Every finding on record at Briarwood Health Care Center

Based on observations, record review and interviews, the facility failed to ensure respiratory care was provided in accordance with professional standards for four (#29, #38, #79 and #89) of five residents out of 35 sample residents.Specifically, the facility failed to ensure oxygen was administered according to physician's orders for Resident #29, Resident #38, Resident #79 and Resident #89.Findings include:I. Facility policy and procedureThe Oxygen Administration (Infection Control, Safety, & Storage) policy, revised 3/3/26, was provided by the nursing home administrator (NHA) on 7/13/26 at 7:55 p.m. It read in pertinent part, Oxygen orders should include the specific liter flow required by the resident. Residents receiving oxygen at 4 liters per minute (LPM) or greater, via concentrator, should be connected to a humidifier. Associates will be educated on oxygen administration, safety and storage upon hire, annually, and as indicated thereafter.II. Resident #29A. Resident statusResident #29, age greater than 65, was admitted on [DATE]. According to the July 2026 computerized physician orders (CPO), diagnoses included chronic respiratory failure, chronic obstructive pulmonary disease (COPD) and unspecified asthma.The 7/9/26 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15.The MDS assessment indicated Resident #29 received oxygen therapy.B. ObservationsOn 7/8/26 at 2:06 p.m. Resident #29 was lying on his bed in his room and did not have the oxygen on. His nasal cannula was connected to an oxygen concentrator and was lying on the bed. An unidentified certified nurse aide (CNA) assisted Resident #29 in putting his nasal cannula back in place. The oxygen concentrator was set at a flow rate of 4 LPM.On 7/9/26 at 4:10 p.m. Resident #29 was lying on his bed with his nasal cannula connected to an oxygen concentrator set at 4 LPM. The resident had his oxygen on.On 7/13/26 at 9:38 a.m. Resident #29 was lying on his bed with his nasal cannula connected to an oxygen concentrator set at 4 LPM. The resident had his oxygen on.-However, the resident's physician's order for oxygen specified an oxygen flow rate of 2 LPM (see record review below).C. Resident interviewResident #29 was interviewed on 7/8/26 at 2:06 p.m. Resident #29 said nasal cannula did not bother him and he did not remove it. He said he did not touch the oxygen concentrator and was not sure who adjusted the oxygen flow rate.D. Record reviewReview of Resident #29's July 2026 CPO revealed the following physician's orders:Oxygen at 2 LPM continuously per nasal cannula indicated for diagnosis of chronic respiratory failure and obstructive sleep apnea. Every shift for shortness of breath, encourage Resident #29 to wear his oxygen and document if not wearing, ordered 1/13/26.-However, observations revealed Resident #29's oxygen flow rate was set at 4 LPM (see observations above).The oxygen therapy care plan, revised 6/5/26, documented Resident #29 had oxygen therapy related to ineffective gas exchange due to sleep apnea, chronic respiratory failure and hypoxia. Resident #29 refused to wear oxygen at times. Interventions included encouraging Resident #29 to wear his oxygen and setting oxygen via nasal prongs at 2 LPM continuously.III. Resident #38A. Resident statusResident #38, age greater than 65, was admitted on [DATE]. According to the July 2026 CPO, diagnoses included COPD, asthma and hypertension.The 6/26/26 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15.The MDS assessment indicated Resident #38 received oxygen therapy.B. ObservationsOn 7/8/26 at 5:00 p.m. Resident #38 was sitting on his bed in his room and had his nasal cannula connected to an oxygen concentrator. The oxygen concentrator was set at a flow rate of 4 LPM.On 7/9/26 at 4:13 p.m. Resident #38 was lying on his bed with his nasal cannula connected to an oxygen concentrator set at 4 LPM. The resident had his oxygen on.On 7/13/26 at 9:44 a.m. Resident #38 was lying on his bed with his nasal cannula connected to an oxygen concentrator set at 4 LPM. The resident had his oxygen on.-However, the resident's physician's order for oxygen specified an oxygen flow rate of 2 LPM (see record review below).C. Resident interviewResident #38 was interviewed on 7/9/26 at 4:13 p.m. Resident #38 said he had not touched the oxygen concentrator. He said the staff were the ones who touched it.D. Record reviewReview of Resident #38's July 2026 CPO revealed the following physician's orders:Oxygen at 2 LPM continuously per nasal cannula and document. Every shift related to asthma and COPD, ordered 1/14/26.-However, observations revealed Resident #38's oxygen flow rate was set at 4 LPM (see observations above).The oxygen therapy care plan, revised 11/3/25, documented Resident #38 had oxygen therapy related to ineffective gas exchange due to chronic hypoxia. Interventions included providing extension tubing or portable oxygen apparatus for residents who should be ambulatory and setting oxygen via nasal cannula at 2 LPM.IV. Resident #79A. Resident statusResident #79, age greater than 65, was admitted on [DATE]. According to the July 2026 CPO, diagnoses included chronic respiratory failure with hypoxia, COPD and chronic respiratory failure with hypercapnia (too much carbon dioxide in the blood).The 5/4/26 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of eight out of 15.The MDS assessment indicated Resident #79 received oxygen therapy.B. ObservationsOn 7/8/26 at 3:54 p.m. Resident #79 was sitting in a wheelchair in the lobby with his oxygen on that was connected to a portable oxygen tank. The portable oxygen tank oxygen was set at a flow rate of 4 LPM.On 7/9/26 at 3:33 p.m. Resident #79 was lying on his bed with his nasal cannula connected to an oxygen concentrator set at 3.5 LPM. The resident had his oxygen on.On 7/13/26 at 9:45 a.m. Resident #79 was lying on his bed with his nasal cannula connected to an oxygen concentrator set at 3.5 LPM. The resident had his oxygen on.-However, the resident's physician's order for oxygen specified an oxygen flow rate of 2 LPM (see record review below).C. Resident interviewResident #79 was interviewed on 7/9/26 at 3:33 p.m. Resident #79 said he did not know who set the oxygen flow rate. Resident #79 said he thought he was getting enough air.D. Record reviewReview of Resident #79's July 2026 CPO revealed the following physician's orders:Oxygen at 2 LPM continuously per nasal cannula and document. Every shift for hypoxia, ordered 12/11/25.-However, observations revealed Resident #79's oxygen flow rate was set at 4 LPM for a portable oxygen tank. The oxygen flow rate was set at 3.5 LPM for the oxygen concentrator (see observations above).The oxygen therapy care plan, revised 9/11/25, documented Resident #79 had oxygen therapy related to ineffective gas exchange due to the diagnosis of chronic respiratory failure with hypercapnia and with hypoxia. Interventions included encouraging or assisting with ambulation as indicated and setting oxygen via nasal cannula at 2 LPM.V. Resident #89A. Resident statusResident #89, age greater than 65, was admitted on [DATE]. According to the July 2026 CPO, diagnoses included COPD, obstructive sleep apnea and chronic respiratory failure unspecified whether with hypoxia or hypercapnia.The 4/21/26 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of seven out of 15.The MDS assessment indicated Resident #89 received oxygen therapy.B. ObservationsOn 7/8/26 at 5:09 p.m. Resident #89 was lying on his bed with his nasal cannula connected to an oxygen concentrator set at 4 LPM. The resident had his oxygen on.On 7/9/26 at 4:15 p.m. Resident #89 was lying on his bed with his nasal cannula connected to an oxygen concentrator set at 4 LPM. The resident had his oxygen on.On 7/13/26 at 9:48 a.m. Resident #79 was lying on his bed with his nasal cannula connected to an oxygen concentrator set at 4 LPM. The resident had his oxygen on.-However, the resident's physician's order for oxygen specified an oxygen flow rate of 1-2 LPM (see record review below).C. Record reviewReview of Resident #89's July 2026 CPO revealed the following physician's orders:Oxygen at 1 to 2 LPM continuously per nasal cannula and document every shift for COPD and respiratory failure, ordered 2/2/26.-However, observations revealed Resident #89's oxygen flow rate was set to 4 LPM (see observations above).-Review of the comprehensive care plan did not reveal an oxygen focus for Resident #89.VI. Staff interviews and observationsCNA #5 was interviewed on 7/13/26 at 9:47 a.m. CNA #5 said she checked residents' oxygen flow rates while obtaining vital signs. CNA #5 said she would notify the nurse if she identified a problem with the flow rate. CNA #5 said she was shown how to verify the prescribed oxygen flow rate in the resident's electronic medical record (EMR) when she started. During the interview, CNA #5 observed Resident #38 and Resident #89 both had oxygen concentrators set at 4 LPM. CNA #5 said those flow rates did not match the physician's orders documented in the EMR. CNA #5 said if she observed an incorrect oxygen flow rate, she would notify the nurse. CNA #5 said she failed to verify the prescribed flow rates for those residents.Licensed practical nurse (LPN) #4 was interviewed on 7/13/26 at 10:03 a.m. LPN #4 said both CNAs and nurses were responsible for checking residents' oxygen flow rates because residents sometimes adjusted the oxygen settings themselves. LPN #4 said if staff adjusted the flow rates temporarily, such as during activities, they would ensure it returned as it was ordered. LPN #4 said to increase or reduce the oxygen flow would require a physician's order. During interview, LPN #4 observed Resident #38 was receiving oxygen at 4 LPM, Resident #89 at 4 LPM, and Resident #79 at 3 LPM, even though physician's orders were 2 LPM for each resident. LPN #4 adjusted the oxygen flow rates for Resident #38, Resident #89 and Resident #79 to 2 LPM according to the physician's orders. LPN #4 also observed Resident #29's oxygen concentrator was set at 4 LPM, even though the resident was not wearing the nasal cannula. LPN #4 did not adjust Resident #29's flow at that time. LPN #4 said CNAs often monitored residents' oxygen saturation, not the flow rate. LPN #4 said checking oxygen saturation was more important than the flow rate as the latter would not affect the resident as long as the saturation remained within normal limits. The assistant director of nursing (ADON) and the regional clinical resource nurse were interviewed together on 7/13/26 at 3:17 p.m. The ADON said the nurses were responsible for verifying oxygen flow rates matched physician orders. The ADON said if the flow rate did not match the orders, staff needed to notify the provider who would review it. The ADON reviewed the physician's orders for Resident #38, Resident #89, Resident #79 and Resident #29. The ADON confirmed the prescribed oxygen flow rate for each resident was 2 LPM.The regional clinical resource nurse said if the flow rate was too high, it would cause issues for breathing and alter the resident's mental status. The regional clinical resource nurse said she would provide education to nursing staff regarding appropriate oxygen therapy management.

Based on observations and interviews, the facility failed to have an adequately equipped call system to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff area.Specifically, the facility failed to ensure all parts of the call light system were functioning properly in the common bathroom near the main dining room and the day room on the first floor.Findings include:I. Facility policy and procedureThe Resident Call System Policy, reviewed 12/23/25, was provided by the nursing home administrator (NHA) on 7/15/26 at 3:38 p.m. The policy read in pertinent part, The nurses stations in the facility will be equipped to receive resident calls with a communication system through audible or visual signals from resident rooms, toilets and bathing facilities. All portions of the system will be maintained and function accordingly. The facility will maintain procedures and an alternate communication in the event the system becomes inoperable. The call light should be positioned within reach of the resident. Return demonstration may be used when educating the resident about call light use. If the resident is unable to demonstrate appropriate call light use, the nurse must be notified to determine an adequate alternative. The call light system must be accessible to residents while in their bed or other sleeping accommodations within the resident's room. The call system must be accessible to the resident at each toilet and bath or shower facility, and would be accessible to a resident lying on the floor in this area. The resident call system is on a monthly preventative maintenance schedule with the documentation as noted in the electronic portal task to ensure all portions of the nurse call steam are functioning.II. Resident interviews and observationsOn 7/8/26 at 1:43 p.m. the resident who resided in room [ROOM NUMBER] was interviewed. The resident said he used his bathroom when he needed to have a bowel movement.The following observations of call lights were made during the survey on 7/8/26 in room [ROOM NUMBER] at 1:40 p.m., on 7/8/26 in room [ROOM NUMBER] at 1:43 p.m and on 7/13/26 in room [ROOM NUMBER] at approximately 12:20 p.m. The call lights were observed to have a call light wall plate in the resident's bathroom mounted on the wall next to the resident's toilet. A one inch black rubber piece was connected to the wall plate and to a string. The call light string extended down and was threaded through a metal hook screw nailed into the wall, and then was strung upwards through a second metal hook screw also nailed into the wall. On the end of the call light string was a brown wooden ball. The upper metal hook screw was approximately eight inches above the call light wall plate, and a second metal hook screw was approximately three to four inches below the call light wall plate. On the end of the call light string was a brown wooden ball. On 7/13/26 at approximately at 2:45 p.m. with the NHA and the director of nursing (DON) the call light in room [ROOM NUMBER] was observed with the NHA and the DON. The call light in room [ROOM NUMBER] was observed to have a call light wall plate in the resident's bathroom mounted on the wall next to the resident's toilet. A one inch black rubber piece was connected to the wall plate and to a string. The call light string extended down and was threaded through a metal hook screw nailed into the wall, and then was strung upwards through a second metal hook screw also nailed into the wall. On the end of the call light string was a brown wooden ball. The upper metal hook screw was approximately eight inches above the call light wall plate, and a second metal hook screw was approximately three to four inches below the call light wall plate. On the end of the call light string was a brown wooden ball. The NHA pulled the call light string down using the end of the string attached to the brown wooden ball. The call light indicator did not turn on in the bathroom. The DON said the call light did not turn on in the hallway above the resident's door.-When the rubber piece was pushed down, the call light indicator on the call light wall plate turned on and the DON said it turned on above the resident's door. However, when the string was pulled it did not.III. Staff interviewsCertified nurse aide (CNA) #6 was interviewed on 7/14/26 at 12:30 p.m. CNA #6 said the staff needed to answer call lights as soon as possible. CNA #6 said if the resident fell on the floor the call light would not be accessible to them but there was a call light on the bed. CNA #6 said she was aware of a fall in the bathroom but it was an observed fall.

Based on observations, record review and interviews, the facility failed to maintain accurate medical records for advance directives on each resident for one (#6) of six residents reviewed out of 35 sample residents. Specially, the facility failed to ensure Resident #6's medical orders for scope of treatment (MOST) form corresponded with the computerized physician orders (CPO) for cardiopulmonary resuscitation (CPR).Findings include:I. Facility policy and procedureThe Advanced Directive and Advance Care Planning policy, reviewed [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 12:16 p.m. It read in pertinent part, Residents have the right to self-determination regarding their medical care. Residents or their responsible parties receive materials concerning their rights under applicable laws to make decisions regarding their medical care, including the right to accept or refuse medical care, the right to accept or refuse medical/surgical treatment, organ donation requests, and the formation of advance directive upon admission. Residents may revise an advanced directive either orally or in writing. With an oral reversal, change is due immediately, the physician is notified immediately, and immediate notation is made on the care plan and an immediate entry is made in the medical record. With written reversals, the physician is notified, and the plan is permanently adjusted. The physician must give an order for any changes in the advanced directives. Each time the resident is admitted to the facility, quarterly and when a change in condition is noted in the resident's condition, the facility should review the advance directive and advance care planning information. The review should focus on if the existing advance directives match the current goals of care for the resident. The social services director or designees should document this conversation in the medical record and assist as needed with updating the documents that need revision in accordance with the state and federal requirements.II. Resident #6A. Resident statusResident #6, age [AGE], was admitted [DATE]. According to the [DATE] computerized physician's orders (CPO), the diagnoses included severe protein calorie malnutrition and gastrostomy malfunction. The [DATE] minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15. The resident needed partial to moderate assistance with activities of daily living.II. Resident interviewResident #6 was interviewed on [DATE] at 5:30 p.m. Resident #6 said he wanted to be saved if his heart were to stop. He said he wanted everything done to save him if his heart stopped. III. Record review and observationsResident #6's advanced directive care plan, revised [DATE], documented the resident's advanced directive was do not resuscitate (DNR) and selective treatment and artificial nutrition by tube (short team or temporary). Pertinent interventions, initiated [DATE], documented the resident's code status would be reviewed on a quarterly basis and PRN (as needed), the resident signed a do not resuscitate (DNR) form and selective treatment with artificial nutrition by tube (short term and temporary).Review of Resident #6's [DATE] CPO revealed a physician's order for advanced directive that Resident #6's code status was full code, ordered [DATE].On [DATE], Resident #6's MOST was form provided by LPN #3 . She said the advanced directive binder was stored at the nurse's station. Resident #6's MOST form revealed the resident signed and dated it [DATE] and signed and dated by the nurse practitioner on [DATE]. The MOST form indicated, no CPR with selective treatment which included intravenous (IV) antibiotics and fluids, do not intubate and to avoid intensive care. -However, the [DATE] physician's order indicated the resident wanted to be full code. On [DATE] at approximately at 3:00 p.m. the NHA provided a MOST form signed by Resident #6 on [DATE] and documented the scope of treatment as full treatment to prolong life by all medically effective means, including temporary or permeate tub feeding. -However, the form failed to include Resident # 6's choice for cardiopulmonary resuscitation (CPR). A new MOST form was updated in the resident's EMR and signed by Resident #6 on [DATE] (during the survey) and by the physician on [DATE] (during the survey). The MOST form documented yes for CPR and full treatment to prolong life by all medically effective means, including temporary or permeate tub feeding. A [DATE] (during the survey) communication note documented at 7:09 p.m. documented the facility had a conversation with the resident's representative about the Resident #6's code status and informed them the resident expressed a wish to be full code. The representative gave consent for the code status to be full code and the MOST form was updated.IV. Staff interviews:Licensed practical nurse (LPN) #3 was interviewed on [DATE] at 2:35 p.m. LPN#1 said that in the case of an emergency for a resident, staff were told to check the MOST form binder first. She said residents' code status was also mentioned in the resident's electronic medical record (EMR). She said the code status was updated at the time of admission and anytime residents changed their decisions. She said the social worker or the nurse helped the resident to complete the MOST form. The regional clinical resource was interviewed on [DATE] at 4:30 p.m. The regional clinical resource said the instructions to staff were to check the MOST form, the MOST forms binder located in the nurse station and EMR in the case of emergencies to find the residents' code status. The regional clinical resource said residents MOST forms were updated during their care conferences. She said if there was no change in the resident's wishes, staff would document no change on the back of the MOST form. She said she trained the staff over the weekend and performed an audit for all residents' MOST forms for establishing accuracy. The regional clinical resource said if a resident or resident's representative wanted to change the MOST form, then whomever they tell, then that staff member took the current MOST form, and on the back form the staff signed their name. She said if there was a change, staff gave the form to medical records staff. Once the form was filled out and signed by the resident it was placed in a doctors box the physicians can sign and fill out. The regional clinical sources said she followed up and at some point there was a discrepancy between Resident #6s order and MOST form. She said they contacted the resident's representative and clarified his wishes, and put a full code to update the most form and update the care plan. She said the facility did educate the nurse who entered the order on [DATE] on protocol for MOST forms.

