). A review of the care plans revealed the resident was careplaned for a need of [MEDICAL TREATMENT] treatment related to [MEDICAL CONDITION] with the following interventions: Peritoneal [MEDICAL TREATMENT] to run in 6 phases different [MEDICATION NAME] strength call ([MEDICAL TREATMENT] center) with numbers and direction 386 258 7719, resident self-administers peritoneal [MEDICAL TREATMENT], monitor/document/report to health care provider as needed (PRN) for any signs and symptoms of infection of [MEDICAL TREATMENT] to abdomen and right chest: redness, swelling, warmth or drainage. Provide exit site care and treatment as ordered. During an interview with Resident #40 on 01/26/21 at 1:55 PM, he stated he did his own peritoneal [MEDICAL TREATMENT]. He stated he had been trained by the ([MEDICAL TREATMENT] center) nurses on how to perform the treatment. He mentioned that while he lived at home, the [MEDICAL TREATMENT] nurse would visit weekly, but when he moved to the facility, the [MEDICAL TREATMENT] nurse visited once a month. He added that the facility nurses were supposed to report the weights and vital signs to the [MEDICAL TREATMENT] nurse weekly. Resident #40 said that it was important for the nurses to report his weights and vital signs to the [MEDICAL TREATMENT] center becasue he used two different [MEDICATION NAME] which were dependent on his blood pressure and weight. When asked about the dressing chnage to the [MEDICAL TREATMENT] port he said, The facility staff do not do anything for me. I do it myself. The resident was on anticoagulant medication which put him at high risk of bleeding. He mentioned that he had been admitted to the hospital in November due to malfuctioning of the peritoneal [MEDICAL TREATMENT] access. He further stated he was put on [MEDICAL TREATMENT] for three weeks. He stated that a [MEDICAL TREATMENT] port was retained on his right upper chest. He said the nephrologist would make a determination of when it would be taken off during his next appointment. On 01/26/21 at 2:10 PM, a 4X4 gauze dressing tapped with paper tape was observed on the exit site. No date or staff initials were on the dressing. The resident stated he had changed the dressing in the morning after the treatment. During an interview on 01/27/21 at 10:40 AM with Employee C, Registered Nurse (RN), she stated she was responsible for taking care of Resident #40. When asked whether she had done a dressing change or completed an assessment on the resident's [MEDICAL TREATMENT] port, she replied, We do not do anything for him. He does everything for himself unless he asks for help. When asked if she reported the vitals signs to the [MEDICAL TREATMENT] nurse, she said only if the they are abnormal. On 01/27/21 at 10:49 AM, Employee A, Licensed Practical Nurse (LPN)/Unit Manager, stated ([MEDICAL TREATMENT] center) conducted an in-service for facility nurses regarding the resident's peritoneal [MEDICAL TREATMENT]. When asked about resident [MEDICAL TREATMENT] treatments, she stated that resident does his own [MEDICAL TREATMENT], however, facility nurses were supposed to oversee the resident starting and stopping treatment. She also stated nurses were supposed to assess the [MEDICAL TREATMENT] exit site daily and performed the dressing change. She stated the facility protocol for dressing change was to initial the new dressing with staff initials and the date the bandage was changed. When asked if there was documentation to verify nursing had been changing the resident's dressing, she checked the medication administration record (MAR) and treatment administration record (TAR), and stated it was not documented. When asked whether the nursing staff notified the [MEDICAL TREATMENT] nurse of the resident's vital signs and weight, she stated she was not sure because it was not documented. A review of the January 2021 MAR and TAR revealed that the order for exit site care - remove old dressing cleanse with cleaning agent (except) inner to outer pat dry, apply [MEDICATION NAME] on a split 2X2 cover with sterile 4X4 window frame with tape, and order to immediately report swelling, warmth or redness around the site, pus drainage from the site. Chill or fever more than 100 degrees Dizziness/[MEDICAL CONDITION] when standing up or shortness of breath (SOB) had not be signed as having been completed from january 1-27, 2021. (Copies obtained) A review of the facility's policy and procedure titled, Physician/Practioner Orders - Rehab/Skilled revised on 11/20/20, revealed: -To provide individualized care to each resident by obtaining appropriate, accurate and timely physician/practitioner orders Wounds: Orders must be obtained for wound care including product to be used when to change and when to reassess. A licensed nurse must provide the wound care. According to the National Library of Medicine at https://pubmed.ncbi.nlm.nih.gov/ 827, exit-site infections increase the risk of developing peritoneal [MEDICAL TREATMENT] peritonitis and peritoneal [MEDICAL TREATMENT] technique failure. Nadarajah L, Yaqoob MM, Fan S. 'Persistent Colonization of Exit Site is Associated with Modality Failure in Peritoneal [MEDICAL TREATMENT]'.

Based on observation and interview, the facility failed to post the nurse staffing data on a daily basis at the beginning of each shift. This data should include: facility name, current date, resident census, total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses. (C) Certified nurse aides. The findings include: On 01/24/21 at 12:30 PM, the staffing schedule posted at the nurse's station on a white board on North, South and Hope units noted two certified nursing assistants (CNAs) and one nurse for all three shifts (6:00 AM- 2:00 PM, 2:00 PM-10:00 PM, and 10:00 PM- 6:00 AM). The staffing ratio was not posted. Additional observations on 01/25/21 at 9:30 AM, 01/26/21 at 9:39 AM, and 1/27/21 at 11:15 AM, revealed that the staffing ratio was not posted. On 01/27/21 at 11:28 AM, the Administrator confirmed that the staffing ratios had not been posted since 1/18/21 after the Director of Nursing (DON) resigned. She stated the facility's DON was the designated person to do that task and had resigned. She added that the task was also delegated to the Unit Managers, however, the facility has had a high staff turnover, and the current Unit Managers and DON were new to their positions. they had not had the training on how to perform the task. She mentioned that she would teach the DON how to do the ratios and would ensure it was posted daily. On 01/28/21 at 2:13 PM, the Administrator was asked if the ratios had been posted. She hesitated then stated she had asked the DON to post them in the morning. The Administrator went to the lobby where the ratio should be posted and confirmed that the ratios had not been posted. She stated she would post them as soon as she concluded her meeting. On 01/28/21 at 3:00 PM, the DON provided a completed copy of the ratios for review. She stated they would implement a process for the night shift supervisor to complete the form, which the DON would review and post every day.