Based on record review and interviews, the facility failed to revise and implement an effective discharge plan for two (#93 and #6) of three residents reviewed for discharge planning out of 35 sample residents. Specifically, the facility failed to ensure a bed hold notice was provided to Resident #93 and Resident #6 within 24 hours upon transfer to a hospital.Findings include:I. Facility admission packetThe facility's admission packet was provided by the nursing home administrator (NHA) on 6/8/2026 at 12:06 p.m. It read in pertinent part, At the time you are to leave the facility for a temporary stay in a hospital or for therapeutic leave (or within 24 hours in case of an emergency transfer), you or your legal representative will be given a written copy of the Bed Hold policy and may elect to hold open your room and bed until our return. At this time, you or your legal representative will indicate in writing whether you desire or decline the bed hold. The facility will not be required to hold your bed if you or your legal representative fail to request a bed hold according to the above procedure; upon discharge from the hospital you require a higher level of care than can be provided by the facility; the bed hold period expires and you or your representative do not extend the bed hold using the above procedure. Private pay residents and medicare beneficiaries will be charged a basic room charge for each day of the bed hold. They will be notified of the rate at the time you are temporarily discharged . If you are a Medicaid beneficiary and Medicaid agrees to pay for the bed hold, the facility will notify you of eligible medicaid days and will bill medicaid up to the maximum number of bed hold days covered by medicaid. In addition, the facility will also bill you or your financial representative for your co-payment as applicable. If the bed hold period exceeds the number of days covered by the Medicaid program, or if Medicaid coverage is unavailable for the bed hold, you or your financial representative may voluntarily choose to privately pay the bed hold.II. Resident #93A. Resident statusResident #93, age [AGE], was admitted on [DATE], discharged to the hospital on 6/9/26, returned to the facility on 6/15/26 and returned to the hospital again on 6/19/26. According to the June 2026 computerized physician orders (CPO), diagnoses included chronic respiratory failure, high blood pressure, and chronic kidney disease stage 4. The 6/4/26 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident needed moderate to substantial assistance with activities of daily living (ADL). The 6/16/26 MDS assessment documented the resident returned from the hospital on 6/15/26.B. Record reviewA 6/9/26 follow up note documented Resident #93 was transferred to the hospital for further workup of hypotension, new oxygen needs, and hematuria (presence of red blood cells in the urine).A 6/15/26 progress note documented Resident #93 returned from a local hospital on 6/15/26, escorted by two emergency medical technicians.-However, a review of Resident #93's electronic medical record (EMR) failed to reveal a bed hold notification was provided to the resident upon his discharge to the hospital on 6/9/26.III. Resident #6A. Resident statusResident #6, age [AGE], was admitted [DATE]. According to the July 2026 CPO, diagnoses included severe protein calorie malnutrition and gastrostomy malfunction. The 7/7/26 MDS assessment documented the resident was cognitively intact with a BIMS score of 15 out of 15. The resident needed partial to moderate assistance with ADLs.B. Record reviewA 3/29/26 discharge summary, documented at 11:30 a.m., revealed Resident #6 was discharged to a local hospital for further evaluation and treatment of his feeding tube that was discovered broken at the tip of the open and close valve.A 3/30/26 admission note, documented at 11:55 p.m., revealed that Resident #6 arrived at his room with one male staff member and was alert and talkative. -However, a review of Resident #6's EMR failed to reveal a bed hold notification was provided to the resident upon his transfer to the hospital on 3/29/26.IV. Additional record reviewA 7/13/26 email, received at 3:28 p.m. from the NHA, documented that the facility did not have bed hold policy notifications for Resident #93 and Resident #6 for their transfers to hospital.V. Staff interviewsThe NHA was interviewed on 7/14/26 at 4:30 p.m. The NHA said the facility gave residents bed hold information upon admission as part of their admission agreement. The NHA said the facility's admissions director talked to residents or their responsible parties and informed them about their room availability. He said the facility conducted an education session with the nurses about the bed hold policy. He said the team kept track of residents' hospitalization during the daily stand-up meetings and internal thread communication.

Based on record review and interviews, the facility failed to ensure proper treatment and assistive devices to maintain vision abilities for one (#74) of two residents reviewed for ancillary services of 35 sample residents. Specifically, the facility failed to ensure Resident #74 received glasses timely.Findings include:I. Facility policy and procedureThe Vision and Hearing Assistive Devices policy and procedure, reviewed 9/18/25, was provided by the nursing home administrator (NHA) on 7/15/26 at 3:38 p.m. The policy read in pertinent part, The facility will assist as needed with making appointments and arranging transportation to obtain needed services. In situations where the resident has lost their device, the facility must assist residents and their representative in locating resources, as well as in making appointments, and arranging for transportation to replace the lost devices.II. Resident #74A. Resident statusResident #74, age [AGE], was admitted on [DATE]. According to the July 2026 computerized physician orders (CPO), diagnoses included unspecified bilateral (both ears) hearing loss, repeated falls, depression, schizoaffective disorder (a chronic mental health condition characterized by a combination of schizophrenia symptoms like hallucinations or delusions and mood disorder symptoms like depression or mania), and unspecified abnormalities of gait (pattern of walking) and mobility.The 6/2/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a BIMS of 15 out of 15. The MDS assessment revealed Resident #74 was independent in dressing, hygiene, and walking. The MDS assessment revealed the resident had impaired vision where he could see large print, but not regular print in newspapers or books and also showed the resident required corrective lenses.B. Resident interviewResident #74 was interviewed on 7/9/26 at 9:13 a.m. Resident #74 said that he got fitted for his normal prescription glasses in January 2026, but he had not actually received the glasses yet. Resident #74 said he asked the social worker about the glasses, but he had not received a follow up about it. Resident #74 pointed to the glasses he was wearing and said they were reading glasses the facility had given him. The glasses had dark teal-blue frames with solid lenses, and no horizontal lines through them that would indicate they were bifocals. Resident #74 said he needed bifocals to read fine print and that it was hard for him to play his black jack game and read texts on his phone. Resident #74 said sometimes he had difficulties watching television and that the screen was blurry with his current glasses.C. Record reviewReview of Resident #74's care plan revealed no vision focused care plan. Review of an ancillary services document, dated 11/19/25, revealed Resident #74 had reader glasses. The diagnosis and treatment section revealed the resident had regular astigmatism (blurred or distorted vision at all distances) in both eyes, hypermetropia (blurred near vision) in both eyes, and presbyopia (age related loss of the eye's ability to focus on close objects).The 4/7/26 NP note documented Resident #74's only concern upon the visit was receiving his updated bifocals, which were to be delivered soon. The note documented the NP was to follow up with social work to confirm that the bifocals would be delivered shortly. The 4/30/26 nurse practitioner (NP) note documented Resident #74 was waiting on new bifocals. The note documented the NP would follow up with the social worker to confirm their arrival.D. Staff interviewsThe social services director (SSD) was interviewed on 7/14/26 at 2:46 p.m. The SSD said the social services department tracked resident needs for ancillary services like hearing vision and dental. The SSD said the previous social worker assistant helped with documentation and that the department typically documents in the progress notes. The SSD said she would have to look into documentation regarding Resident #74's vision/glasses needs. The SSD said she knew he had glasses, but she was unsure whether or not the glasses he had were readers because she knew that sometimes Resident #74 watched television with his head tilted back. The nursing home administrator (NHA) was interviewed on 7/14/26 at 6:23 p.m. The NHA aid the facility reached out to the optometry office and found out Resident #74 had not received his glasses, but that the glasses were currently in route. -However, Resident #74 did not receive her glasses for approximately six months.

Based on observations, record review and interviews, the facility failed to ensure fall interventions were in place for two (#5 and #11) of three residents reviewed for accidents out of 35 sample residents.Specifically, the facility failed to ensure Resident #5 and Resident #11's fall interventions were consistently implemented.Findings include:I. Facility policy and procedureThe Fall Management policy and procedure, reviewed 9/25/25, was provided by the nursing home administrator (NHA) on 7/15/26 at 3:38 p.m. The policy read in pertinent part, Implement interventions, including adequate supervision, consistent with the resident's needs, goals, care plan, and current professional standards of practice in order to eliminate or reduce the risk of an accident. Monitor the effectiveness of the interventions and modify the interventions as necessary, in accordance with current professional standards of practice.II. Resident #5A. Resident statusResident #5, age [AGE], was admitted on [DATE]. According to the July 2026 computerized physician orders (CPO), diagnoses included adult failure to thrive, muscle wasting and atrophy, other abnormalities of gait and mobility, and shortness of breath. The 6/19/26 minimum data set (MDS) assessment revealed the Resident #5 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #5 required substantial assistance from staff to dress and was fully dependent on staff for transferring.B. Record reviewResident #5's fall care plan, revised on 3/22/26, documented Resident #5 was at risk for falls related to deconditioning, medical devices, weakness, incontinence, and a history of fall with hip fracture. Pertinent interventions, initiated 2/16/26, included a fall mat next to the bed.Review of Resident #5's Kardex (staff directive tool) on 7/13/26 revealed the safety section of the Kardex documented Resident #5 should have a fall mat next to the bed.An interdisciplinary team note, dated 2/16/26, documented the team met with Resident #5 regarding a fall from the bed. A fall mat was placed at the bedside and Resident #5 was also to be educated to keep the bed in the lowest position. An event note, dated 2/16/26 at 7:27, documented a fall mat would be added to the side of the bed.C. Observations On 7/8/26 at 3:32 p.m. Resident #5 was lying in bed. His bed was raised to waist height. Resident #5 was leaning to the side of the bed away from the wall, with one arm dangling off of the bed. There was no fall mat next to his bed. On 7/9/26 at 11:10 a.m. Resident #5 was lying in bed. His bed was at waist height. There was no fall mat at the side of his bed. On 7/13/26 at 9:34 a.m. Resident #5 was lying in his bed. His bed was at waist height. There was no fall mat next to his bed.D. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 7/14/26 at 10:21 a.m. CNA #1 said he knew what fall interventions need to be in place based off of his experience with the residents and based off of how the resident transferred. CNA #1 said they put fall mats in place by the resident's' bed to prevent injury. CNA #1 said he had not seen a fall mat in Resident #5's room and that Resident #5 would call if he needed something. CNA #1 said if a resident declined to have a fall intervention in place, he would tell a nurse or let a nurse manager know.III. Resident #11Resident #11, age greater than 65, was admitted on [DATE]. According to the July 2026 CPO, diagnoses included unspecified dementia, paranoid personality disorder, muscle weakness, cognitive communication deficit, history of falling, syncope and collapse, and unspecified protein-calorie malnutrition.The 5/12/26 MDS assessment revealed Resident #11 had short term and long term memory problems, according to the staff assessment for mental status. Resident #5 required substantial assistance from staff to dress and transfer.B. Record reviewResident #11's fall care plan, revised on 3/22/26, documented Resident #11 was at risk for falls related to psychotropic medications, trauma, dementia, PTSD, and an unstable gait. It further documented that Resident #11 was impulsive and had weakness, a prior fall with fracture, and poor safety awareness. Pertinent interventions, initiated 4/27/26, included providing Resident #11 a lipped mattress to help with spacial awareness. Additional interventions included encouraging Resident #11 to lay in bed when noticed sleeping in her chair, ensuring the bed was in the lowest position when in bed, and using an autolock break on the wheelchair. Review of Resident #11's Kardex on 7/13/26 documented The safety section of Resident #11's Kardex documented Resident #11's bed should be kept in the lowest position and using a lipped mattress to help Resident #11 with spatial awareness.An event note written on 4/27/27 at 9:54 a.m. documented the interdisciplinary team reviewed Resident #11's fall. It further documented that Resident #11 would receive a lipped mattress as a fall intervention. C. Observations and staff interviewsOn 7/13/26 at 3:24 p.m. Resident #11 was lying in bed. The mattress was flat and was not lipped. CNA #1 was interviewed on 7/14/26 at 10:30 a.m. CNA #1 said Resident #11 did not have a lipped mattress. CNA #1 said the resident had a regular mattress. CNA #1 lifted the sheets to show the mattress. The mattress was flat and had no raised sides.D. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 7/24/26 at 11:21 a.m. LPN #1 said Resident #11 had a regular mattress.The director of nursing (DON) was interviewed on 7/14/26 at 4:29 p.m. The DON said if a resident fell, the facility updated the residents care plan and added fall interventions for that resident. The DON said the facility recently completed environmental rounds for fall risk residents to make sure fall interventions were still in place and effective. The DON said documentation on fall related topics was documented in interdisciplinary team notes and in the care plan. The DON said the assistant director of nursing (ADON), the DON, and the MDS coordinator were all responsible for ensuring the care plans and fall interventions were in place for each resident. The DON said if a resident refused an intervention there would be a refusal note or the resident's care plan would be resolved. The DON said the Kardex that CNAs use would also be updated when the care plan was updated. The regional clinical resource was interviewed on 7/14/26 at 4:26 p.m. She said the facility conducted education with staff on where to find the Kardex and find information on falls