Based on observation, staff interview and record review, the facility failed to ensure fall precautions were in place to ensure the safety of one (Resident #2) out of three residents reviewed for falls. The findings include: On 12/10/2020 at 10:06 AM, Resident #2 was observed in bed. There was a blue mat on the floor on the door side of the bed. During an interview with Resident #2's certified nursing assistant, CNA A, on 12/10/2020 at 10:15 AM, she was asked what fall precautions were in place for Resident #2. She stated Resident #2 had a floor mat on one side of the bed. It was on the one side because Resident #2 leaned to that side, and that was the side she was on when she fell . A record review for Resident #2 revealed she was originally admitted to the facility on [DATE]. A review of her [DIAGNOSES REDACTED]. A review of the annual minimum data set (MDS) assessment for Resident #2 revealed she had a brief interview for mental status (BIMS) score of 0 out of 15, indicating severely impaired cognition. Section J1800 of the MDS found Resident #2 had one fall without injury and two or more falls with major injury since admission or the previous assessment. A review of the fall risk care plans for Resident #2 revealed the approach of bilateral floor mats while in bed was initiated on 6/24/2020. A review of the progress notes for Resident #2 revealed that on 8/11/2020, Resident #1 was found on the floor in her room. Further review revealed she sustained a hematoma (a collection of blood outside of the blood vessels) to the right eye and non-disclosed clavicle (collarbone) fracture. On 9/18/2020 at 11:22 AM, Resident #2 was found in her room face down on the floor next to her bed. She sustained a nasal fracture. During a second observation of Resident #2 on 12/10/2020 at 2:00 PM with Resident #2's nurse (Employee B), Resident #2 was observed in bed. A floor mat was observed on the right side of the bed. During an interview with the nurse (Employee B) she was asked why Resident #2 only had a floor mat on the right side of the bed. She stated that was the side the resident always gets up on. She was notified that Resident #2 was care planned for bilateral floor mats. She stated she would get another floor mat. During an interview with the Director of Nursing on 12/10/2020 at 2:05 PM, she was asked to review the fall risk care plans for Resident #2. She confirmed the care plan for falls included the intervention of bilateral fall mats. On 12/10/2020 at 2:10 PM, Employee C was asked to pull up the CNA care plan in the facility's computer system to show the fall prevention approaches for Resident #2. A review of the approaches revealed that Resident #2 should have had bilateral floor mats. (Photographic evidence obtained)

Based on record review and staff interview, the facility failed to ensure that allegations involving abuse/neglect were reported to the State Agency within 24 hours and reported results of the investigation to the administrator and the State Agency within five working days of the incident for one (Resident #1) of two residents sampled for allegations of abuse/neglect. The findings include: A record review for Resident #1 revealed an [AGE] year-old male admitted on [DATE] with [DIAGNOSES REDACTED]. He was alert with confusion. He required extensive assistance with activities of daily living. He had a brief interview for mental status (BIMS) score of 6 out of a possible 15 points, indicating severe cognitive impairment. He was determined to be at a high risk for falls due to his history of multiple falls. A review of a nursing progress note dated 4/3/20, revealed Resident #1 was found on the floor beside his bed. Upon examination, the nurse observed his right upper leg was bent, and he yelled out stating it hurt. He was transferred to the hospital with a new [DIAGNOSES REDACTED]. On 4/4/20, an investigation was conducted by the Director of Nursing (DON) regarding how the fall occurred. The conclusion of the investigation revealed that the Certified Nursing Assistant (CNA), Employee A, assigned to Resident #1, failed to make rounds every two hours as required and as a result, Resident #1 got up out of bed to remove his urine-soaked brief and fell . Employee A was suspended pending investigation. After further interviews and investigation, the facility determined there was neglect on the part of Employee A and the CNA was terminated from employment. An interview was conducted with the DON at 3:08 pm on 7/28/20. She was asked if an immediate and five-day report was filed after the incident regarding the fall of Resident #1 on 4/3/20. She stated she conducted the investigation but did not report the event as potential abuse/neglect.

Based on observations, interviews and record review, the facility failed to ensure that dishes and utensils were cleaned under sanitary conditions in accordance with professional standards for food service safety. The findings include: A review of the WH Series Rack Conveyor Dishmachine Installation and Operation manual for the Ecolab Model WH-44 revealed that the minimum water temperature requirement for the rinse temperature in chemical sanitizing mode was 120°F. During testing of the dish machine with the Certified Dietary Manager (CDM) on 1/28/2019 at 11:15 a.m., the rinse cycle temperature failed to reach 120°F. During two additional tests of the dish machine water temperatures performed by the CDM on 1/28/2019 at 11:22 a.m., the rinse cycle failed to reach the required minimum water temperature of 120°F both times. During an interview with the CDM on 1/28/2019 at 12:37 p.m., she confirmed that the dish machine failed to reach the minimum required temperature during the rinse cycle. When she was asked how that concern would be addressed, she stated: I'll call them (Ecolab), and they're going to have to come out. On 1/28/2019 at 1:30 p.m., a review of the temperature log maintained by the facility kitchen staff for the WH-44 dish machine revealed that the rinse cycle also failed to reach 120°F on 1/27/2019, 1/26/2019, 1/21/2019, 1/17/2019, 1/13/2019 and 1/12/2019. On 1/1/2019 and 1/2/2019 the facility kitchen staff failed to record temperatures for the WH-44 dish machine. During an interview on 1/28/2019 at 1:40 p.m. with the CDM, she was shown the temperature log maintained by the facility kitchen staff, and was asked why no action was taken to repair the machine prior to the survey. She responded; I don't know. I don't know why they didn't tell me. They know that they are supposed to tell me things like this.