Based on record review and interviews the facility failed to ensure residents with a feeding tube received appropriate treatment and services for two (#6 and #30) of three residents reviewed with a feeding tube out of 35 sample residents.Specifically, the facility failed to:-Ensure timely administration of Resident #30's water flush; and,-Ensure timely administration of Resident #6's bolus tube feeding Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2021), E. [NAME], St. Louis Missouri, pp. 605-606. Medication errors include inaccurate prescribing, administering the wrong medication, giving the medication using the wrong route or time interval, administering extra doses, and/or failing to administer a medication. II. Facility policy and procedure The Administration of Medications policy, reviewed 9/9/25, was provided by the nursing home administrator (NHA) on 7/15/26 at 3:38 p.m. The policy read in pertinent part, The facility will ensure medications are administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms. Staff who are responsible for medication administration will adhere to the ten Rights of Medication Administration: right drug, right resident, right dose, right route, right time and frequency, right documentation, right assessment, right to refuse, right evaluation/response, right education and information. III. Resident #30 A. Resident status Resident #30, age [AGE], was admitted on [DATE]. According to the July 2026 computerized physician's orders (CPO), diagnoses included dysphagia (difficulty swallowing) following cerebral infarction (stroke), gastrostomy status (the resident has an artificial opening and tube in their stomach used for long term nutritional support or medication administration), and type 2 diabetes mellitus. The 5/14/26 minimum data set (MDS) assessment revealed the resident had memory problems with both long and short term memory per staff assessment. The MDS assessment documented the resident was dependent on staff for eating and required maximal assistance for hygiene and dressing. The MDS assessment documented the resident had a percutaneous endoscopic gastrostomy (PEG) feeding tube (a flexible medical device inserted into the abdominal wall into the stomach that delivers liquid nutrition, fluids, and medications directly into the stomach for individuals who cannot safely swallow). The MDS assessment indicated Resident #30 received 51 percent (%) or more of her total calories through the feeding tube and her daily fluid intake was 501 cubic centimeter (cc) or more. B. Record review The nutrition care plan, dated 4/25/25, documented Resident #30 was at risk for fluid imbalance related to nausea, PEG tube with nutrition, chronic kidney disease, obesity, and having an order of nothing by mouth (NPO -(the resident can not have any food or drinks by mouth). Pertinent interventions included administering medications as ordered, assessing bowel sounds and frequency of bowel movements, educating the resident/family/caregivers on the importance of fluid intake, inviting the resident to activities that promote additional fluid intake, and observing and reporting as needed any signs or symptoms of dehydration such as thirst, concentrated urine, or cracked lips. The weight fluctuation care plan, dated 1/24/26, documented Resident #30 was at risk for weight fluctuation and received all nutrients through a PEG tube. Pertinent interventions included monitoring the resident's tolerance of tube feeding and flushes, adhering to the diet order of [NAME] Farms (enteral formula) via the PEG tube, giving water flushes as ordered, and monitoring weight trends. Review of the July 2026 CPOs revealed the following physician's orders: Administer at least 400 milliliter (ml) of water via enteral access device for free water hydration four times a day: 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m., ordered on 5/29/25. Review of the July 2026 (7/1/26 to 7/13/26) medication administration record revealed the following: On 7/12/26 it indicated Resient #30 did not received the 8:00 p.m. fluid flush and did not indicate a reason On 7/13/26 there was no documentation indicating if the resident received his 6:00 p.m. bolus feed or indication why. It indicated the resident did not receive the 4:00 p.m. or 8:00 p.m. fluid flush and did not indicate a reason. The MAR documented the resident received the 12:00 p.m. fluid flush on 7/13/26. -However, observations revealed the resident did not receive the 12:00 p.m. fluid flush (see observations below). C. Observations During a continuous observation on 7/13/26, beginning at 9:12 a.m. and ending at 2:15 p.m. the following was observed: At 9:12 a.m. Resident #30 was lying in bed. At 12:33 p.m. Resident #30 asked LPN #2 for water. Licensed practical nurse (LPN) #2 said staff had to lay the resident down to give her water through her PEG tube. -However, the resident did not receive water until 2:02 p.m., despite the resident having a physician's order for 400 ml of water via his PEG tube at 12:00 p.m. (see record review above). At 2:02 p.m. LPN #2 administered 400 ml of water -However, the facility failed to administer the 12:00 p.m. fluid flush. D. Staff interviews LPN #1 was interviewed on 7/14/26 at 11:21 a.m. LPN #1 said that Resident #30 could not chew or swallow normally because she had a stroke and the left side of her body was paralyzed afterward. LPN #1 said it was important to give tube feeds on time, because Resident #30 was unable to eat and the tube feeds were considered her dietary intake. LPN#1 said staff had to make sure she got enough calories for nutrition purposes and to function. The regional clinical resource were interviewed together on 7/14/26 at 4:53 p.m. The regional clinical resource said tube feeding boluses and water should be given per the physician's order. The regional clinical resource said there was an hour window before or after the scheduled time where tube feeds could be given. The regional clinical resource said staff should give the bolus or water within that time frame, otherwise it was considered late. IV. Resident #6 A. Resident status Resident #6, age [AGE], was admitted [DATE]. According to the July 2026 CPO, diagnoses included chronic obstructive pulmonary disease, severe protein calorie malnutrition, encounter for attention to gastronomy), dependence on supplemental oxygen, dysphagia (difficulty swallowing) and gastrostomy malfunction. The 7/7/26 MDS assessment documented the resident was cognitively intact with a BIMS score of 15 out of 15. The resident needed partial to moderate assistance with activities of daily living and set up assistance at meals. The assessment documented the resident received 51% or more of his total calories through parenteral or tube feeding while a resident; his average fluid intake per day by IV or feeding tube while a resident was 501 cc (cubic centimeters) a day or more, and indicated the use of a feeding tube while a resident. B. Resident interview Resident #6 was interviewed on 7/8/26 at 1:43 p.m. Resident #6 said he had a tube feeding and he ate regular food. He said he received a bolus feed in the morning and evening, but different staff members started it at different times, even sometimes at 8:30 p.m. He said he felt like he got full with the tube feed and he could feel it go up his chest and it felt hard to breathe. He said the tube feeding (bag) might not be taken down right away when the feeding was done. C. Observation and staff interview On 7/13/26 at 12:30 p.m. RN #2 was administering Resident # 6's Jevity 1.5 via his feeding tube. RN #2 had the feeding tube supplies laid on the Resident # 6's room's basin counter top on a clean paper towel. She used a 60 cc syringe to draw the Jevity 1.5 formula form its container and drew about 400 cc of the Jevity 1.5 formula, she primed the tubing to take the air out of the tube and measured 320 CCs in the bag. She hung the bag to an IV pole. She flushed the PEG tube with 100 ml purified water with the 60 CCs syringe; then administered the Jevity by connecting the tube attached to the formula bag to Resident # 6'a PEG tube. She left the resident room. RN #2 said it took about 10 to 15 minutes for the formula to be fully administered. She came back to the Resident room at 12:57 p.m., detached the formula bag's tube from the Resident's PEG tube and pushed an additional 100 cc of purified water in the PEG tube. RN# 2 said she was late for administering Resident #6 feeding tube formula. She said she was the unit manager and was helping on the floor the last three weeks. At 1:10 p.m. RN #2 asked Resident # 6 if he had his lunch. The resident said he needed to wait before he took his food. D. Record review The tube feeding care plan, initiated 4/25/25, documented the resident required a tube feeding due to diagnoses of dysphagia, a swallowing problem, and silent aspiration. Pertinent interventions, initiated 4/25/25, documented the resident needed the head of bed elevated 45 degrees during and thirty minutes after tube feed administration; discuss with the resident, family and caregivers any concerns about tube feeding, the advantages, disadvantages, and potential complications; and (initiated 7/16/25) check for tube placement and gastric contents/residual volume per the facility protocol and record. Resident #6's nutritional care plan, revised 6/30/26, documented the resident was at risk for weight fluctuation related to his current health status; the need for PEG tube feeding to meet nutrient needs (secondary to a history of severe dysphagia); he often refused one or more bolus feedings per day. The resident only wanted to receive two bolus feedings per day. The care plan documented esophageal dilation was performed October 2025. The resident was approved to eat regular foods by mouth, but usually did not accept a full meal. He frequently refused to be weighed. Pertinent interventions, initiated 3/24/25, included to monitor tube feeding tolerance and adjust the feeding as necessary with any significant changes, monitor weight per facility protocol; and (initiated 3/1/26), to educate resident and family regarding potential weight fluctuation as he frequently refused bolus tube feedings and only currently wanted to receive bolus feedings two times a day (which may not adequately meet estimated needs along with po intake). Assist with meals as needed (revised 4/2/26) as the resident was an aspiration risk, and insisted on staying in his room for meals and snacks. Enteral feeding (revised 6/15/26), Jevity 1.5, give 320 ml two times a day with a 100 ml water flush before and after each feeding as the resident preferred that his tube feeding be dispensed from ready to hang bottles. The resident refused the tube feeding if individual cartons (8oz cartons) were used. Resident #6's swallowing care plan, revised 3/21/26 documented the resident had a swallowing problem related to thick oral secretions. Pertinent interventions initiated 3/21/26, included to check the resident's mouth after a meal for pocketed food and debris, report to the nurse and provide oral care to remove debris; diet to be followed as prescribed; and instruct the resident to eat in an upright position, to eat slowly, and to chew each bite thoroughly. A review of the July 2026 CPO revealed the following physician's orders: Enteral order two times a day, Jevity 1.5 every 12 hours (via bolus gravity via PEG tube) a total amount of 320 ml. Flush with 100 ml purified water before and after feeding from 5:00 a.m. to 10:00 a.m. and 7:00 p.m. to 11:00 p.m, ordered 3/21/26. Resident #6's 2/10/26 nutritional assessment documented the resident had a varied meal intake and usually minimal. The assessment also documented the resident had swallowing problems that included loss of liquids/solids from the mouth when eating and/or drinking and coughing/choking during meals or medication administration, and did not consume adequate foods/fluids by mouth to maintain weight. Bolus feedings of three and four times a day have been attempted but he ended up refusing additional feedings. He felt comfortable with two bolus feedings per day and was aware that two bolus feedings did not meet his daily needs. The resident would not increase the amount of each feeding. E. Staff interviews LPN #3 was interviewed on 7/14/26 at 12:21 p.m. LPN #3 said Resident #6's morning tube feeding was scheduled to be administered between 5:00 a.m. to 10:00 a.m. She said she was late today. LPN #3 said Resident # 6 refused his feeding tube formula first when he was admitted to the facility. She said there had been many changes with the formula and the frequency of the feeding tube to make it to what he preferred. She said Resident #6's routine was to order coffee and cookies early in the morning; then receive his feeding tube. She said if she were on time, she would have administered the feeding tube order at 8:00 a.m. The registered dietitian (RD) and the dietary manager (DM) were interviewed together on 7/14/26 at 12:47 p.m. The RD said Resident #6 had an esophageal stretch in the past and was cleared to eat whatever he wanted. She said he was afraid of food not going down well. The DM said Resident #6 ate for pleasure, and he did not want to eat a plate of food and instead he wanted cookies, ice cream, coffee and snacks. The RD said the tube feeding order for Resident #6 when he first admitted was his tube feeding order he previously had. She said sometimes people were admitted from the hospital with continuous feedings but the schedule was not conducive because the resident was full all the time. The RD said the facility would change to a bolus feeding versus a continuous feeding because it was a more regular schedule. The RD said the resident started refusing the tube feeding because he was too full. She said they rearranged the feeding schedule multiple times to get a schedule the resident liked. She said the resident needed to have a higher calorie formula because he wanted two feedings a day, what worked was Jevity. She said she touches base with him every once in a while and he wants to stay on his current scheduled tube feeding. The assistant director of nursing (ADON) was interviewed on 7/14/26 at 4:30 p.m. The ADON said she was unsure how the facility managed time frames for the bolus tube feedings. She said the registered dietitian set up Resident #6's bolus feeding because he used to get three administrations instead of two.

Based on record review and interviews, the facility failed to ensure residents who required dialysis services received such services consistent with professional standards of practice for one (#8) of two residents reviewed for dialysis out of 35 sample residents. Specifically, the facility failed to consistently and thoroughly complete the dialysis communication forms between the facility and the dialysis center for Resident #8.Findings include:I. Facility policy and procedureThe Hemodialysis Offsite policy, revised 9/16/25, was provided by the nursing home administrator (NHA) on 7/15/26 at 3:38 p.m. It read in pertinent part, The facility assures that each resident receives care and services for the provision of offsite hemodialysis dialysis consistent with professional standards of practice. This includes ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. The facility should weigh the resident and document the findings based on orders. The care of the resident receiving dialysis services must reflect ongoing communication, coordination and collaboration between the facility and the dialysis staff. The communication process should include how the communication will occur, who is responsible for communicating, and where the communication and responses will be documented in the medical record, including but not limited to physician/treatment orders, laboratory values, and vital signs. Observe vascular access site prior to dialysis and initiate the pre/post dialysis communication form to be sent to the dialysis clinic with the resident. Obtain vital signs of resident upon return from dialysis and complete the pre/post dialysis communication form. Maintain dialysis transfer form in the resident's medical record - do not destroy.II. Resident #8A. Resident statusResident #8, age greater than 65, was admitted on [DATE]. According to the July 2026 computerized physician orders (CPO), diagnoses included end stage renal disease, dependence on renal dialysis (process to filter wastes from the body), chronic kidney disease and unspecified hydronephrosis (swelling of the kidney caused by a problem preventing urine from draining normally).The 6/17/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She required substantial to maximum assistance for toileting and bathing. She was dependent on staff for personal hygiene.The MDS assessment indicated the resident received dialysis treatment.B. Record reviewReview of Resident #8's dialysis care plan, initiated 9/8/25, revealed the resident received dialysis related to end stage renal disease. Interventions included dialysis treatments as ordered, obtaining dry weights from the dialysis center, observing for bleeding at dialysis access site, and therapeutic diet as ordered.-However, the care plan did not include monitoring the resident's weights pre- and post-dialysis treatment.Review of Resident #8's July 2026 CPO revealed the following physician's orders related to dialysis:Obtain vital signs before and after dialysis appointment on Mondays, Wednesdays, Fridays, ordered 3/17/26.Send to dialysis on Mondays, Wednesdays, Fridays with midodrine medication (used to treat symptomatic orthostatic hypotension), ordered 2/10/26.Resident #8's dialysis communication form binder was provided by licensed practical nurse (LPN) #1 on 7/13/26 at 4:40 p.m. The binder had only the dialysis communication forms for July 2026. The regional clinical resource nurse provided dialysis communication forms for June 2026 on 7/13/26 at 5:50 p.m. Each communication form had three sections on one sheet of paper, which revealed the following: The first section of the communication form was to be filled in by the facility before dialysis with the facility's name, date, the resident's vital signs, which included temperature, pulse, respirations, blood pressure, and weight. The section indicated to document the resident's lung sounds, the resident's dialysis access site condition and the resident's prescribed antibiotic and the diagnosis for the antibiotic. The section also prompted the nurses to document if any medication and meal were given to the resident to take at the dialysis center. A facility nurse's signature, title, date and time were required to validate that the information was completed. The second section of the communication form was to be filled in by the dialysis center staff with the dialysis center information, the resident's vital signs and the resident's weight pre- and post-dialysis. The section indicated to document the resident's dialysis access site condition and any additional notes indicating if the resident ate lunch and was given any medication at the dialysis center; and if there were any instructions for the facility. A dialysis nurse's signature, title, date and time were required to validate that the information was completed.The third section of the communication form was to be filled in by the facility after dialysis with the resident's vital signs and weight. The section indicated to document the resident's dialysis access site condition. A facility nurse's signature, title, date and time were required to validate that the information was completed. The resident's name and the physician's name were required to be documented at the bottom of the communication form.Review of Resident #8's dialysis communication forms revealed the following:The pre-dialysis section had the weight left blank on 6/8/26, 6/15/26, 6/17/26, 7/6/26 and 7/13/26.The post-dialysis section was not filled out in its entirety on 6/19/26, 7/8/26 and 7/13/26. The post-dialysis section was not filled out in its entirety on 7/3/26, only Resident #8's vital signs were documented.The post-dialysis section was not filled out in its entirety on 7/6/26, only Resident #8's weight was documented.The post-dialysis section had the weight left blank on 6/12/26 and 6/15/26. The post-dialysis section had the weight and vital signs left blank on 7/1/26. III. Staff interviewsLPN #1 was interviewed on 7/13/26 at 5:09 p.m. LPN #1 said nurses obtained and documented Resident #8's weight, vital signs including the blood pressure, respirations, pulse and temperature in the dialysis communication form prior to sending the resident to the dialysis center. LPN #1 said nurses assessed Resident #8's dialysis access site and notified the physician if there were some abnormalities LPN #1 said nurses provided Resident #8 with the dialysis communication form binder to take to the dialysis center. LPN #1 said nurses obtained and documented Resident #8's vital signs and weight upon her return to the facility. LPN #1 said she was unsure why a few dialysis communication forms were not filled out in their entirety. The assistant director of nursing (ADON) and the regional clinical resource nurse were interviewed together 7/13/26 at 6:01 p.m. The ADON said nurses should fill out the dialysis communication form in its entirety. She said it was important because the dialysis center would have current vital signs prior to proceeding with the dialysis treatment. The ADON said the completed dialysis communication form also ensured the facility could appropriately follow up on the dialysis center's recommendations.The regional clinical resource nurse said the facility needed to communicate with the dialysis center through the communication forms. The regional clinical resource nurse said she would provide education to the nurses regarding accurate completion of the communication forms and appropriate follow up care. She said facility management would be monitoring the dialysis communication binder to ensure the forms were completed accurately and kept up to date.