Based on observations, facility and resident record reviews, and interviews with residents and staff, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice by failing to ensure timely and appropriately labeled [MEDICATION NAME] medications for three (Residents #61, #22 and #81) of three sampled residents observed with [MEDICATION NAME] medicated patches; failing to administer blood pressure medications as ordered for two (Residents #81 and #10) of six sampled residents whose medications were reviewed, and by failing to notify the physician of abnormal blood glucose readings per the physician's order for one (Resident #25) of six residents whose medications were reviewed, out of a total of 40 residents in the sample. The findings include: 1. An observation and interview with Resident #61 on 1/28/19 at 2:34 PM revealed a 3 x 4 inch white rectangular shaped patch on the left side of his chest. The resident stated it had been applied that morning. On 1/29/19 at 3:36 PM, Resident #61 was observed and interviewed in his room. When asked how he was, he said he would be doing better if he had his pain patch. He tried to look to see if the patch was on his chest, but could not tell. This surveyor could not either, despite his attempts to pull the neck of his T-shirt down. While he denied pain at the time of interview, he insisted that he would be in pain soon if they did not give him his pain patches on his chest and hip. On 1/30/19 at 8:43 AM, Resident #61 was observed in his wheelchair near the nurse's station. He stated he was not doing well, as he had not gotten his pain patches yet. He explained that his hip and shoulder were hurting. The Regional Nurse walked over, intervened, and notified the Director of Nursing (DON) and the resident's nurse (Employee H) of the issue. They took Resident #61 to his room, and obtained a mechanical lift in preparation to transfer him back to bed. Resident #61 was asked if he had his chest patch on. He removed his shirt, and the rectangular white 3 x 4 inch patch was observed on his upper left chest; however, the entire patch was folded in half underneath itself, and the medicated surfaces stuck to each other. There was no skin contact with the medicated surfaces. The folded patch hung from the left shoulder by a corner of the surrounding adhesive strip. At this time (approximately 9:00 AM), the Regional Nurse reached over with her bare hands and removed the patch from Resident #61's chest. She held the patch up, and it was observed to be unlabeled and undated. An interview was conducted with Employee Z, Certified Nursing Assistant (CNA), on 1/30/19 at 1:48 PM. She stated Resident #61 complained of hip and shoulder pain, and that his pain medications/patches were all he asked for. She stated the patch seemed to work and calm him down. An observation of Resident #61 on 1/31/19 at 8:52 AM found him in bed. He had no shirt on, and there was a large 3 x 4 inch white rectangular patch on top of his left shoulder. The patch was not labeled or dated. He stated he was feeling good, but later in the conversation said his pain level was a 12 on a scale of 0-10 with zero representing no pain and 10 representing the worst possible pain. When asked the location of his pain he did not answer. A record review for Resident #61 found a Medicare Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/5/19. He had a Brief Interview for Mental Status (BIMS) score of 00, as he was unable to answer any of the questions asked. He required extensive assistance with all activities of daily living and personal hygiene, and he used a wheelchair as a mobility aid. [DIAGNOSES REDACTED]. Resident #61 received scheduled pain medication in the last five days over the assessment period and was offered and declined, or received, as-needed (prn) pain medication. He was unable to answer whether he had been in pain over the past five days. Resident #61 received opioid medication on seven of seven days over the assessment look back period. Resident #61 was care planned on 12/9/18 for acute/chronic pain/discomfort related to [MEDICAL CONDITION] ([MEDICAL CONDITION] - stroke) as evidenced by disease process. The goal was to verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. Approaches included identification of level of pain tolerated using a 1-10 scale, report signs and symptoms of pain or discomfort to nursing, notify the physician if interventions are unsuccessful. Evaluate effectiveness of pain interventions, review for compliance, alleviation of symptoms, dosing schedules and resident satisfaction with results Resident #61 had a physician's order for a [MEDICATION NAME], 5%, apply to left shoulder topically one time per day for pain and remove per schedule, apply at 0800 (8:00 AM) and remove at 2000 (8:00 PM). A review of the current medication administration record (MAR) and notes found the following late application times for the 8:00 AM [MEDICATION NAME] chest patch: On 1/5/19 the patch was not applied until 9:20 AM by Employee O, Licensed Practical Nurse (LPN). On 1/6/19 it was not applied until 11:13 AM by Employee K, LPN. On 1/9/19 it was not applied until 9:03 AM by Employee M, Registered Nurse. On 1/17/19, it was not applied until 10:00 AM by Employee P, LPN. On 1/18/19, it was not applied until 9:40 AM by Employee P, LPN. On 1/25/19, it was not applied until 9:12 AM by Employee Y, LPN. On 1/29/19, it was not applied until 9:27 AM by Employee H, LPN. Resident #61 had a second order for a [MEDICATION NAME], 5%, to his left hip topically every 12 hours, apply at 0800 (8:00 AM) and remove at 2000 (8:00 PM), related to pain unspecified (discontinued 1/30/19). Review of the (MONTH) 2019 MAR and medication administration notes found the following late application times for the [MEDICATION NAME] hip patch: On 1/5/19, the patch was not applied until 9:20 AM by Employee O, LPN. On 1/6/19, the patch was not applied until 11:13 AM by Employee K, LPN. On 1/9/18, the patch was not applied until 9:03 AM by Employee M, RN. On 1/17/19, the patch was not applied until 10:00 AM by Employee P, LPN. On 1/18/19, the patch was not applied until 9:40 AM by Employee P, LPN. On 1/25/19, the patch was not applied until 9:12 AM by Employee Y, LPN. On 1/29/19, the patch was not applied until 9:27 AM by Employee H, LPN. (Photographic evidence obtained) 2. An observation of Resident #22 was conducted on 1/28/19 at 11:28 AM. He was in his bed lying on his back, but did