Based on record review and interviews the facility failed to failed to ensure accurate medical records were kept for two (#70 and #71) of four residents reviewed for medications out of 35 sample residents.Specifically, the facility failed to ensure:-Resident #70's admission documentation was accurate in regards to her anticoagulant medication (Eliquis); -Ensure documentation was complete regarding administration of Resident #70's Eliquis administration upon admission; and,-Ensure complete hospice documentation was apart of Resident #71's electronic medical record (EMR). Findings include: I. Facility policy and procedure The Administration of Medications policy, reviewed 9/9/25, was provided by the nursing home administrator (NHA) on 7/15/26 at 3:38 p.m. It read in pertinent part, The facility will ensure medications are administered safely and appropriately per physician order to address residents' diagnosis and signs and symptoms. Medication error-this means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order; manufacturer's specifications (not recommendations) regarding the preparation of administration of the medication or biological; or Accepted professional standards and principle which apply to professional providing services. Accepted professional standards and principles include the various practice regulations in each state, and current commonly accepted health standards established national organizers, boards, and councils. Significant medication error means one that causes the resident discomfort or jeopardizes his or her health and safety. Significance may be subjective or relative depending on the individual situation and duration. Every drug administered must have an order from the provider. Compare the order with the medication administration record (eMAR) for accuracy. Compare the label on the drug to the information on the eMAR three times: before removing the container from the drawer, as the drug is removed from the container, and at the bedside before administering it to the resident. Be sure to verify drugs at the patients bedside with the EMAR and tow patient identifiers. Check the MAR and the doctor's order before medicating. Use standard measuring devices such as syringes, graduated cups, or scaled droppers. If there is any doubt about the dose on the MAR or if there is a question on the drug, stop and verify all information before administering. Check the order for when it would be given and when was the last time it was given. MAke sure to write the time and any remarks on the chart correctly. Medication administrations should be documented timely following the administration to the resident. Note the resident's history and any parameters around drug administration. Be aware of high-alert medications and hazardous medications, High-alert medications included, but are not limited to: anticoagulants, chemotherapeutic agents, hypoglycemics, insulins, parenteral nutrition preparations, opioids. II. Resident #70 A. Resident status Resident #70, age [AGE], was admitted on [DATE]. According to the July 2026 computerized physician orders (CPO), diagnoses included essential hypertension, pulmonary embolism without acute core pulmonale (clot in lung arteries), chronic obstructive pulmonary disease, injury at t7-t10 level of thoracic spinal cord (affecting lower chest and abdominal muscles), and the need for personal care. The 7/14/26 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was dependent or needed maximal assistance with activities of daily living (ADL). The MDS assessment documented Resident #70 received anticoagulant medication. B. Representative interview Resident #70's representative was interviewed on 7/14/26 at 3:12 p.m. Resident #70's representative said the resident was discharged from the previous facility with 24 hours of medication. The representative said she has learned to carry the medication in case a facility did not have medication for the resident. C. Record review A review of Resident #70's care plan revealed the resident did not have a focused care plan for anticoagulant use. A review of Resident #70's admission assessment, opened 7/3/26 and signed 7/4/26 failed to document Resident #70's anticoagulation use. A review of Resident #70's July 2026 CPO revealed the following physician's order: Eliquis, Oral Tablet 5 milligram (mg) (Apixaban). Give 1 tablet by mouth two times a day for pulmonary embolism, ordered 7/4/26 at 2:11 a.m. Review of the July 2026 medication administration record (MAR) revealed an X for the evening dose of Eliquis on 7/3/26. The MAR documented see progress notes for the morning dose of Eliquis on 7/4/26. -However, the medication list did not document the medication, dose, frequency, how medications were taken or the reason for taking the medication. A review of two 7/3/26 admission medication reconciliation forms opened at 3:39 p.m. and locked at 9:40 p.m. documented an admission medication reconciliation and to see the MAR. -However, the medication reconciliation forms did not include any medications. A 7/4/26 administration note documented at 2:43 p.m. medications were yet to be delivered and daughter brought from home. The pharmacy was contacted. The 7/4/26 progress note written at 10:27 p.m. documented Resident #70's medication arrived in the afternoon, and she accepted all her ordered medication. D. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 7/14/26 at 12:21 p.m. LPN #3 said when the resident arrived at the facility, the admitting nurse informed the medical director about the new admission arrival and the nurse read all the orders to the medical director to confirm and approve the orders. LPN #3 said when a resident was admitted to the facility during the week, the nursing supervisor entered the physician's orders into the EMR. LPN #3 said the nursing manager then informed the floor nurse that the new admit orders were in the system. LPN #3 said the medical director was able to make changes to the orders at that time if needed. LPN #3 said sometimes the process for confirming the new admission orders with the medical director took a while. She said after the confirmation process, the nurse printed the physician's orders and faxed them to the pharmacy. She said it normally took some time to receive the medication from the pharmacy. She said the pharmacy might send the medication the same day or next morning. She said sometimes the nurses were able to obtain the medication from the emergency kit if the medication did not arrive timely from the pharmacy. She said for some medications it took time for the pharmacy to deliver. LPN #3 said Resident # 70's medication took a while to be delivered from the pharmacy. She said Resident # 70's family member brought her medication on 7/4/26 from home. She said on 7/4/26 around 2:00 p.m. or 3:00 p.m. the resident's medication was delivered from the pharmacy. LPN #3 said she went to the Resident #70's room to told her, the resident's medication had arrived, and the resident told her she took her morning medication because some of them were with her family member. LPN #3 said she informed the resident and her family member that the resident medication was delivered and asked not to give any more medication from home to the resident. -However, review of the EMR did not reveal documentation indicating the family provided the medication and review of the July 2026 MAR was blank (see record review above). LPN #1 was interviewed on 7/14/2026 at 2:26 pm. LPN #1 said sometimes when residents admitted to the facility they came to the facility with their medications. She said if the resident did not come with their medication, and the facility did not have the medication, nurses called the doctor or the pharmacy for rushed delivery. LPN #1 said Resident #70's family member had a list of her medication and all of her medications. She said the family member showed her all of Resident #70's medication and she confirmed the orders with the nurse practitioner (NP). LPN #1 said she told Resident #70's family member that the family member could give the resident her medication till the pharmacy delivered her medication. -However, review of the EMR did not reveal documentation indicating the family provided the medication and review of the July 2026 MAR was blank (see record review above) The regional clinical resource and the assistant director of nursing (ADON) were interviewed together on 7/14/26 at 4:30 p.m. The regional clinical resource said if a nurse signed off on a medication on the MAR, then it was that nurse who administered the medication. E. Facility follow up A clarification note for 7/4/26 (see above) was provided on 7/15/26 at 5:22 p.m. by the NHA. The note documented the resident's daughter spent the night at the facility. The daughter notified the nurse during the morning medication pass that the daughter had provided and administered all of the residents morning medications. III. Resident #71 A. Resident status Resident #71, age greater than 65, was admitted on [DATE]. According to the July 2026 CPO, diagnoses included atherosclerotic heart disease of native coronary artery without angina pectoris (plaque buildup of the heart arteries), weakness, chronic pain, adult failure to thrive, dementia with behavioral disturbance, age related physical debility, vascular dementia, need for assistance with personal care. The 6/18/26 MDS assessment revealed the resident had memory problems and she was moderately impaired to make cognitive decisions per staff assessment. The assessment revealed the resident was dependent on staff for all activities of daily living (ADL). B. Hospice agreement The hospice agreement, dated 8/29/24, was provided by the NHA on 7/8/26. It read in pertinent part, Each party shall prepare and maintain complete and detailed clinical records concerning each hospice patient receiving hospice services under the agreement in accordance with its usual record keeping procedures, and as required by applicable federal and state law and regulations and applicable Medicare and Medicaid program guidelines. Each party shall retain such records as required by applicable federal and state law. Each record shall document that the specified services are furnished with this agreement and shall be easily accessible and systematically organized to facilitate retrieval by either party, in accordance with federal and state patient privacy laws. C. Record review The 6/29/26 facility notification form indicated the resident admitted to hospice services on 6/29/26. Review of the resident's EMR did not reveal documentation from the hospice company regarding the resident's care. A review of the comprehensive care plan, initiated on 7/14/26 (during the survey), revealed the resident was receiving hospice services effective 6/29/26. Pertinent interventions included hospice would provide a nurse and a certified nurse aide (CNA) twice weekly. A review of the certification of terminal illness created on 6/29/26 revealed Resident #71 was diagnosed with cerebrovascular disease and had a prognosis of six months or less. A review of the coordination notes from 6/29/26 to 7/13/26 revealed the notes were uploaded into the Resident #71`s EMR on 7/14/26 (during the survey). E. Staff interview Registered nurse (RN) #1 was interviewed on 7/14/26 at 12:03 p.m. RN #1 said he was not able to find Resident #71`s hospice care plan. He said there was no written documentation of the communication between the entities staff. The social service director (SSD) was interviewed on 7/14/26 at 12:44 p.m. The SSD said communication between hospice and facility staff occurred through verbal communication and could also be documented in the hospice binder or the EMR. She said the hospice nurse would let the facility nurse know about changes. She said the facility nurse would report the changes to the DON or the ADON. She said hospice would document significant changes, active dying, in the progress notes but there was no significant change since hospice started. The SSD was interviewed on 7/14/26 at 2:07 p.m.She said because there had been no significant changes with Resident #71, no hospice notes had been documented. She said nursing staff would begin documenting hospice communication and changes in the progress notes. She said the hospice documentation had been uploaded into the medical records that day (7/14/26 during the survey). The regional director of clinical resource was interviewed on 7/14/26 at 3:29 p.m. The regional director of clinical resource said she did not find clear documentation on Resident #71`s comprehensive care plan identifying which services were the responsibility of the facility and which services were the responsibility of hospice. She said she was unsure about how often the hospice communication and notes were uploaded into the system. She said she was unaware if there was any written agreement with hospice regarding how to record communication. The regional director of clinical resource was interviewed again on 7/14/26 at 5:53 p.m. She said these hospice notes were uploaded into the facility`s chart and also communicated verbally to the director of nursing.

Based on record review and interviews, the facility failed to ensure one (#5) of 12 residents reviewed for medication management were free from significant medication errors out of 12 sample residents. Resident #5 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis (weakness and paralysis on one side of the body) following cerebrovascular disease (a condition that affects the blood vessels in the brain) and epilepsy (seizure disorder).On 6/7/25 the facility received a delivery from the pharmacy. Licensed practical nurse (LPN) #1 signed for the delivery and did not open the box to check the contents. LPN #1 placed the box in the medication room. When LPN #1 went to administer Resident #5's Dilantin medication (a medication used to prevent seizures) on 6/20/25 and 6/21/25, she was unable to locate the medication. This resulted in Resident #5 missing three consecutive doses of Dilantin. On 6/21/25 Resident #5 was transferred to the hospital for a possible seizure. The resident was monitored with a continuous electroencephalography (cEEG) (monitors brain activity), which showed focal status epilepticus (a prolonged seizure) as well as secondary generalized seizures. The resident was treated in the hospital with anticonvulsants intravenously (IV). Specifically, the facility failed to ensure Resident #5 was given her antiseizure medication as ordered. Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 7/15/25 to 7/16/25, resulting in the deficiency being cited as past noncompliance with a correction date of 6/27/25. I. Medication error on 6/20/25 and 6/21/25On 6/7/25 LPN #1 received and signed for a delivery from the pharmacy. She did not open the box and inventory the contents. She placed the delivered box in the medication room. On 6/20/25 at 6:55 p.m. LPN #1 documented she was unable to administer Dilantin 150 milligrams (mg) due to not having the medication. On 6/21/25 at 8:21 a.m. LPN #1 documented she was unable to administer Dilantin 100 mg due to not having the medication. On 6/21/25 at 4:58 p.m. LPN #1 documented she was unable to administer Dilantin 150 mg due to not having the medication. On 6/21/25, Resident #5 was sent to the hospital for a possible seizure and treatment. On 6/22/25 it was discovered that Resident #5's Dilantin medication was in the box that was delivered by the pharmacy on 6/7/25 and was not administered to the resident as ordered. II. Facility's performance improvement planThe performance improvement plan (PIP) the facility implemented in response to Resident #5's medication errors was provided by the nursing home administrator (NHA) on 7/15/25 at 12:18 p.m. The plan documented the problem identified was three doses of Dilantin were not given to Resident #5, resulting in the resident being sent to the hospital. The plan revealed the following:A. Root cause analysisLPN #1 failed to open the medication delivery box and the medication remained in the medication room, which was not noticed by any employees and the protocol for reporting unavailable medications to the physician was not followed. B. Identification of other residentsResident #5 was transferred to the hospital when she started showing signs of seizure activity. A medication administration record (MAR) audit of all residents who received anticonvulsant medication was implemented on 6/25/25 to ensure they were all receiving their anticonvulsant medications. The audit was still ongoing for monitoring. B. Systemic changesThe director of nursing (DON) completed a verbal corrective action form with LPN #1 and educated her on the process of receiving medication deliveries from the pharmacy and the process of when a resident was missing a medication. The education was given over the phone on 6/23/25 and the form was signed on the next shift that LPN #1 worked, which was 6/26/25. The staffing development coordinator (SDC) reeducated nursing staff on proper medication handling and documentation procedures and proper notification of the physician, the DON and the unit manager (UM) when medications were not available. Nursing staff were also given handouts on medication handling, when a medication was not available and significant medication errors. All nursing staff were educated by 6/27/25. C. MonitoringThe UM would conduct a weekly MAR audit on all residents receiving anticonvulsant medications to ensure no doses were missed. The UM would turn in the audit to the DON to double-check the audit. The audit was started on 6/25/25 and was ongoing. The UM or the DON would conduct a weekly audit on medications received to ensure that the medications are put away timely. The first audit was conducted on 6/20/25 and was ongoing. The UM or the DON would audit all medication rooms to ensure received medications were not left in the medication room. The DON conducted the first audit on 6/25/25 and was ongoing. The facility's determined date of compliance was 6/27/25. III. Professional referenceAccording to [NAME], P.A., [NAME], A.G et.al,, Fundamentals of Nursing, 10th ed., Elsevier, St. Louis, Missouri, pp. 606-607, Take appropriate actions to ensure the patient receives medication as prescribed. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation 7. The right indication. IV. Facility policy and procedureThe Medication Administration policy, revised 2/13/23, was provided by the regional director of clinical services on 7/16/25 at 10:08 a.m. It read in pertinent part, Staff who are responsible for medication administration will adhere to the 10 rights of medication administration: right drug, right resident, right dose, right route, right time and frequency, right documentation, right assessment, right to refuse, right evaluation/response, right education and information.The Reordering, Changing, and Discontinuing Medication Orders policy, revised 7/1/24, was provided by the regional director of clinical services on 7/16/25 at 10:16 a.m. It read in pertinent part, Facilities are encouraged to reorder medications electronically or by fax whenever possible. Facility staff should review the transmitted re-orders for status and potential issues and pharmacy response. The facility should retain a copy of the refill/order form communicated to the pharmacy to reconcile the medications delivered by the pharmacy against what was ordered.V. Resident #5A. Resident statusResident #5, age [AGE], was admitted on [DATE]. According to the July 2025 computerized physician orders (CPO), diagnoses included hemiplegia and hemiparesis following cerebrovascular disease and epilepsy.The 6/6/25 minimum data set (MDS) assessment indicated the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of six out of 15. The assessment documented that the resident was dependent on staff for the majority of her activities of daily living (ADL). The assessment documented that the resident was taking anticonvulsant medication and had a diagnosis of epilepsy. B. Resident #5's representative interview Resident #5's representative was interviewed on 7/15/25 at 1:38 p.m. The representative said Resident #5 was receiving her medications as ordered from what he knew. The resident's representative said he assumed Resident #5 was getting her medications, as when one of her medications became unbalanced, she had to be sent out to the hospital. The representative said Resident #5 was sent to the hospital two or three weeks prior. The representative said Resident #5 had been having seizures due to an imbalance in her medications, but the resident had been fine since she was readmitted to the facility. C. Record reviewThe June 2025 CPO revealed Resident #5 had physician's orders for the following daily scheduled medications: Dilantin Infatabs Tablet Chewable 50 milligrams (mg) for seizures). Give 100 mg by mouth one time a day every Tuesday, Wednesday, Thursday, Friday, Saturday and Sunday, ordered on 9/1/23. Dilantin Infatabs Tablet Chewable 50 mg. Give 150 mg by mouth every evening shift, ordered on 9/1/23.Review of the June 2025 MAR (from 6/1/25 to 6/31/25) documented that Resident #5 did not receive the 150 mg dose of Dilantin on the evening of 6/20/25 and 6/21/25 and the 100 mg dose of Dilantin on the day shift on 6/21/25. The administration notes for each of the missed doses entered by LPN #1 documented that the Dilantin Infatabs were on order for Resident #5. A progress note, dated 6/21/25 at 9:25 p.m. revealed Resident #5 was sent to the hospital for a possible seizure. The hospital after visit summary, dated 6/24/25, documented Resident #5 was diagnosed with focal status epilepticus (a constant, unending seizure) caused by missed doses of her anti-seizure medication. The summary documented she was treated with intravenous anti-seizure medications while at the hospital and then restarted on her home medications. It was recommended that she was to take all her anti-seizure medications consistently to prevent any further seizures. The hospital Discharge summary, dated [DATE], documented Resident #5 presented from the nursing home with abnormal twitching with unclear symptoms during the transport with emergency medical services (EMS) to the hospital. The discharge summary documented Resident #5's symptoms escalated during transport to more generalized shaking, flexion and stiffness of her extremities. She was treated by EMS with 12.5 mg of Versed (a sedative that can treat seizures). Upon arrival to the emergency department at the hospital, Resident #5 was lethargic and appeared to be postictal (period immediately following a seizure). The discharge summary documented that she was treated with a Keppra (anticonvulsant medication) loading dose and neurology recommended a fosphenytoin (anticonvulsant medication) load since her level was low due to her missed doses of Dilantin. She was also given phenobarbital (anti-seizure medication) intravenously. The summary documented the resident's Dilantin level was 8.3 mcg/ml (micrograms/milliliter) which was considered low, upon her admission to the hospital. On day two of her hospital stay her focal status epilepticus resolved and she was restarted on her home medications, but she was still being monitored at the hospital. On day four she was discharged back to the nursing home. The physician progress note, dated 6/26/25, documented Resident #5 had been at her baseline since her return from the hospital. The note documented the physician went over Resident #5's medications with the unit nurse that was onsite. VI. Staff interviewsThe pharmacist was interviewed on 7/15/25 at 12:37 p.m. The pharmacist said she was not notified of the three missed Dilantin doses for Resident #5. She said the therapeutic level for Dilantin was between 10 to 20 mcg/ml. She said the half-life (the time it takes the medication to decrease by half in the blood stream) of Dilantin varied depending on how the resident metabolized the medication. She said the half-life could go down to as low as seven hours, depending on how the resident metabolized and processed the medication. She said that she would expect the facility to administer the medications per the physician's orders. LPN #1 was interviewed on 7/15/25 at 1:47 p.m. LPN #1 said she was really busy on 6/7/25 when the box was delivered from the pharmacy. She said she had only read the label on the outside of the box. She said she did not open the box and look inside. She said she was unaware that there was medication inside of the box. She said because of her mistake, Resident #5 had a seizure and went to the hospital. She said she tried to order the medication from the pharmacy before it ran out. She said when a medication ran out, she would let the pharmacy know as well as the physician. She said she thought she had let Resident #5's physician know, but she could not remember if she did. She said that she should have documented that the medication was not given and if she had contacted the physician. She said there was a button in the electronic medical record (EMR) to reorder medications. She said the pharmacy would let the facility know if the reorder was too early, had been ordered already, or if there were any other issues with the medication order. She said there was a print out at the nurses' station which would let the staff know the status of the reorder. She said when the medication was not available she documented on the MAR the code number 10, which meant the medication was on order. Registered nurse (RN) #1 was interviewed on 7/16/25 at 10:10 a.m. RN #1 said he was recently trained on receiving medication orders from the pharmacy. He said he could not remember the date that he received the education. He said when receiving a bag from the pharmacy, the contents should always be inventoried and put away in its proper area. He said a pharmacy order should never be left in the medication room unopened. He said if a medication was missing he would let the pharmacy know, the DON and the physician. He said if it was a medication that was needed right away, he would get authorization from the DON to open the emergency kit (E-kit) and use the medication from there. The DON was interviewed on 7/16/25 at 11:34 a.m. The DON said when the nurses received an order from the pharmacy they should open the box to make sure the medication was correct and put the medication in the correct place. The DON said when a medication was not in the medication cart, the nursing staff should be checking to see if the medication had been reordered and let the pharmacy know. She said that if the missing medication was one that could be found in the E-kit, they could open the E-kit and use it. She said that Dilantin was not in the E-kit and the physician should have been notified. She said Resident #5's physician was not notified of the missed doses of medication but was notified when she was sent to the hospital. She said the nurses had to use their own discretion on when to notify the physician on missed doses of medication. The DON said LPN #1 might not have realized how important it was to let the physician know because Resident #5 was also on phenobarbital (another medication used to prevent seizures). She said the facility discovered the medication was in the medication room in a box on 6/22/25. She said when LPN #1 called the pharmacy, the pharmacy told her that the medication had been delivered and that was when they started searching the facility for the medication. She said they had missed the medication in the box on 6/20/25 when they did their medication room audit because they were looking for bags of medication, not boxes. She said that since 6/27/25, when all nursing staff had been educated, the facility had not had any missed doses of antiseizure medication.

Based on observation, record review, interview, and review of facility policy, the facility failed to ensure two residents (Resident (R)51 and R72) out two residents observed with catheter bags out of 20 sampled residents reviewed had dignity bags for their use of a foley catheter. This failure had the potential to cause embarrassment and loss of dignity to the two residents. Findings include: Review of the facility's policy, provided by the facility, titled Dignity with an issued date of 05/06/19 and reviewed on 09/25/23 revealed Each resident has the right to be treated with dignity and respect. The procedure was to promote resident independence and dignity while dining and refrain from practices demeaning to the resident, such as leaving urinary catheter bags uncovered. 1. Review of R51's Face Sheet located in the electronic medical record (EMR) under the Admission Record revealed R51 was admitted to the facility on [DATE]. Review of R51's annual Minimum Data Set (MDS) located in the EMR under the MDS tab with an Admission Reference Date (ARD) of 04/03/23 revealed a Brief Interview of Mental Status (BIMS) score of three out of 15 which indicated severely impaired cognition. The MDS indicated R51 had an indwelling suprapubic catheter. During an observation on 10/01/24 at 10:19 AM revealed R51's foley catheter (indwelling urinary catheter) was attached to the bed frame on the side facing the door and there was a clear plastic bag over the catheter but you could still observe the bag and urine from the resident's doorway. 2. Review of R72's Face Sheet located in the EMR under the Admission tab revealed R72 was admitted to the facility on [DATE]. Review of R72's significant change MDS located in the EMR under the MDS tab with an ARD of 08/16/24 revealed a BIMS of zero out of 15 which indicated he was unable to complete the cognition assessment. The MDS revealed that R72 had an indwelling urinary catheter. During an interview on 10/01/24 at 12:01 PM Certified Nursing Assistant (CNA)1 confirmed the catheter bags were not covered yesterday or earlier today for R51 and R72. CNA1 stated they had the blue dignity bags today and she had placed them on R51's and 72's catheter bag. CNA1 stated the catheter bag should be covered for resident dignity and privacy. During an interview on 10/02/24 at 10:59 AM with Licensed Practical Nurse (LPN)1 revealed a catheter bag should be covered with a privacy bag to keep it private from others to maintain the dignity of a resident. LPN1 revealed there was a master key to the supply room, on the second floor, that staff had access to and could get a blue privacy bag anytime. During an interview with the Director of Nursing (DON) on 10/02/24 at 11:25 AM revealed catheter bags should be in a privacy bag to ensure the residents dignity. During an interview with the Administrator on 10/02/24 at 4:30 PM revealed the catheter bag should be covered with a dignity bag to ensure a resident maintained their dignity.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure four residents (Resident (R) 2, R6, R30, and R41) out of a total sample of 20 residents reviewed for respiratory services received appropriate care of their oxygen tubing. This created the potential for infection. Findings include: Review of the facility policy titled Oxygen Administration (Safety, Storage, and Maintenance), issued 12/03/18 and revised 02/27/24 and under the sub section titled Infection Control indicated .Change oxygen supplies weekly and when visibly soiled. Equipment should be labeled with patient name and dated when set-up or changed out . 1. Review of R2's Admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R2 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia and dependence on supplemental oxygen. Review of R2's Physician Orders located under the Orders tab of the EMR revealed an order for oxygen at three liters per minute (lpm), continuously, per nasal cannula and an order to change the oxygen tubing every night shift, on every Sunday. During an observation on 10/01/24 at 1:25 PM revealed R2's oxygen tubing had no date to indicate when the tubing change was last changed. 2. Review of R6's Admission Record, located under the Profile tab of the EMR, revealed R6 was admitted to the facility on [DATE] with a diagnosis of obstructive sleep apnea. Review of R6's Physician Orders located under the Orders tab revealed an order for the titration of oxygen to keep her pulse ox (measurement of the oxygen content of the blood) over 90%, the use of Bi-pap (breathing assistance via a mask and oxygen) at night, and an order to change the oxygen tubing every night shift on every Sunday. During an observation on 10/01/24 at 2:00 PM revealed R6 had her oxygen on and there was no date on the tubing to indicate when it had last been changed. 3. Review of R30's Admission Record, located under the EMR under the Profile tab, revealed R30 was admitted to the facility on [DATE]. Review of R30's Physician Orders revealed orders for oxygen at two liters continuously per nasal cannula and an order to change the oxygen tubing and nebulizer circuit every night shift on every Sunday as per the Physician order. During an observation on 09/30/24 at 2:46 PM and on 10/02/24 at 11:00 AM revealed R30's oxygen tubing was not dated to indicate when the last time it was changed. 4. Review of R41's Admission Record, located in the EMR under the Profile tab, revealed R41 was admitted to the facility on [DATE] with a diagnosis which included chronic obstructive pulmonary disease (COPD). Review of R41's Physician Orders revealed an order for oxygen at three liters/minute continuously per nasal cannula and an order to change the oxygen tubing and nebulizer circuit every night shift every Sunday. During an observation on 10/01/24 at 1:50 PM indicated R41's oxygen tubing was not dated to indicate the last time it had been changed. During an interview with the Unit Manager on 10/02/24 at 1:00 PM, the Unit Manager confirmed that the oxygen tubing for R2, R6, R30, and R41 had not been changed on the night shift on Sunday per physician's orders.

Based on record review, interview, and review of facility policy, the facility failed to ensure weights were documented for one (Resident (R) 31) of two residents reviewed for dialysis out of a sample of 20 residents. This had the potential for the resident to have unmet care needs. Findings include: Review of the facility policy titled Hemodialysis Offsite Policy effective 04/24/19 and last reviewed 09/06/24 indicated that under the Procedure section revealed, the facility should weigh the resident. Under the Day of Dialysis section indicated, the facility should observe the vascular access site prior to dialysis and initiate the Pre/Post Dialysis Communication Form to be sent to the dialysis with the resident. The Day of Dialysis section indicated on return to the facility, facility staff should obtain vital signs and complete the Pre/Post Dialysis Communication Form. Review of R31's Admission Record, located in the EMR under the Profile tab, revealed R 31 was admitted to the facility on [DATE] with a diagnosis including, end stage renal disease (ESRD). Review of the Physician Order in R31's EMR revealed an order for R31 to have dialysis on Tuesdays, Thursdays, and Saturdays. Review of Pre/post Dialysis Communication Form located in the EMR under the Documents tab dated between 06/01/24 and 09/28/24 indicated R31's pre and post weights, which were to be done by the facility staff according to the Pre/post Dialysis Communication Forms, were not completed as follows: 06/01/24-pre and post weights 06/04/24-pre and post weights 06/06/24-pre weight 06/08/24-pre and post weights 06/11/24-pre and post weights 06/20/24-pre and post weights 06/22/24-pre and post weights 06/25/24-pre and post weights 06/27/24-post weight 07/02/24-pre weight 07/08/24- pre and post weight 07/11/24-pre and post weight 07/13/24-pre and post weight 07/18/24-pre and post weight 08/01/24-pre and post weight 08/03/24-pre and post weight 08/08/24-post weight 08/10/24-pre and post weight 08/13/24-pre and post weight 08/15/24-pre and post weight 08/17/24-pre and post weight 08/20/24-pre and post weight 08/22/24-pre and post weight 08/24/24-pre and post weight 08/31/24-pre and post weight 09/03/24-pre and post weight 09/05/24-pre and post weight 09/07/24-pre weight 09/10/24-pre and post weight 09/12/24-pre and post weight 09/14/24-pre weight 09/17/24-pre and post weight 09/21/24-pre and post weight 09/24/24-pre and post weight 09/26/24-pre and post weight 09/28/24-pre and post weight During an interview on 10/03/24 at 2:37 PM with the Minimum Data Set Coordinator (MDSC) and the Director of Nursing (DON) both confirmed the Pre/post Dialysis Communication Records, did not contain the pre and/or post weights as listed above for R31.

Based on observation, record review, interview, and review of facility policy, the facility failed to ensure one resident (Resident (R)51) observed out of 20 sampled residents had their call light within reach. This failure had the potential to cause R51 needs to not be met . Findings include: Review of the facility's policy, provided by the facility, titled Keeping a Resident Room in Order, issued :08/09/2019 and reviewed 06/02/24 revealed The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safely, call lights must be within easy reach of the resident in bed and out of bed. Review of R51's Face Sheet located in the electronic medical record (EMR) under the Admission Record revealed R51 was admitted to the facility on [DATE] with diagnoses of cognitive communication deficit, muscle weakness, need for assistance with care, and schizophrenia. Review of R51's annual Minimum Data Set (MDS) assessment located in the EMR under the MDS tab with an Admission Reference Date (ARD) of 04/03/23 revealed a Brief Interview of Mental Status (BIMS) score of three out of 15 which indicated severely impaired cognition Review of R51's comprehensive Care Plan with a target date of 10/20/24 located in the EMR under the Care Plan tab revealed a problem for ADL (activities of daily living) self-care deficit and one of the interventions was to encourage R51 to use the bell to call for assistance. Review of the problem for impulsiveness and impaired memory revealed an intervention was for the call light to be in reach. During an observation on 09/30/24 at 1:20 PM revealed R51's in bed with his eyes closed and the call light was hanging on the drawers beside his bed and not in his reach. During an observation on 10/02/24 at 3:17 PM revealed R51s was in bed with his eyes closed and his call light was on the floor behind the bed and not in the resident's reach. During an interview on 10/02/24 at 3:17 PM with Licensed Practical Nurse (LPN)1 she confirmed the call light was on the floor and not within R51's reach. LPN1 revealed the call light should have a clip on it so it can be clipped to the blanket, and it did not have a clip. LPN1 stated R51 was able to utilize the call light. During an interview on 10/02/24 at 4:30 PM with the Administrator revealed the call light should be in reach of the resident and not on the floor. During an interview on 10/03/24 at 1:10 PM with the DON revealed call lights should be in reach of the residents for safety. The DON further revealed the call light should have a clip on it so it can be clipped to the bed so it would not fall on the floor. The DON stated the resident needed to be able to use the call light if he needed help.