not respond to this surveyor. A small round tan patch, approximately the size of a dime, was observed behind his right ear. The patch was not labeled or dated. On 1/30/19 at 8:50 AM, Resident #22 was observed in his bed. A small, round, tan patch was observed in the same location under his right ear. The patch was not labeled or dated. On 1/31/19 at 8:54 AM, Resident # 22 was observed in his bed. A small, round, tan patch with some faint manufacturer's printing was observed under his left ear. It appeared to be new. There was no date, label, or staff initials on the patch. In an interview with Employee H, Licensed Practical Nurse (LPN), on 1/30/19 at 1:38 PM, she stated the patch behind his ear was a [MEDICATION NAME] (a medication that can be used to decrease saliva, or nausea/vomiting or motion sickness). Employee H explained Resident #22 was dependent on staff for all care. A record review for Resident #22 revealed a quarterly MDS assessment with an assessment reference date (ARD) of 1/10/19. Resident #22 was coded as comatose, and in persistent vegetative state. He was assessed with [REDACTED]. [DIAGNOSES REDACTED]. Resident #22 was care planned on 1/10/19 for risk of altered nutrition and dehydration related to muscle spasms, convulsions, disturbances of salivary secretion, and chronic [MEDICAL CONDITION]. The goal was to maintain adequate nutritional and hydration status and show no signs of dehydration through the review date. He had a care plan for potential fluid deficit related to anoxia (lack of oxygen to the brain), with a goal to be free of signs of dehydration, and maintain moist mucous membranes and good skin turgor. Approaches included monitoring for signs of dehydration and dry mucous membranes. Resident #22 had a physician's order for [MEDICATION NAME] 0.125 milligrams (mg) every 4 hours as needed for increased secretions. He also had a physician's order for [MEDICATION NAME]-[MEDICATION NAME] (Trans-Scop)1.5 mg patch, 72 hour, 1 mg/3 days. Apply [MEDICATION NAME] (through or across the skin) every 3 days for secretions related to disturbances of salivary secretion. Per the medication administration record (MAR) instructions dated 1/18/19, the patch was to be applied at 1800 (6:00 PM) every three days. On the third day, it was to be removed at 1759 (5:59 PM), and a new patch reapplied at 1800 (6:00 PM). Closer review of the (MONTH) 2019 MAR revealed that on 1/21/19, the patch that was scheduled to be removed at 1759 (5:59 PM) was not removed until 2205 (8:05 PM) by Employee L, Licensed Practical Nurse (LPN). The patch was replaced at 2206 (8:06 PM), over 2 hours past the scheduled replacement time. Prior to the 1/19/19 order, the application times for the Trans-Scop patch (ordered 10/14/18 and discontinued on 1/18/19) were for an 8:00 AM application time, and a 7:59 AM removal time on day 3. A review of the MAR found on 1/9/19 the existing patch scheduled for 7:59 AM removal was not removed until 9:04 AM. The replacement patch, scheduled for 8:00 AM, was not applied until 9:07 AM by Employee M, Registered Nurse (RN). On 1/12/19, the patch was not removed until 9:16 AM, and reapplied at 9:18 AM by Employee M. (Photographic evidence obtained) An interview was conducted with Employee H, LPN, on 1/30/19 at 1:55 PM. She was asked about the late administration times for the [MEDICATION NAME] for Resident #61. She explained his physician's order for the [MEDICATION NAME] had recently changed because they could not get the patch from pharmacy. She believed the reason for late application of the patch on his hip may be due to the fact he was already up and in his wheelchair. He would need to be placed back in the bed for the hip patch replacement, and he was dependent on staff and a mechanical lift for all transfers. Employee H stated that Resident #61's chest patch, however, could be applied anytime (and without a transfer). When asked if [MEDICATION NAME] medication patches should be labeled once they were applied, she turned to Employee L, LPN, who had come to the desk. Employee L explained that sometimes there were only two nurses on the unit in the mornings, but there were typically three. The nurses usually began their medication pass in a different hall, because there were multiple diabetic patients on that hall. When asked again whether [MEDICATION NAME]es were supposed to be labeled and dated, she said yes, they should. Employee N, Registered Nurse (RN)/Unit Manager, was interviewed on 1/31/19 at 9:25 AM. He reviewed the clinical records, and confirmed the late application times for the [MEDICATION NAME]es on his unit. He did not know why patches were being applied outside of the one hour before and one hour after time window permitted for medication administration. Employee N stated the expectation was for all [MEDICATION NAME]es to be labeled and dated once applied. Resident #22's and Resident #61's rooms were visited along with Employee N for observation, and he confirmed the presence of the unlabeled and undated patches. 3. A record review for Resident #81 revealed a Quarterly MDS assessment with an ARD of 1/3/19. The resident was comatose in a persistent vegetative state, and with no discernable consciousness. She was totally dependent on staff for all needs. [DIAGNOSES REDACTED]. Resident #81 had a physician's order for a [MEDICATION NAME], 72 hour, apply 1 patch [MEDICATION NAME] every 72 hours for excessive secretions related to disturbances of salivary secretion. Remove old patch and remove per schedule, remove at 0759 (7:59 AM and apply at 0800 (8:00 AM). The patch was applied late on the following dates: On 1/7/19 the 8:00 AM patch was not applied until 9:21 AM by Employee H, LPN. On 1/13/19 the 8:00 AM patch was not applied until 9:18 AM by Employee K, LPN. Resident #81 had a physician's order for [MEDICATION NAME] 200 milligrams (mg), give 2 tabs via [DEVICE] every 12 hours related to hypertension. There was no physician's instruction to hold this medication based on blood pressure measurements. A review of the MAR found on the following dates, the nurse held/did not administer the [MEDICATION NAME]: On 1/1/19 at 2000 (8:00 PM), the medication was not given, with no corresponding nurse's note. On 1/22/29, it was held with a note that referenced the [DIAGNOSES REDACTED]. The note stated the resident's blood pressure was 101/50, and was authored by Employee A, LPN. On 1/23/19 it was not administered, with a corresponding note at 9:03 PM by Employee A that Resident #81's blood pressure was 118/58. On 1/25/19 it was not administered, with a corresponding note at 7:27 PM by Employee A that her blood pressure was 102/52. On 1/27/19 it was not administered, with a corresponding note at 7:18 PM by Employee A that her blood pressure was 100/60. On 1/28/19 it was not administered, with a corresponding note at 9:12 PM by Employee J, LPN, that blood pressure was 92/62. On 01/31/19 at 3:12 PM, an interview was conducted with the Assistant Director of Nursing (ADON). She reviewed the clinical record, and confirmed there were no hold parameters for Resident #81's [MEDICATION NAME]. The Director of Nursing, who entered the room at this time, stated he had already started re-education of the nurses, and the physician's order had been clarified with the physician. 