Based on observations, record review and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Observations and interviews revealed the nursing staff lacked the knowledge, training, and equipment to manage the residents' routine and emergency blood glucose monitoring needs. The facility's failure to monitor the blood glucose meters (glucometer) according to standard practice, coupled with the staff's lack of knowledge to ensure blood glucose meters were cleaned, sanitized and stored properly in between each resident's use created the situation for serious harm likely to occur at a level of immediate jeopardy if the blood glucose meters continued to be shared among residents due to potential transmission of blood-borne pathogens. One resident who shared the glucometer with another had a diagnosis of chronic viral hepatitis C (HCV, a viral infection that is spread by contact with contaminated blood). In addition, nursing staff and student nurses failed to administer medication in a sanitary manner where hand hygiene was performed appropriately to prevent potential cross contamination during the procedure. Findings include: I. Immediate Jeopardy A. Findings of Immediate Jeopardy Blood glucose meters The facility had six blood glucose meters, which were shared among 18 residents who required routine blood sugar checks. This included one resident who had a diagnosis of chronic viral hepatitis C. Resident #38 had an active diagnosis of methicillin-resistant staphylococcus aureus infection (MRSA) and had been placed on enhanced barrier precautions. Resident #38 had an order for blood sugar checks before each meal and at bedtime. Observation During an observation on 5/4/23 beginning at 3:24 p.m. and ending at 3:50 p.m., the following was observed: -At 3:24 p.m. registered nurse (RN) #2 used hand sanitizer and then collected the blood glucose monitor from the top drawer of the medication cart along with an alcohol swab and a lancet. RN #2 carried the supplies to Resident #79 and without donning gloves proceeded to clean the resident's finger with the alcohol swab and then used the lancet to puncture the resident's finger for the blood sample. The sample was collected into the test strip on the blood glucose monitor and the previously used alcohol swab was then used to stop the bleeding on the resident's finger. RN #2 returned to the medication cart and disposed of the used lancet in the sharps container and placed the blood glucose monitor back in the top drawer of the medication cart without performing any cleaning or sanitation of the device and closed the drawer of the medication cart. A few minutes later RN #2 used hand sanitizer and began collecting supplies for another blood glucose check. RN #2 opened the top drawer and removed the blood glucose monitor, an alcohol swab and a lancet. RN #2 closed the drawer and locked the cart. RN #2 did not clean or disinfect the glucometer and proceed to Resident #38's room. RN #2 walked to the room of Resident #38 with the supplies, knocked on the door and entered the room. RN #2 asked for Resident #38's pain level; the resident expressed pain and a need for pain medications. RN #2 returned to the nurses' station to review the resident's medication orders for available pain medication orders. RN #2 consulted with RN #1(RN #1 was providing RN #2 supervision as RN #2 was a new employee and was still in orientation). After the consultation, RN #2 picked up a paper and a pen from the desk and walked over to the medication cart; RN #1 remained at the nurses station. RN #2 logged into the computer on the medication cart and began documenting in the resident's record. RN #2 retrieved the keys to the medication cart from his pocket, unlocked the cart and returned the keys to his pocket. RN #2 did not use hand sanitizer again to clean his hands before collecting medications for Resident #38. RN #2 opened the drawer on the medication cart and removed a card of pills for Resident #38, pushed the medication out of the back of the medicine card and directly into his contaminated bare hand and then put the pills in the medicine cup. Without any hand hygiene, RN #2 returned the pill card to the drawer in the medication cart and then closed the drawer and locked the cart. RN #2 walked back to the room of Resident #38, knocked on the door and entered the room. RN #2 gave the medication to Resident #38 and then removed the unsanitized blood glucose monitor, alcohol swab and lancet from his pocket where he had keys and other items stored. RN #2 had not performed hand hygiene as he began to perform the blood glucose check on Resident #38. The nurse began by cleaning the finger of Resident #38 and proceeded to puncture the resident's finger with the lancet and collect the blood sample onto the test strip into the device. RN #2 returned to the medication cart and placed the blood glucose monitor on the top of the cart while he disposed of the lancet in the sharps container. RN #2 did not clean and sanitize the blood glucose monitor at any point and began to look on the computer for the third resident that needed to have their blood sugar checked. RN #2 gathered the unsanitized blood glucose device and supplies for testing the third resident's blood glucose level and without attempts to sanitize the device started to the third resident's room. RN #2 was stopped from proceeding to the third resident's room for an interview about infection control practices and procedures (see below). Interviews Registered nurse (RN) #2 was interviewed on 5/4/23 at approximately 3:47 p.m. RN #2 said he was in orientation with RN #1 being his mentor today. There were four residents who had orders for evening blood sugars checked. RN #2 said there were normally two glucometers on the medication cart but one of them was missing so only one was available for use. RN #2 said the blood glucose monitor was shared between the four residents in that unit. RN #2 said infection control and prevention for the medication pass included for the nurse to use hand sanitizer to clean their hands between administering medications and treatments to each resident. RN #2 said it was not appropriate to touch medications with bare hands. RN #2 said the blood glucose monitor was supposed to be cleaned in the resident's room with an alcohol pad before the blood glucose check. RN #2 was not aware of the manufacturer's recommendations for cleaning and disinfecting the blood glucose devices provided for shared use with residents to test their blood glucose levels. RN #1 was interviewed on 5/4/23 at 3:48 p.m. RN #1 said she was training RN #2 on the facility's clinical procedure. RN #1 said the blood glucometer device should be cleaned with the foaming hand sanitizer after each use, being careful not to get the device too wet. RN #1 was not aware of the manufacturer's recommendations for the blood glucometer. The director of nurses (DON) was interviewed on 5/4/23 at approximately 4:05 p.m. The DON said the facility used shared glucometers and the nursing staff used Oxivir disinfectant to sanitize the glucometer devices in between each resident. The disinfectant contact time was one minute. Further interviews with nurses from each unit on 5/4/23 revealed each nurse had a different method of cleaning the shared glucometers in between resident use. RN #6 said the device was to be sanitized with Oxivir and ensure a contact time of one minute to kill pathogens. Licensed practical nurse (LPN) #5 said the device was to be disinfected with [NAME] brand disinfecting wipes with a contact time of eight to 10 minutes. RN #5 said the device was to be disinfected with an alcohol wipe and no contact time wait. All glucometers were observed on 5/4/23 and they were all stored in the medication carts for each unit. They were not in individual storage spaces. Each blood glucose monitor was in a space shared with alcohol pads and lancets. Facility policy and procedure The Infection Prevention and Control Program (IPCP) and Plan, revised on 1/25/23, was provided by the nursing home administrator (NHA) on 53/23 at 11:15 a.m. The policy read in the pertinent part: The facility administration, infection preventionist, and medical director should ensure that current infection control standards of practice are based on recognized guidelines and facility assessment. These standards should be incorporated in the Infection Prevention and Control Program (IPCP). Ensure staff follow the IPCP's standards, policies and procedures (hand hygiene and appropriate use of PPE) while other needs are specific to particular roles, responsibilities, and situations (injection safety and point of care testing); Methods to reduce the risks associated with procedures, medical equipment, and medical devices . Appropriate storage, cleaning, disinfection, and/or disposal of supplies and equipment; Applicable precautions, as appropriate, based on the following: a. The potential for transmission b. The mechanism of transmission. c. The care, treatment, and services setting The Cleaning and Disinfection of the Glucometer policy, revised 9/28/22, was provided by the DON on 5/4/23 at 5:45p.m. It read in pertinent part: The meter should be cleaned and disinfected after use on each patient. The Assure Prism multi Blood Glucose Monitoring System may only be used for testing multiple patients when standard precautions and the manufacturer's disinfection procedures are followed. The cleaning procedure is needed to clean dirt, blood and other bodily fluids off the exterior of the meter before performing the disinfection procedure. The disinfecting procedure is needed to prevent the transmission of blood borne pathogens. B. Facility notice of immediate jeopardy On 5/4/23 at 7:18 p.m. the NHA was notified of the immediate jeopardy. C. Facility plan to remove immediate jeopardy On 5/4/23 at 8:12 p.m., the director of clinical services (DDCS) provided a plan to remove the immediate jeopardy. The plan read: Divisional and Regional team members for (facility name) are on-site and assisting the facility with the corrective action and management of this plan. Super Sani-Cloth was obtained by the facility. The facility has placed an order for additional supply and anticipates increased stock by end of day tomorrow, 5/5/23. Based on the manufacturer's guideline and facility policy and procedure, this germicidal disposable wipe is approved for use in cleaning the facility glucometers. This is the only approved disinfectant that the facility will utilize for cleaning of glucometers. If there is ever a problem with availability of the Super Sani-Cloth, the Director of Nursing (DON)/designee will determine the correct disinfect ant to be used until the Super Sani-Cloth is available and education will be provided to nurses. A copy of the manual for the glucometer utilized in the facility was placed on each unit on 5/8/23 and nurses were informed. This manual includes cleaning and disinfecting instructions, along with approved disinfectants. On 5/4/23, education regarding proper cleaning procedures of the glucometers and return demonstration competency was initiated immediately, including for the RN #1. 100 percent nurses currently in the facility received this education and return-demonstration competency check and this was documented. Education was provided by the DON/IP (infection preventionist)/designee(s). As of 5/8/23, all nurses except one prn nurse who has not worked in greater than three (3) weeks and one nurse who is out on leave. Education regarding proper cleaning procedures of the glucometers and return demonstration will be done with those nurses upon their return, prior to the start of their shift. No finger stick blood glucose checks were performed until each glucometer was cleaned properly with the Super Sani -Cloth and each nurse received the education and return demonstration competency. Nurses will receive education regarding proper cleaning procedures of the glucometers and return demonstration competency prior to the start of their shift until completed for 100 percent of nurses. This will include any agency nurses. Education was provided by the DON/IP/designee(s). The facility Medical Director was notified of the concerns identified and of the plan of correction. A quality improvement (QAPI) meeting was held with the Medical Director via telephone on 5/4/23. Identification of Others: A list of residents that require finger stick blood glucose tests was created. Each glucometer in use in the facility was identified. Systemic Changes: Finger stick Blood Glucose Glucometers are cleaned between each use with an Environmental Protection Agency (EPA) approved product for the correct amount of time based on manufacturer's guidelines: -Treated surface must remain wet for recommended contact time. -For all other contact times, refer to wipe manufacturers' instructions. Do not wrap the meter in a wipe. -Once contact time is complete, wipe the meter dry. Nurses will receive education and return-demonstration competency upon hire and as needed. Education regarding proper cleaning procedures of the glucometers and return demonstration competency will be done for nurses upon hire during the skills orientation. The education and competency will remain in their education file. This education will be provided by the DON/ IP/designee(s). Nurses will not use the glucometer until the education and competency is completed and documented. D. Removal of immediate jeopardy The facility's plan to remove immediate jeopardy was accepted on 5/8/23 at 3:35 p.m. Record review and observations revealed the facility educated 14 nurses on the policy and proper procedure for performing cleaning and disinfection of a shared blood glucometer between use with multiple residents. On duty nurses (5/8/23) were able to provide verbal instruction on proper cleaning and disinfection with return demonstration of acceptable infection control practices when using a shared blood glucose device. However, deficient practice remained at an E scope and severity, a pattern with the potential for more than minimal harm. E. Additional interviews and observations LPN #1 was interviewed on 5/8/23 at 11:25 a.m. regarding the training received on blood glucose monitor cleaning and disinfection. LPN #1 said the training was completed on 5/4/23 and that the blood glucose monitor should be cleaned with a sani-cloth wipe by scrubbing vertically three times on each side then scrubbing horizontally three times on each side and allowing it to dry for two minutes before performing the blood sugar check. LPN #1 said the device should be cleaned after each resident. RN #3 was interviewed on 5/8/23 at 11:30 a.m. regarding the training received on blood glucose monitor cleaning and disinfection. RN #3 said the training was received and the device should be cleaned with the sani-cloth wipe by wiping three times horizontally and three times vertically on each side of the device. RN #3 said the device should be allowed to dry for two minutes before it is used on a resident. RN #3 said the device should be cleaned after each use. RN #2 was observed on 5/8/23 at 3:11 p.m. while he prepared to perform a blood sugar check for Resident #19. RN #2 wiped each side of the blood glucose monitor vertically and horizontally three times with a sani-cloth wipe and allowed the device to dry for two minutes. II. Failure to ensure blood glucose meters were cleaned, stored, and sanitized in a manner consistent with standards of practice A. Professional reference According to the Centers for Disease Control and Prevention (CDC) Injection Safety, Infection Prevention during Blood Glucose Monitoring and Insulin Administration, retrieved from https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html (5/11/23): The CDC has become increasingly concerned about the risks for transmitting hepatitis B virus (HBV) and other infectious diseases during assisted blood glucose monitoring and insulin administration. CDC is alerting all persons who assist others with blood glucose monitoring and/or insulin administration of the following infection control requirements: Finger stick devices should never be used for more than one person. Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared. Meters requiring preloading of the test strip may come in direct or close contact with the resident's finger stick wound. Subsequent residents can be exposed when the meter is used on them. Staff hands can become contaminated with blood that is transferred to the meter when they obtain the reading. Blood remaining on the meter can be transferred to subsequent residents through staff hands when they perform the next procedure. According to the CDC Infection Prevention during Blood Glucose Monitoring and Insulin Administration, retrieved from https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html#anchor_1556215485 on 5/11/23, Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions to prevent carry-over of blood and infectious agents. B. Manufacturer instructions According to Arkray USA Inc. Ark Care Technical Brief: Cleaning and Disinfecting the Assure Platinum Blood Glucose Monitoring System (BGMS) retrieved from: https://www.arkrayusa.com/english/upload/docs/Assure%20Prism%20multi%20Cleaning%20%26%20Disinfecting%20Guide.pdfon 5/11/23. To minimize the risk of transmitting bloodborne pathogens, the cleaning and disinfecting procedures should be performed as recommended in the instructions below. -The Assure Prism multi BGMS is intended to be used for testing multiple patients in a professional healthcare setting when standard precautions and the manufacturer's cleaning and disinfecting procedures are followed. -The meter should be cleaned and disinfected after use on each patient. Cleaning and Disinfecting: The cleaning procedure is needed to clean dirt, blood and other bodily fluids off the exterior of the meter before performing the disinfecting procedure. The disinfecting procedure is needed to prevent the transmission of bloodborne pathogens. Only wipes with EPA registration numbers listed below have been validated for use in cleaning and disinfecting the meter. Any disinfectant product containing these EPA registration numbers may be used on this device. Manufacturer recommendations for the glucometer cleaning indicated only the following wipes for use: Clorox healthcare bleach germicidal wipes, Dispatch hospital cleaner disinfectant towels with bleach, Super sani-cloth germicidal disposable wipes, and CaviWipes1. Guidelines for cleaning and disinfecting the Assure Prism multi BGMS -Each time the cleaning and disinfecting procedure is performed, two wipes are needed; one wipe to clean the meter and a second wipe to disinfect the meter. -Always wear the appropriate protective gear, including disposable gloves. -Open the disinfectant package and pull out one towelette. -Squeeze any excess liquid out of the towelette. -Wipe the entire surface of the meter using the towelette at least three times vertically and three times horizontally to clean blood and other body fluids from the meter. -Dispose of the towelette. -Repeat the above steps with a new towelette to disinfect the meter. -Meter surfaces must remain wet according to contact times listed in the wipe manufacturer's instructions. Once complete, wipe the meter dry. C. Facility cleaning product after immediate jeopardy The facility used a product by PDI manufacturer, Super Sani-Cloth germicidal disposable wipes, to clean all blood glucose meter devices after the immediate jeopardy. The wipe required a two minute surface disinfectant time and was documented to be effective against non-enveloped viruses, bacteria, tuberculosis, fungi, multidrug resistant organisms and blood borne pathogens. III. Hand hygiene failure when administering medications A. Professional reference According to the CDC Hand Hygiene in Healthcare Settings, last reviewed 1/30/2020, retrieved on from https://www.cdc.gov/handhygiene/providers/guideline.html on 5/11/23, Healthcare facilities should: Require healthcare personnel to perform hand hygiene in accordance with Centers for Disease Control and Prevention (CDC) recommendation. Use an alcohol-based hand sanitizer immediately before touching a patient, before performing an aseptic task or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids or contaminated surfaces, and immediately after glove removal. B. Facility policy and procedure The Infection Prevention and Control Program (IPCP) and Plan, revised 1/25/23, was provided by the NHA on 5/3/23 at 11:15 a.m. The policy read in the pertinent part: Standard and transmission-based precautions to be followed to prevent the spread of infections. The hand hygiene procedures to be followed by staff involved in direct resident contact. Interventions implemented may include the following: A facility-wide hand hygiene program that complies with CDC hand hygiene guidelines and Joint Commission National Patient Safety Goals, as warranted. C. Observation On 5/4/23 at 3:24 p.m. RN #1 gathered supplies for a blood glucose check. RN #1 did not wear gloves prior to performing the fingerstick for Resident #19. At 3:31 p.m. RN #1 gathered supplies for a blood glucose check. RN #1 did not use hand sanitizer prior to collecting supplies and the RN had just finished performing a blood glucose check on a separate resident and touched the laptop and mouse prior. RN #1 did not put gloves on prior to performing the fingerstick for Resident #38 and the resident was on enhanced barrier precautions for MRSA. On 5/8/23 at 12:40 p.m. licensed practical nurse (LPN) #1 assisted student nurses (SN #1 and SN #2) to prepare medications for Resident #19, neither student nurses performed hand hygiene prior to preparing or administering oral medications for Resident #19. The supervising LPN did not prompt the student nurses to perform any hand hygiene for the procedure. At 2:17 p.m. LPN #1 was observed preparing medications for a resident without performing hand hygiene. Prior to gathering the medications, the LPN had been sitting at the nurses station typing on the computer and touching papers on the desk. On 5/9/23 at 9:52 a.m. LPN #1 was observed supervising SN #1 and SN #2 while they gathered medications for a resident. Neither of the student nurses performed hand hygiene prior to collecting the medications. The supervising LPN did not prompt the nurse to perform hand hygiene during the procedure. D. Staff interviews The student's clinical institution instructor was interviewed on 5/9/23 at 11:25 a.m. She said the student nurses were to perform hand hygiene prior to preparing medications. The DON was interviewed on 5/9/23 at 6:05 p.m. The DON said the student nurses were to wash their hands or use hand sanitizer prior to preparing medications and delivering resident medications, then they should wash their hands or use hand sanitizer again.

Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to infection control and shared glucometers, quality of care and activities to meet resident needs. Findings include: I. Facility policy The QAPI (Quality Assurance and Performance Improvement) Program Design and Scope policy, last reviewed on 10/24/22, was received from the nursing home administrator (NHA) on 5/9/23 at 6:45 p.m. The policy read in pertinent part: The facility will have a QAPI program that is ongoing, comprehensive and capable of addressing the full range of care and services it provides. At a minimum, the QAPI program will: -Address all systems of care and management practices; -Include clinical care, quality of life and resident choice; -Utilize the best available evidence to define measure indicators of quality and facility goals that reflect processes of care and facility operations that have been shown to be predictive of desired outcomes for residents; and -Reflect the complexities, unique care and services that the facility provides. II. Review of the facility's regulatory record revealed it failed to operate a QAPI program in a manner to prevent repeat deficiencies and initiate a plan to correct F880 Infection control During a recertification survey on 7/25/19 F880 (infection control) was cited at a F scope and severity. During a recertification survey on 1/14/21 F880 (infection control) was cited at an E scope and severity. During a recertification survey on 3/15/22 F880 (infection control) was cited at an E scope and severity. During a recertification survey on 5/9/23 F880 (infection control) was cited at an increased scope and severity for failure to maintain proper infection control procedures at a J (immediate jeopardy) level. F684 Quality of care During a recertification survey on 7/25/19 F684 (quality of care) was cited at a D scope and severity. During a recertification survey on 1/14/21 F684 (quality of care) was cited at a Gscope and severity. During a recertification survey on 3/15/22 F684 (quality of care) was cited at an E scope and severity. During a recertification survey on 5/9/23 F684 (quality of care) was cited at a D scope and severity. F679 Activities to meet the interests, needs of a resident(s) During a recertification survey on 3/15/22 F679 (activities of interests) was cited at a D scope and severity. During a recertification survey on 5/9/23 F679 (activities of interests) was cited at a D scope and severity. III. Interview The NHA was interviewed on 5/9/23 at 6:14 p.m. The NHA said the QAPI committee met monthly with the interdisciplinary team (IDT) and the medical director in attendance. The QAPI had identified several areas of opportunity including improvements to the activities program and an area identified and an action plan had been developed to enhance programming for residents diagnosed with multiple sclerosis. The NHA said IDT/program managers presented trending concerns which could include infection control and resident care matters for QAPI review and from there the QAPI committee determined the need for performance improvement plans. The division director of clinical services (DDCS) was interviewed on 5/8/23 at 10:20 a.m. The DDCS said the regional and division directors were assisting the facility (QAPI committee) with an improvement plan related to infection control.

Based on observations and interviews the facility failed to ensure three out of four medication refrigerators stored narcotic, non-narcotic medications and biologicals in accordance with accepted professional standards and that only licensed staff had access to resident-prescribed medications. Specifically, the facility failed to: -Ensure controlled medications were in a locked storage area that was permanently secured to the refrigerator; -Ensure the medication cart was locked when the nurse was not at the cart; and, -Ensure food was not stored with medications. Findings include: I. Facility policy and procedure The Storage and Expiration Dating of Medications policy and procedure, last revised on 7/21/22, was provided by the director of nursing (DON). It read in the pertinent part, Facility should ensure that only authorized facility staff, as defined by the facility, should have possession of the keys, access cards, electronic codes, or combinations which open medication storage areas. Authorized staff may include nursing supervisors, charge nurses, licensed nurses, and other personnel authorized to administer medications in compliance with applicable Law. Facility should store Schedule II - V Controlled substances, in a separate compartment within the locked medication carts and should have a different key or access device. -Store all drugs and biologicals in locked compartments, including the storage of Schedule II-V medications in separately locked, permanently affixed compartments, -Facility should ensure that Schedule II -V controlled substances are only accessible to licensed nursing, Pharmacy, and medical personnel designated by Facility. Facility should ensure that resident medication and biological storage areas are locked and do not contain non-medication/biological items. Facility should ensure that food is not to be stored in the refrigerator, freezer, or general storage areas where medications and biologicals are stored. III. Observations On 5/8/23 from 12:30 p.m. to 1:20 p.m. during a continuous observation the medication cart on four [NAME] was unlocked and licensed practical nurse (LPN) #1 was not within direct line of sight or with the cart for at least eight minutes while she was sitting at the nurse's station working on the computer behind a half wall. Two nursing students were refilling the water pitcher for the medication cart at this time. The student nurses did not lock the cart. From 12:31 p.m. to 1:20 p.m. Resident #284, a resident with severe cognitive deficits and diagnosed with dementia with behavioral disturbance, was wandering on the unit during the times the mediation was observed to be unlocked. Resident #284 was going into other resident rooms, opening doors, opening drawers and was touching the items on the unlocked medication cart. This resident had an observed history of continuous wandering; touching items belonging to others; and unplugging electronic devices. The resident was not easily redirected by staff when staff attempted to redirect the resident from the room of other residents; upsetting other residents; or when touching items that did not belong to this resident. (Cross referenced to F744 failure to a resident diagnosed with dementia, received the appropriate treatment and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being). At 12:38 p.m. LPN #1 returned to the medication cart, the cart was unlocked; LPN #1 began preparing medications with the two nursing students. The nurse and the student nurses left the cart to administer the medications and left the cart unlocked. At 12:40 p.m. LPN #1 returned to the medication cart and locked the medication cart. At 1:11 p.m. LPN #1 returned to the medication cart to prepare resident medications and walked away from the medication cart leaving the cart unlocked. LPN #1 continued to leave the medication cart unlocked while she followed a resident down the hall attempting to get the resident to take her medications. At 1:20 p.m. LPN #1 returned to the medication cart and locked the medication cart. At 4:04 p.m. the four East medication room medication refrigerator was observed with LPN #6. The refrigerator contained a locked box to hold controlled medications needing refrigeration. The narcotic locked box was not permanently affixed to the refrigerator. Additionally, there were containers of yogurt stored in the medication refrigerator on the same shelf as the controlled substance medication locked box. The nurse confirmed the locked controlled substance locked box inside of the refrigerator contained controlled substance medications. At 4:20 p.m. the two East medication room medication refrigerator was observed with LPN #2. The controlled medication box was not permanently affixed to the refrigerator. The nurse confirmed the locked controlled substance locked box inside of the refrigerator contained controlled substance medications. At 6:50 p.m. the four [NAME] medication room medication refrigerator was observed with RN #2. The controlled medication box was not permanently affixed to the refrigerator. The nurse confirmed the locked controlled substance locked box inside of the refrigerator contained controlled substance medications. IV. Staff interviews LPN #6 was interviewed on 5/8/23 at 4:05 p.m. LPN #6 said the medication refrigerator should not have food stored in it and she removed the yogurt to take elsewhere. The director of nursing (DON) was interviewed on 5/9/23 at 6:05 p.m. The DON acknowledged medication carts should be locked at all times when the nurses stepped away from the medication cart. The DON said the narcotic boxes in the refrigerators were in a locked box in a locked room and was not aware that the boxes needed to be permanently affixed to the refrigerator itself.

Based on record review and interviews the facility failed to ensure the nursing services were provided by individuals who had the skills, experience, knowledge and proper licensure to meet the residents' needs. Specifically, the facility failed to monitor unlicensed student nurses during medication administration with a resident. Findings include: I. Facility policy A request was made to the facility for a policy regarding the use of student nurses for resident care; no policy was provided during the survey. A signed contract agreement between a named educational institute for student nurses and the facility was provided by the director of nursing (DON) on 5/8/23 at 2:12 p.m. It read in the pertinent part: The facility agrees to: permit (affiliate's name) students to perform services for facility patients only when under the direct supervision of a registered, licensed or certified facility caregiver licensed in the discipline in which supervision is to be provided. Retain ultimate responsibility for the provision of all services provided to patients or residents of the facility. II. Observations On 5/8/23 at 12:40 p.m. licensed practical nurse (LPN) #1 permitted and assisted student nurses (SN #1 and SN #2) to prepare medications for Resident #19. The student nurse prepared oral medication (including a narcotic medication) for Resident #19. After the medications were prepared LPN #1 told the student nurses to administer the medication to the resident and return to the nurses station and sat down at the desk while two student nurses delivered a controlled medication to Resident #19 in the resident room and out of sight of LPN #1. The student nurse who handled the resident medication and passed the medication to the resident did not confirm the resident's name prior to giving the resident the cup of medications. III. Interviews The director of nursing (DON) was interviewed on 5/9/23 at 6:05 p.m. The DON said student nurses should be supervised by a nurse until they have completed the task enough to be checked off on it. The education institution's clinical instructor (CI) for the student nurses was interviewed on 5/9/23 at 11:25 a.m. The CI said student nurses were to perform the six rights of medication administration when preparing and giving a resident their prescribed medications; introduce themselves in the resident's room upon arrival to the resident's room, and confirm the resident's name prior to giving the resident the medication for consumption. The CI said it was required that the student nurses be supervised by a licensed nurse during every medication pass because the student nurses had not yet earned their license to practice nursing unsupervised.

Based on observation, record review and interviews, the facility failed to ensure one (#10) of one resident reviewed for activities of daily living of 44 sample residents were provided appropriate treatment and services to maintain or improve their abilities. Specifically, the facility failed to ensure strategies were in place to effectively communicate with Resident #10, who spoke a language other than English. Findings include: I. Facility policy and procedure The Meaningful Communication with Persons with Limited English policy and procedure, revised 2022, was provided by the nursing home administrator (NHA) on 5/9/23 at 6:02 p.m. It documented in pertinent part, Individuals who do not speak English as their primary language and who have a limited ability to read, write, speak, or understand English may be limited English proficient (LEP). The facility will take reasonable steps to ensure that LEP residents with have meaningful access and an equal opportunity to participate in our services, activities, programs and other benefits. The policy of the facility is to ensure meaningful communication (language assistance services, qualified sign language interpreters, or auxiliary aids if hearing is impaired) with LEP residents and their authorized representatives involving their medical conditions and treatment. All interpreters, translators and other aids needed to comply with this policy shall be provided without cost to the LEP resident being served, and patients/clients and their families will be informed of the availability of such assistance will be provided free of charge. Language assistance will be provided through use of staff interpreters, and through formal arrangements with interpretation or translation services, or technology and telephonic interpretation services. Some LEP residents may prefer or request to use a family member or friend as an interpreter. However, family members or friends of the LEP resident will not be used as interpreters unless specifically requested by that individual and after the LEP resident has understood that an offer of an interpreter at no charge to the person has been made by the facility. Such an offer and the response will be documented in the resident's medical record. If the LEP resident chooses to use a family member or friend as an interpreter, issues of competency of interpretation, confidentiality, privacy, and conflict of interest will be considered. If the family member or friend is not competent or appropriate for any of these reasons, competent interpreter services will be provided to the LEP resident. II. Resident #10 A. Resident status Resident #10, age under 65, was admitted on [DATE]. According to the May 2023 computerized physician orders (CPO), the resident's diagnoses included osteomyelitis (inflammation of bone or bone marrow, usually due to infection), cerebral infarction (ischemic stroke) and type two diabetes. According to the 3/16/23 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for a mental status score of 15 out of 15. She required extensive assistance of two people with bed mobility and extensive assistance of one person for transfers, dressing and toileting. She preferred Spanish and required an interpreter. B. Resident interview Resident #10 was interviewed on 5/8/23 at 12:59 p.m. Resident #10 said most of the time staff did not use interpreters or other tools to communicate with her. Resident #10 said she did not feel like the staff was communicating with her or understanding her concerns. Resident #10 said the facility used a hotline but not often. Resident #10 said she felt frustrated and the staff did not try to communicate with her effectively which upset her. C. Observations On 5/3/23 observations from 11:30 a.m. until 2:30 p.m. the resident's room did not have signs indicating communication needs or interventions staff could use. The staff were not observed using the communication hotline or any other communication tools. On 5/8/23 observations from 11:30 a.m. until 2:00 p.m. the resident's room did not have signs indicating communication needs or interventions staff could use. The staff were not observed using the communication hotline or any other communication tools. D. Record review The communication care plan on 4/11/23, revealed the resident has a communication problem. Resident#10 primary language was Spanish and she understood very little English. Interventions include using the communication hotline 100% of the time. III. Staff interviews Certified nurse aide (CNA) #6 was interviewed on 5/9/23 at 9:08 a.m. CNA #6 said Resident #10 only spoke Spanish. CNA #6 said she thought there was a hotline number the staff could use to communicate with the residents that did not speak English; posted at the nursing station. CNA #6 said she would find another CNA that spoke Spanish if she needed to communicate with her. Registered nurse (RN) #4 was interviewed on 5/9/23 at 11:45 a.m. RN #4 said the staff used the Spanish speaking CNAs and there was a hotline number staff could use to communicate with Resident #10. The social worker (SW) was interviewed on 5/9/23 at 2:49 p.m. She said Resident #10 spoke Spanish and understood very little English. The SW said staff could use the language hotline or a Spanish speaking staff member. The SW said staff would know to use the hotline when they were oriented to the floor. The director of nursing (DON) was interviewed on 5/9/23 at 6:16 p.m. She said individuals who had a primary language other than English, should be provided with a communication hotline for translation purposes. The DON said the staff did use pictures for some residents and Spanish speaking CNAs. The DON said some residents refused to use the communication hotline. The DON said Resident #10 did not refuse to use the hotline.

Based on observations, record review and staff interviews, the facility failed to provide appropriate care and services to maintain the activities of daily living for one (#54) of five residents who required extensive assistance out of 44 sample residents. Specifically, the facility failed to provide regular nail care for Resident #54. Findings include: I. Facility policy The Nail Care policy, revised August 2022, was provided by the nursing home administrator (NHA) #1 on 5/9/23 at 5:00 p.m. The policy read in part: The resident will receive assistance as needed to complete activities of daily living (ADLs). Any concerns with skin or nails identified during completion of nail care should be reported to the nurse who will document and report to the practitioner as needed. Ensure fingernails are clean and trimmed to avoid injury and infection. Report any abnormalities to the nurse. II. Resident #54 A. Resident status Resident #54, age 78, was admitted on [DATE]. According to the May 2023 computerized physician orders (CPO), the resident's diagnoses included chronic obstructive pulmonary disease, hemiplegia (one-sided paralysis) and encephalopathy (a disease in which the functioning of the brain is affected). According to the 3/7/23 minimum data set (MDS) assessment, Resident #54 was unable to participate in a brief interview for mental status. The MDS assessment further revealed Resident #54 required extensive assistance with one-person physical assistance for ADLs of transfers, bed mobility, toileting, dressing, eating and personal hygiene. B. Observations Observation on 5/3/23 at 2:30 p.m. the resident's nails were half an inch long and yellow. Observation on 5/4/23 at 1:36 p.m. the resident's nails were half an inch long and yellow. On 5/9/23 at 1:00 p.m. registered nurse (RN) #4 went into Resident #54's room and acknowledged that Resident #54's fingernails were very long and needed to be cut. RN #4 asked the resident if his nails could be cut. Resident #54 held up his hand and said too long and said thank you. RN #4 said the resident's nails would be cut right away. C. Record review The care plan reviewed 4/6/23, documented that the resident has ADL self-care performance deficit and requires assistance with bathing and dressing. Encourage the resident to participate to the fullest extent possible with each interaction. III. Staff interviews Certified nurse aide (CNA) #6 was interviewed on 5/9/23 at 9:08 a.m. CNA #6 said Resident #54 was easy to work with if the resident knew the staff that was working with him. CNA #6 said CNAs did not perform nail care and an outside service provided the residents' nail care. RN #4 was interviewed on 5/9/23 at 11:45 a.m. RN #4 said Resident #54 could be difficult to work with but he worked well with preferred staff. RN #4 said CNAs did resident nail care during their baths including bed baths. The director of nursing (DON) was interviewed on 5/9/23 at 6:16 p.m. The DON said all nursing staff were responsible for nail care. The DON said the residnet's nails should be checked anytime staff interacted with the residents. The DON said if a resident refused nail care they should ask another staff to try. The DON said resident nails should be trimmed as needed.