4. A record review was conducted for Resident #10 and revealed a [AGE] year-old male, admitted to the facility on [DATE]. He was admitted with [DIAGNOSES REDACTED]. A review was conducted of his Medication Administration Records (MARs) for (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) 2019. It revealed the following order: [MEDICATION NAME] (blood pressure medication) Give 50 mg (milligrams) by mouth two times a day for hypertension. Hold for systolic blood pressure (b/p) <120 and/or heartrate (hr) <60 beats per minute. Document b/p and hr prior to giving [MEDICATION NAME]. Further review of his MARs revealed the facility failed to follow the physician's order and the medication was administered when it should have been held, due to b/p and/or hr. The medication should have been held per paramters, however it was administered on the following dates: 11/4/18 at 1600 (4 pm) - b/p was only 118 11/10/18 at 8:00 am - hr was only 58 and at 1600 hr was only 57 11/11/18 at 8:00 am - hr was only 57 11/13/18 at 1600 - b/p was only 110 11/16/18 at 1600 - hr was only 56 11/20/18 at 1600 - b/p was only 114 11/28/18 at 8:00 am - hr was only 59 11/30/19 at 1600 - b/p was only 116 12/1/18 at 1600 - b/p was only 110 12/17/18 at 1600 - hr was only 59 12/20/18 at 1600 - hr was only 58 12/21/18 at 1600 - hr was only 56 12/23/18 at 1600 - hr was only 53 12/28/18 at 8:00 am - hr was only 54 12/29/18 at 1600 - hr was only 55 1/2/19 at 1600 - hr was only 56 1/4/19 at 8:00 am - hr was only 56 1/6/19 at 1600 - hr was only 59 1/8/19 at 1600 - hr was only 58 1/11/19 at 1600 - hr was only 53 1/13/19 at 1600 - b/p was only 113 1/16/19 at 1600 - hr was only 56 1/18/19 at 1600 - hr was only 57 1/19/19 at 8:00 am - hr was only 57 1/22/19 at 1600 - hr was only 54 On 1/31/19 at 5:07 PM, an interview was conducted with the Director of Nursing (DON), and he reviewed the MARs for Resident #10. He confirmed they should have held the blood pressure medications. He stated, We will notify the physician in reference to the parameters being adjusted or removed. 5. An interview was conducted with Employee I, Licensed Practical Nurse (LPN), on 1/30/19 at 12:09 PM. She stated Resident #25 was on insulin (for diabetes). Blood sugars had been fluctuating, and his insulin orders were all changed today. Any physician notification regarding abnormal blood sugars would be documented in the nursing progress notes. A record review for Resident #25 revealed a quarterly MDS assessment with an ARD of 10/28/18. Resident #25's active [DIAGNOSES REDACTED]. He received injections and insulin on seven of seven days over the assessment period. Resident #25 had physician's orders for Insulin Detemir 15 units subcutaneously every day for diabetes mellitus (DM); Insulin [MEDICATION NAME] 6 units subcutaneously every day at lunch for DM, hold if patient does not eat or is NPO (nothing by mouth), or if blood sugars are below or equal to 90. Call the physician for each, call for blood sugars over 450; and, Insulin [MEDICATION NAME] 8 units subcutaneously with dinner, hold if patient does not eat or is NPO (nothing by mouth), or if blood sugars are below or equal to 90. Call the physician for each, call for blood sugars over 450. A review of the clinical record and the MARs from (MONTH) (YEAR) through (MONTH) 2019 found Resident #25's blood sugars dropped below the specified parameters (blood sugar reading of 90 or less) on the following dates without evidence of physician notification, per the order: Resident #25 was noted with a blood sugar (BS) of 70 on 1/1/19 by Employee H, LPN. BS was noted at 88 on 1/10/19 by Employee H, LPN. BS was noted at 89 on 1/17/19 by Employee I, LPN. BS was noted at 86 on 12/11/18 by Employee I, LPN at both 7:00 AM and 11:00 AM. BS was noted at 77 on 12/14/18 by Employee I, LPN. BS was noted at 76 on 11/28/18 by Employee I, LPN. BS was noted at 88 on 11/19/18 at 6:14 AM and 7:15 AM by Employee I, LPN. BS was noted at 71 on 11/18/18 by Employee F, LPN. In an interview with the Assistant Director of Nursing (ADON) on 1/31/19 at 3:10 PM, she reviewed Resident #25's record and confirmed there was no documented evidence that the physician was notified of the abnormal blood sugar readings, per the order. A review of the facility Procedure for [MEDICATION NAME] Patch Application revised 10/17 noted the purpose was to administer medication as ordered and to release a continuous and controlled dosage over a specific time period. Equipment was clean disposable gloves and medication. Procedure number 1. Verify physician order . 3. Obtain patch and read manufacturer's guidelines. 4. Gloves should be worn to apply/remove [MEDICATION NAME]es . 9. Press the [MEDICATION NAME] system firmly in place . 11. Label patch or paper with date, time and initials. A review of the Facility Policy and Procedure on Medication Administration Including Scheduling and Medication Aides revised 10/17 revealed: Policy: Medication Administration: . If a medication is given but not signed for, the responsible medication person has 24 hours to sign, provided there is definitive evidence that the medication was actually administered. If it is not signed for within 24 hours, it is considered a medication error and an incident report must be completed Procedure: .4. Follow the Six Rights: Right medication, right dose, right route, right time and right documentation . 9. Administer medications within at least 60 minutes on each side of the ordered time . 11. Document that the medication was given as soon as possible after administration. Photographic evidence was obtained for all findings.

Based on observations, facility and resident record reviews, and interviews with residents and staff, the facility failed to provide care and services which met professional standards of care/quality by failing to ensure timely and appropriately labeled [MEDICATION NAME] medications for three (Residents #61, #22 and #81) of three sampled residents observed with [MEDICATION NAME] medicated patches; it failed to administer blood pressure medications as ordered for two (Residents #81 and #10) of six sampled residents whose medications were reviewed, and it failed to notify the physician of abnormal blood glucose readings per the physician's order for one (Resident #25) of six residents whose medications were reviewed, out of a total of 40 residents in the sample. Professional Standard of Care is defined in Chapter 766.102 as the prevailing professional standard of care for a given health care provider shall be that level of care, skill, and treatment which in light of all relevant surrounding circumstances is recognized as acceptable and appropriate by reasonably prudent similar health care providers. The Florida Nurse Practice Act, Chapter 464.003 defines the practice of professional nursing as the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not limited to: the administration of medications and treatments as prescribed or authorized by a duly licensed practitioner. Practice of practical nursing as the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured or infirmed and the promotion of wellness, maintenance or health, and the prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician or a licensed dentist. The findings include: 1. An observation and interview with Resident #61 on 1/28/19 at 2:34 PM revealed a 3 x 4 inch white rectangular shaped patch on the left side of his chest. The resident stated it had been applied that morning. On 1/29/19 at 3:36 PM, Resident #61 was observed and interviewed in his room. When asked how he was, he said he would be doing better if he had his pain patch. He tried to look to see if the patch was on his chest, but could not tell. This surveyor could not either, despite his attempts to pull the neck of his T-shirt down. While he denied pain at the time of interview, he insisted that he would be in pain soon if they did not give him his pain patches on his chest and hip. On 1/30/19 at 8:43 AM, Resident #61 was observed in his wheelchair near the nurse's station. He stated he was not doing well, as he had not gotten his pain patches yet. He explained that his hip and shoulder were hurting. The Regional Nurse walked over, intervened, and notified the Director of Nursing (DON) and the resident's nurse (Employee H) of the issue. They took Resident #61 to his room, and obtained a mechanical lift in preparation to transfer him back to bed. Resident #61 was asked if he had his chest patch on. He removed his shirt, and the rectangular white 3 x 4 inch patch was observed on his upper left chest; however, the entire patch was folded in half underneath itself, and the medicated surfaces stuck to each other. There was no skin contact with the medicated surfaces. The folded patch hung from the left shoulder by a corner of the surrounding adhesive strip. At this time (approximately 9:00 AM), the Regional Nurse reached over with her bare hands and removed the patch from Resident #61's chest. She held the patch up, and it was observed to be unlabeled and undated. An interview was conducted with Employee Z, Certified Nursing Assistant (CNA), on 1/30/19 at 1:48 PM. She stated Resident #61 complained of hip and shoulder pain, and that his pain medications/patches were all he asked for. She stated the patch seemed to work and calm him down. An observation of Resident #61 on 1/31/19 at 8:52 AM found him in bed. He had no shirt on, and there was a large 3 x 4 inch white rectangular patch on top of his left shoulder. The patch was not labeled or dated. He stated he was feeling good, but later in the conversation said his pain level was a 12 on a scale of 0-10 with zero representing no pain and 10 representing the worst possible pain. When asked the location of his pain he did not answer. A record review for Resident #61 found a Medicare Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/5/19. He had a Brief Interview for Mental Status (BIMS) score of 00, as he was unable to answer any of the questions asked. He required extensive assistance with all activities of daily living and personal hygiene, and he used a wheelchair as a mobility aid. [DIAGNOSES REDACTED]. Resident #61 received scheduled pain medication in the last five days over the assessment period and was offered and declined, or received, as-needed (prn) pain medication. He was unable to answer whether he had been in pain over the past five days. Resident #61 received opioid medication on seven of seven days over the assessment look back period. Resident #61 was care planned on 12/9/18 for acute/chronic pain/discomfort related to [MEDICAL CONDITION] ([MEDICAL CONDITION] - stroke) as evidenced by disease process. The goal was to verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. Approaches included identification of level of pain tolerated using a 1-10 scale, report signs and symptoms of pain or discomfort to nursing, notify the physician if interventions are unsuccessful. Evaluate effectiveness of pain interventions, review for compliance, alleviation of symptoms, dosing schedules and resident satisfaction with results Resident #61 had a physician's order for a [MEDICATION NAME], 5%, apply to left shoulder topically one time per day for pain and remove per schedule, apply at 0800 (8:00 AM) and remove at 2000 (8:00 PM). A review of the current medication administration record (MAR) and notes found the following late application times for the 8:00 AM [MEDICATION NAME] chest patch: On 1/5/19 the patch was not applied until 9:20 AM by Employee O, Licensed Practical Nurse (LPN). On 1/6/19 it was not applied until 11:13 AM by Employee K, LPN. On 1/9/19 it was not applied until 9:03 AM by Employee M, Registered Nurse. On 1/17/19, it was not applied until 10:00 AM by Employee P, LPN. On 1/18/19, it was not applied until 9:40 AM by Employee P, LPN. On 1/25/19, it was not applied until 9:12 AM by Employee Y, LPN. On 1/29/19, it was not applied until 9:27 AM by Employee H, LPN. Resident #61 had a second order for a [MEDICATION NAME], 5%, to his left hip topically every 12 hours, apply at 0800 (8:00 AM) and remove at 2000 (8:00 PM), related to pain unspecified (discontinued 1/30/19). Review of the (MONTH) 2019 MAR and medication administration notes found the following late application times for the [MEDICATION NAME] hip patch: On 1/5/19, the patch was not applied until 9:20 AM by Employee O, LPN. On 1/6/19, the patch was not applied until 11:13 AM by Employee K, LPN. On 1/9/18, the patch was not applied until 9:03 AM by Employee M, RN. On 1/17/19, the patch was not applied until 10:00 AM by Employee P, LPN. On 1/18/19, the patch was not applied until 9:40 AM by Employee P, LPN. On 1/25/19, the patch was not applied until 9:12 AM by Employee Y, LPN. On 1/29/19, the patch was not applied until 9:27 AM by Employee H, LPN. (Photographic evidence obtained) 2. An observation of Resident #22 was conducted on 1/28/19 at 11:28 AM. He was in his bed lying on his back, but did not respond to this surveyor. A small round tan patch, approximately the size of a dime, was observed behind his right ear. The patch was not labeled or dated. On 1/30/19 at 8:50 AM, Resident #22 was observed in his bed. A small, round, tan patch was observed in the same location under his right ear. The patch was not labeled or dated. On 1/31/19 at 8:54 AM, Resident # 22 was observed in his bed. A small, round, tan patch with some faint manufacturer's printing was observed under his left ear. It appeared to be new. There was no date, label, or staff initials on the patch. In an interview with Employee H, Licensed Practical Nurse (LPN), on 1/30/19 at 1:38 PM, she stated the patch behind his ear was a [MEDICATION NAME] (a medication that can be used to decrease saliva, or nausea/vomiting or motion sickness). Employee H explained Resident #22 was dependent on staff for all care. A record review for Resident #22 revealed a quarterly MDS assessment with an assessment reference date (ARD) of 1/10/19. Resident #22 was coded as comatose, and in persistent vegetative state. He was assessed with [REDACTED]. [DIAGNOSES REDACTED]. Resident #22 was care planned on 1/10/19 for risk of altered nutrition and dehydration related to muscle spasms, convulsions, disturbances of salivary secretion, and chronic [MEDICAL CONDITION]. The goal was to maintain adequate nutritional and hydration status and show no signs of dehydration through the review date. He had a care plan for potential fluid deficit related to anoxia (lack of oxygen to the brain), with a goal to be free of signs of dehydration, and maintain moist mucous membranes and good skin turgor. Approaches included monitoring for signs of dehydration and dry mucous membranes. Resident #22 had a physician's order for [MEDICATION NAME] 0.125 milligrams (mg) every 4 hours as needed for increased secretions. He also had a physician's order for [MEDICATION NAME]-[MEDICATION NAME] (Trans-Scop)1.5 mg patch, 72 hour, 1 mg/3 days. Apply [MEDICATION NAME] (through or across the skin) every 3 days for secretions related to disturbances of salivary secretion. Per the medication administration record (MAR) instructions dated 1/18/19, the patch was to be applied at 1800 (6:00 PM) every three days. On the third day, it was to be removed at 1759 (5:59 PM), and a new patch reapplied at 1800 (6:00 PM). Closer review of the (MONTH) 2019 MAR revealed that on 1/21/19, the patch that was scheduled to be removed at 1759 (5:59 PM) was not removed until 2205 (8:05 PM) by Employee L, Licensed Practical Nurse (LPN). The patch was replaced at 2206 (8:06 PM), over 2 hours past the scheduled replacement time. Prior to the 1/19/19 order, the application times for the Trans-Scop patch (ordered 10/14/18 and discontinued on 1/18/19) were for an 8:00 AM application time, and a 7:59 AM removal time on day 3. A review of the MAR found on 1/9/19 the existing patch scheduled for 7:59 AM removal was not removed until 9:04 AM. The replacement patch, scheduled for 8:00 AM, was not applied until 9:07 AM by Employee M, Registered Nurse (RN). On 1/12/19, the patch was not removed until 9:16 AM, and reapplied at 9:18 AM by Employee M. (Photographic evidence obtained) An interview was conducted with Employee H, LPN, on 1/30/19 at 1:55 PM. She was asked about the late administration times for the [MEDICATION NAME] for Resident #61. She explained his physician's order for the [MEDICATION NAME] had recently changed because they could not get the patch from pharmacy. She believed the reason for late application of the patch on his hip may be due to the fact he was already up and in his wheelchair. He would need to be placed back in the bed for the hip patch replacement, and he was dependent on staff and a mechanical lift for all transfers. Employee H stated that Resident #61's chest patch, however, could be applied anytime (and without a transfer). When asked if [MEDICATION NAME] medication patches should be labeled once they were applied, she turned to Employee L, LPN, who had come to the desk. Employee L explained that sometimes there were only two nurses on the unit in the mornings, but there were typically three. The nurses usually began their medication pass in a different hall, because there were multiple diabetic patients on that hall. When asked again whether [MEDICATION NAME]es were supposed to be labeled and dated, she said yes, they should. Employee N, Registered Nurse (RN)/Unit Manager, was interviewed on 1/31/19 at 9:25 AM. He reviewed the clinical records, and confirmed the late application times for the [MEDICATION NAME]es on his unit. He did not know why patches were being applied outside of the one hour before and one hour after time window permitted for medication administration. Employee N stated the expectation was for all [MEDICATION NAME]es to be labeled and dated once applied. Resident #22's and Resident #61's rooms were visited along with Employee N for observation, and he confirmed the presence of the unlabeled and undated patches. 3. A record review for Resident #81 revealed a Quarterly MDS assessment with an ARD of 1/3/19. The resident was comatose in a persistent vegetative state, and with no discernable consciousness. She was totally dependent on staff for all needs. [DIAGNOSES REDACTED]. Resident #81 had a physician's order for a [MEDICATION NAME], 72 hour, apply 1 patch [MEDICATION NAME] every 72 hours for excessive secretions related to disturbances of salivary secretion. Remove old patch and remove per schedule, remove at 0759 (7:59 AM and apply at 0800 (8:00 AM). The patch was applied late on the following dates: On 1/7/19 the 8:00 AM patch was not applied until 9:21 AM by Employee H, LPN. On 1/13/19 the 8:00 AM patch was not applied until 9:18 AM by Employee K, LPN. Resident #81 had a physician's order for [MEDICATION NAME] 200 milligrams (mg), give 2 tabs via [DEVICE] every 12 hours related to hypertension. There was no physician's instruction to hold this medication based on blood pressure measurements. A review of the MAR found on the following dates, the nurse held/did not administer the [MEDICATION NAME]: On 1/1/19 at 2000 (8:00 PM), the medication was not given, with no corresponding nurse's note. On 1/22/29, it was held with a note that referenced the [DIAGNOSES REDACTED]. The note stated the resident's blood pressure was 101/50, and was authored by Employee A, LPN. On 1/23/19 it was not administered, with a corresponding note at 9:03 PM by Employee A that Resident #81's blood pressure was 118/58. On 1/25/19 it was not administered, with a corresponding note at 7:27 PM by Employee A that her blood pressure was 102/52. On 1/27/19 it was not administered, with a corresponding note at 7:18 PM by Employee A that her blood pressure was 100/60. On 1/28/19 it was not administered, with a corresponding note at 9:12 PM by Employee J, LPN, that blood pressure was 92/62. On 01/31/19 at 3:12 PM, an interview was conducted with the Assistant Director of Nursing (ADON). She reviewed the clinical record, and confirmed there were no hold parameters for Resident #81's [MEDICATION NAME]. The Director of Nursing, who entered the room at this time, stated he had already started re-education of the nurses, and the physician's order had been clarified with the physician. 4. A record review was conducted for Resident #10 and revealed a [AGE] year-old male, admitted to the facility on [DATE]. He was admitted with [DIAGNOSES REDACTED]. A review was conducted of his Medication Administration Records (MARs) for (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) 2019. It revealed the following order: [MEDICATION NAME] (blood pressure medication) Give 50 mg (milligrams) by mouth two times a day for hypertension. Hold for systolic blood pressure (b/p) <120 and/or heartrate (hr) <60 beats per minute. Document b/p and hr prior to giving [MEDICATION NAME]. Further review of his MARs revealed the facility failed to follow the physician's order and the medication was administered when it should have been held, due to b/p and/or hr. The medication should have been held per paramters, however it was administered on the following dates: 11/4/18 at 1600 (4 pm) - b/p was only 118 11/10/18 at 8:00 am - hr was only 58 and at 1600 hr was only 57 11/11/18 at 8:00 am - hr was only 57 11/13/18 at 1600 - b/p was only 110 11/16/18 at 1600 - hr was only 56 11/20/18 at 1600 - b/p was only 114 11/28/18 at 8:00 am - hr was only 59 11/30/19 at 1600 - b/p was only 116 12/1/18 at 1600 - b/p was only 110 12/17/18 at 1600 - hr was only 59 12/20/18 at 1600 - hr was only 58 12/21/18 at 1600 - hr was only 56 12/23/18 at 1600 - hr was only 53 12/28/18 at 8:00 am - hr was only 54 12/29/18 at 1600 - hr was only 55 1/2/19 at 1600 - hr was only 56 1/4/19 at 8:00 am - hr was only 56 1/6/19 at 1600 - hr was only 59 1/8/19 at 1600 - hr was only 58 1/11/19 at 1600 - hr was only 53 1/13/19 at 1600 - b/p was only 113 1/16/19 at 1600 - hr was only 56 1/18/19 at 1600 - hr was only 57 1/19/19 at 8:00 am - hr was only 57 1/22/19 at 1600 - hr was only 54 On 1/31/19 at 5:07 PM, an interview was conducted with the Director of Nursing (DON), and he reviewed the MARs for Resident #10. He confirmed they should have held the blood pressure medications. He stated, We will notify the physician in reference to the parameters being adjusted or removed. 5. An interview was conducted with Employee I, Licensed Practical Nurse (LPN), on 1/30/19 at 12:09 PM. She stated Resident #25 was on insulin (for diabetes). Blood sugars had been fluctuating, and his insulin orders were all changed today. Any physician notification regarding abnormal blood sugars would be documented in the nursing progress notes. A record review for Resident #25 revealed a quarterly MDS assessment with an ARD of 10/28/18. Resident #25's active [DIAGNOSES REDACTED]. He received injections and insulin on seven of seven days over the assessment period. Resident #25 had physician's orders for Insulin Detemir 15 units subcutaneously every day for diabetes mellitus (DM); Insulin [MEDICATION NAME] 6 units subcutaneously every day at lunch for DM, hold if patient does not eat or is NPO (nothing by mouth), or if blood sugars are below or equal to 90. Call the physician for each, call for blood sugars over 450; and, Insulin [MEDICATION NAME] 8 units subcutaneously with dinner, hold if patient does not eat or is NPO (nothing by mouth), or if blood sugars are below or equal to 90. Call the physician for each, call for blood sugars over 450. A review of the clinical record and the MARs from (MONTH) (YEAR) through (MONTH) 2019 found Resident #25's blood sugars dropped below the specified parameters (blood sugar reading of 90 or less) on the following dates without evidence of physician notification, per the order: Resident #25 was noted with a blood sugar (BS) of 70 on 1/1/19 by Employee H, LPN. BS was noted at 88 on 1/10/19 by Employee H, LPN. BS was noted at 89 on 1/17/19 by Employee I, LPN. BS was noted at 86 on 12/11/18 by Employee I, LPN at both 7:00 AM and 11:00 AM. BS was noted at 77 on 12/14/18 by Employee I, LPN. BS was noted at 76 on 11/28/18 by Employee I, LPN. BS was noted at 88 on 11/19/18 at 6:14 AM and 7:15 AM by Employee I, LPN. BS was noted at 71 on 11/18/18 by Employee F, LPN. In an interview with the Assistant Director of Nursing (ADON) on 1/31/19 at 3:10 PM, she reviewed Resident #25's record and confirmed there was no documented evidence that the physician was notified of the abnormal blood sugar readings, per the order. A review of the facility Procedure for [MEDICATION NAME] Patch Application revised 10/17 noted the purpose was to administer medication as ordered and to release a continuous and controlled dosage over a specific time period. Equipment was clean disposable gloves and medication. Procedure number 1. Verify physician order . 3. Obtain patch and read manufacturer's guidelines. 4. Gloves should be worn to apply/remove [MEDICATION NAME]es . 9. Press the [MEDICATION NAME] system firmly in place . 11. Label patch or paper with date, time and initials. A review of the Facility Policy and Procedure on Medication Administration Including Scheduling and Medication Aides revised 10/17 revealed: Policy: Medication Administration: . If a medication is given but not signed for, the responsible medication person has 24 hours to sign, provided there is definitive evidence that the medication was actually administered. If it is not signed for within 24 hours, it is considered a medication error and an incident report must be completed Procedure: .4. Follow the Six Rights: Right medication, right dose, right route, right time and right documentation . 9. Administer medications within at least 60 minutes on each side of the ordered time . 11. Document that the medication was given as soon as possible after administration. Photographic evidence was obtained for all findings.