Based on observations, record review and interviews, the facility failed to ensure one (#58) of four residents reviewed for range of motion (ROM) and mobility out of 26 sample residents received appropriate treatment and services to prevent further decrease in ROM and mobility. Resident #58 admitted to the facility for long term care on 11/8/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required staff assistance with activities of daily living (ADLs) and was admitted to the facility with a contracture in his right hand (as indicated by staff interviews and minimum data assessment 11/12/21). The facility failed to assess, provide services to maintain or improve his ADLs to include his swallowing function. The facility failed to assess the level of the resident's contracture and whether his hand/s had worsened during his stay at the facility. Recommendations from the restorative certified occupational therapy assistant were recommended on 2/13/22 and 2/17/22, which was three months into the resident's stay at the facility but were not initiated until after he had a decline. Due to the facility's failures, the resident had an avoidable decline with his ADLs to include transferring, toileting, personal hygiene and dressing. In addition, per record review and staff interviews, his contractures worsened since his admission to the facility. Furthermore, the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Cross-reference F692 for maintaining acceptable parameters of his nutritional status. Findings include: I. Facility policies and procedures A. The Managing Referrals policy and procedure, revised 12/19/16, was provided by the director of nursing (DON) on 3/15/22 at 12:04 p.m. It read, in pertinent part, Referrals made for therapy are handled in an efficient and professional manner. If (facility) is not a participating provider in the patient's insurance plan, the therapy may assist the patient in locating a provider in the area. B. The Restorative Nursing policy and procedure, revised 8/7/21, was provided by the DON on 3/15/22 at 12:04 p.m. It read, in pertinent part, The facility is responsible for providing maintenance and restorative programs as indicated by the resident's comprehensive assessment to achieve and maintain the highest practicable outcome. To promote the resident's optimum function, a restorative program may be developed by proactively identifying, care planning, and monitoring of a resident's assessments and indicators. Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities of daily living do not diminish. Generally, restorative nursing programs can be initiated when a patient is discharged from a formalized physical, occupational, or speech rehabilitation therapy. II. Resident status Resident #58, age 70, was admitted on [DATE]. According to the March 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . III. Decline in Resident #58 activities of daily living A. 11/12/21 minimum data set (MDS) assessment The 11/12/21 admission MDS assessment documented the resident had severe cognitive impairment with a score of four out of 15 according to the brief interview for mental status (BIMS). The resident had no behaviors or rejection of care. The resident had functional limitations in range of motion for upper extremities on one side and lower extremities on one side. It indicated he had no swallowing trouble. Therapy and restorative programs were not coded. It indicated the resident had an active discharge plan to return to the community. The assessment indicated the resident was extensive assistance of two staff for bed mobility, extensive assistance of two staff with transfers, extensive assistance of one staff for locomotion on the unit, extensive assistance of one staff for dressing, extensive assistance of one staff for eating, extensive assistance of one staff for toileting, and supervision of one staff for personal hygiene. The assessment indicated that direct care staff believed the resident was capable of increased independence in at least some ADLs. B. 2/5/22 MDS assessment The 2/5/22 MDS assessment indicated the resident was not cognitively intact and unable to complete a brief interview for mental status. It indicated the resident's cognitive skills for daily decision making were severely impaired. It indicated no behaviors related to rejection of care. The resident had functional limitations in range of motion for upper extremities on one side and lower extremities on one side. It indicated he had no swallowing trouble. No therapy or restorative programs were indicated on the assessment. It indicated the resident had an active discharge plan to return to the community. The assessment indicate the resident was extensive assistance of two staff for bed mobility, total dependence of two staff for transfers, extensive assistance of one staff for locomotion on the unit, total dependence on two staff for dressing, extensive assistance of one staff for eating, total dependence of one staff for toileting and extensive of one staff for personal hygiene. -From the initial 11/12/21, the resident had a decline in transferring from extensive assistance of two staff to total dependence of two staff; in dressing he was extensive assistance of one staff to total dependence of two staff; toileting he was extensive with one staff to total dependence of one staff; and with personal hygiene he was supervision of one staff to extensive with one staff. IV. Resident representative interview The resident representative was interviewed on 3/14/22 at 8:33 a.m. The resident representative said the resident was sent out to the hospital on the previous day due to fever and vomiting. He said he saw the resident and thought his contractures looked worse. He said the resident had a carrot to help with range of motion for his hands but he had not seen the resident use it and was unsure where it was. He said he was unsure if the resident had therapy services but said it was recommended by a nurse at one point. He said his family wanted to bring the resident home but since the resident's contractures had worsened, he did not think this was possible. V. Additional record review The activities of daily living (ADL) care plan, initiated 11/11/21, indicated ADL assistance and therapy services were needed to maintain or attain the highest level of function. Interventions included assistance with ADL as needed and therapy services as ordered. -The care plan did not indicate services related to contracture management. The director of therapy (DOT) provided physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The orders were faxed to the home health care provider on 11/18/21. The DOT provided an email exchange with the home health care provider on 3/14/22 at 4:11 p.m. The document indicated the outside therapy service provider attempted a physical therapy evaluation on or around 2/2/22 and the resident declined services. -This was the only documentation provided regarding the resident being provided therapy services. In addition, staff interviews indicated the resident did not refuse care and in addition the restorative certified occupational therapist was able to provide services on 2/13/22 and 2/17/22 (see below). The restorative progress notes were reviewed. The notes were documented by the restorative certified occupational therapist assistant (COTA): A restorative progress note from 2/13/22 indicated therapist monitored contractures. It indicated attempts had been made to provide therapy services. The note indicated the resident had a palm guard and may be able to work up to using a carrot. A restorative progress note from 2/17/22 indicated the therapist measured upper and lower extremity contractures to establish a restorative nursing program for two times a week. The note indicated initial measurements and education provided to the resident on passive range of motion. It indicated the resident used a palm guard. -The initial measurements were taken on 2/17/22 of his left and right wrist indicating that they were both contracted, when the resident was admitted to the facility on [DATE] with only one contracted hand (see staff interviews). -No other restorative progress notes were provided to indicate that he was receiving restorative treatment two times a week as indicated on the 2/17/22 progress note. In addition, the restorative COTA was unavailable for interview during the survey. Review of March 2022 CPO revealed the following: -Physical therapy evaluation and treatment as indicated one time only for contracture management for upper and lower extremities ordered on 3/7/22. -Occupational therapy evaluation and treatment as indicated one time only for contracture management for upper and lower extremities ordered 3/7/22. The director of therapy (DT) provided the speech therapy evaluation and plan of treatment on 3/15/22 at 2:00 p.m. The evaluation indicated the resident had mild oropharyngeal dysphagia (swallowing problems occurring in the mouth and throat). Recommendations included to continue with puree texture and thin liquids. Carryover of swallowing techniques included alternating liquids and solids, modification of size of bite, using tongue to clear oral cavity, upright position for all meals, and monitoring signs and symptoms of aspiration including coughing and throat clearing, changes in respiratory symptoms, and fever. -The speech therapy evaluation was completed on 3/15/22 despite the initial referral for evaluation on 11/17/21(cross-reference F692). VI. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 3/10/22 at 2:49 p.m. She said when a resident required therapy services, orders were inputted into the resident's electronic health record. She said Resident #58 had recently had orders placed for therapy services. The DOT was interviewed on 3/14/22 at 4:11 p.m. He said Resident #58 was not on the therapy caseload because there were issues with the resident's insurance. He said Resident #58 was admitted to the facility with orders for physical and occupational therapy for contracture management in November 2021. He said he sent this referral to the home health care provider to be handled. He said the therapy team at the facility could not provide services due to insurance constrictions. He said he had documentation that Resident #58 declined physical therapy services from the home health care provider in February 2022. He said Resident #58's contractures had worsened during this time and he needed restorative services. He said the restorative staff was able to see the resident in February 2022 and made a plan, though typically residents were seen by therapy prior to a restorative plan. He said Resident #58 also had orders for speech therapy but the home health care provider said they did not have a speech therapist. The DON was interviewed on 3/17/22 at 10:17 a.m. She said Resident #58 was coughing during meals and a swallowing evaluation with a speech-language pathologist was recommended. She said she was unsure of the dates. She said the DOT would be responsible for the follow up and would have more information. The DOT was interviewed again on 3/15/22 at 10:40 a.m. He said restorative staff took measurements of the contractures in February 2022 but there were no contracture measurements at admission. He said he believed Resident #58 had declined since admission and needed a lot more assistance with ADLs. He said Resident #58 had not been seen by the speech-language pathologist for swallowing difficulties and would be seen that day. LPN #3 was interviewed again on 3/15/22 at 11:44 a.m. She said Resident #58 required a lot of assistance. She said she had worked at the facility for two months and during that time he had contractures. She said she could not speak to whether the contractures had worsened. Certified nurse aide (CNA) #2 was interviewed on 3/15/22 at 12:10 p.m. She said Resident #58 had always required a lot of assistance. She said initially his right hand was more contractured, but now both hands were contracted. She said he sometimes coughed during meals and when she helped assist him with eating. She said he did not refuse care. The MDS coordinator (MDSC) was interviewed on 3/15/22 at 1:43 p.m. She said if contractures were observed at the initial MDS assessment, she would notify the therapy department so they could monitor. She said at the initial assessment, Resident #58 required extensive assistance with ADL involving bed mobility, transfers, locomotion on unit, dressing, and eating and required set up assistance for personal hygiene. She said at his quarterly assessment on 2/5/22, Resident #58 required extensive and total assistance for ADL involving bed mobility, transfers, locomotion on unit, dressing, and eating and extensive assistance with personal hygiene which indicated a decline with personal hygiene. -However, the resident had more decline than just in personal hygiene, the resident had decline in transferring, dressing and toileting (refer to MDS assessment 2/5/22). She said Resident #58 was motivated to get strong because he wanted to go home and live with family. She said the family no longer believed Resident #58 would be able to discharge home due to the level of care needed. The DON was interviewed on 3/15/22 at 2:40 p.m. She said Resident #58 was recently seen by restorative services. She said she did not know if the residents' contractures had worsened since admission and that therapy typically measures contractures. She said if a resident had contractures there should be a contracture care plan. She said she was unsure if Resident #58 had a care plan related to his contractures. She said it had been challenging to work with the resident's insurance in order to get rehabilitation services. -However, the facility was aware of what limitations, medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to provide the care and services needed to maintain his current functioning in order to avoid decline with his ADLs, swallowing function and contractures. VII. Facility follow-up The nursing home administrator (NHA) provided additional documentation on 3/16/22 at 12:48 p.m. The documentation indicated Resident #58 came from a rehabilitation facility without orders for physical or occupational therapy at admission. It indicated an attempt for a physical therapy evaluation was completed around 2/2/22 and Resident #58 declined the evaluation. It also noted the restorative COTA had worked with the resident on range of motion. Included in this documentation was the email exchange with the home health care provider that indicated Resident #58 declined physical therapy services and copies of progress notes from the restorative COTA. The documentation also indicated the restorative COTA provided education to staff on contracture management for Resident #58. -However, there was no formal documentation of the education to the staff on contracture management. In addition, there was no additional documentation submitted regarding restorative or therapy that was not included (refer to additional record review). The primary care physician was interviewed on 3/23/22 at 2:20 p.m. He said he was aware Resident #58 had contractures on both right and left hands. He said the resident's contractures had worsened since admission but he did not know the severity. He said he did not know if the resident was receiving any services for his contractures.

Based on interviews and record review the facility failed to ensure the environment was free of accidents and hazards and failed to provide adequate supervision and assistance to prevent an accident for one (#25) of four out of 26 sample residents. Resident #25 had a known history of elopement and wandering behaviors. Resident #25 often verbalized she was looking for something in attempts to leave the unit. The facility failed to implement measures to ensure her safety with her wandering, attempting to leave the unit and history of elopement. Resident #25 was assisted on 2/23/22 by a male resident to the elevator at around 9:45 p.m. where he reported to staff he sent the resident down on the elevator. The facility staff began looking for her on the unit and other units. About an hour and 15 minutes later, Resident #25 was found in the boiler room in the basement of the facility. When Resident #25 was found at 11:00 p.m. she had complaints of right arm pain, a large hematoma was located on her elbow and her right shoulder was noted to droop. Resident #25 was sent to the hospital for evaluation and treatment. Due to the facility's failures, Resident #25 had wandered off her unit and was found in the facility's boiler room, where she had an unwitnessed fall and sustained a fracture to the right humeral head (shoulder) requiring hospital care. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 3/9/22 to 3/15/22, resulting in the deficiency being cited as past noncompliance with a correction date of 2/24/22. I. Facility policies and procedures A. The Missing Residents/Actual Elopement Event policy and procedure, revised 4/22/21, was provided by the director of nursing (DON) on 3/15/22 at 12:04 p.m. It read in pertinent part, Residents will be assessed for unsafe wandering and elopement indicators upon admission, readmission, change in condition, quarterly and with any unsafe wandering or elopement event. During the admission and readmission process, a care plan will be initiated by the admitting nurse on any residents assessed with unsafe wandering or elopement behaviors. B. The Fall Management policy and procedure, revised 8/2/21, was provided by the DON on 3/15/22 at 12:04 p.m. It read in pertinent part, The facility will assess the resident upon admission/readmission, quarterly, with change in condition, and with any fall event for any fall risks and will identify appropriate interventions to minimize the risk of injury related to falls. Implement interventions, including adequate supervision, consistent with the resident's needs, goals, care plan, and current professional standards of practice in order to eliminate or reduce the risk of an accident. Monitor the effectiveness of the interventions and modify the interventions as necessary, in accordance with current professional standards of practice. II. Resident status Resident #25, age 80, was admitted on [DATE] and readmitted from the hospital on 2/24/22. According to the March 2022 computerized physician orders, diagnoses included dementia, [CONDITION(S)], wandering, and arthritis. The 1/7/22 minimum data set (MDS) assessment indicated the resident had a severe cognitive impairment with a brief interview for mental status score of seven of 15. The resident required one person assistance for locomotion on and off the unit. It indicated both walker and wheelchair were used for mobility. It indicated the resident did not have behaviors including wandering. It indicated the resident had not had any falls since the last MDS assessment on 11/1/21. III. Resident observations and interview Resident #25 was interviewed on 3/9/22 at 10:20 a.m. Resident #25 was sitting on her bed watching television. A sling was visible on her right arm. She said she broke her arm recently when she had a fall. She pointed out the window when asked where she fell . She said she was in constant pain because of the fall but the nurses helped her manage the pain. On 3/9/22 at 12:30 p.m. Resident #25 was observed walking out of room using her four wheeled walker with a sling on her right arm. Licensed practical nurse (LPN) #3 redirected the resident back to her room and to use her wheelchair when out of her room. On 3/15/22 at 11:49 p.m. Resident #25 was observed sitting in her wheelchair in the dining area. Resident #25 was watching television. IV. Record review The elopement care plan, revised on 10/20/2020, was reviewed on 3/10/22. It indicated Resident #25 would search for her dog or parents and displayed exit seeking behavior. Interventions included addition of the resident to the elopement board at reception, completing elopement risk assessments, frequent monitoring by staff, and use of visual barriers. The 1/2/22 fall risk assessment indicated the resident did not have a fall within the past 90 days. It indicated the resident ambulated with problems, with device and maintained position as required. Her score was marked at 16 with ten being a score in which fall interventions should be in place. The fall care plan, revised on 1/7/21, indicated Resident #25 had a history of falls with risk factors including: unsteady gait, wandering, and wakefulness during night. Interventions included assist Resident #25 to bed, anticipate needs, and orient to room. The 2/2/22 elopement risk assessment indicated Resident #25 ambulated independently, had a history of elopement, wandered, and became agitated when diverted from exits. It indicated the resident was not at risk for elopement. -However, based on the resident's risk factors of ambulating independently, history of elopement, wandered, and became agitated when diverted from exits, she should have been at risk for elopement since she was care planned for it since 10/20/2020 (see elopement care plan above). Progress notes were reviewed for behaviors and falls from the past six months and revealed the following: -On 12/23/21 a progress note indicated Resident #25 was confused in the hallway and asked staff to call family. It was noted the resident had not slept in 48 hours and the physician was notified. The resident was redirected to bed. -On 1/13/22 a progress note indicated Resident #25 was verbally aggressive towards staff and repeatedly asked about her family. Staff members redirected. It noted Resident #25 had a history of wandering and often attempted to leave the floor by getting on the elevator. -On 1/14/22 a progress note indicated Resident #25 was verbally aggressive towards staff. It noted she repeatedly attempted to get on the elevator and staff redirected her. Progress notes from 2/24/22 were reviewed. The progress notes indicated that on 2/23/22, Resident #25 was assisted onto the elevator by a male resident and went down to the basement around 9:45 p.m. She was found at 11:00 p.m. in the boiler room, located in the basement, with complaints of right arm pain. A large hematoma was located on her elbow and her right shoulder was noted to droop. She was sent to the emergency room for evaluation and the physician and family were notified. The progress notes indicated the resident returned from the hospital on 2/24/22 and was lethargic, confused, and had a sling on her right arm. The Abuse/Adverse event investigation was provided by the DON on 3/14/22 at 11:30 a.m. It indicated the event, fall with injury, occured on 2/23/22 at 9:45 p.m. The incident was described by staff in the report. It noted Resident #25 was assisted onto the elevator by another resident and went to the basement. The other resident told staff that he sent the resident down on the elevator. The staff then began to search the unit for Resident #25 and later moved to other units. A licensed practical nurse (LPN) went to the basement and located Resident #25 in the boiler room. She was holding her right arm. Resident #25 was sent to the hospital. The investigation included notes for training that occured after the incident related to missing persons and audits for checks of the locks on doors in the basement initiated after the event. The report indicated stop signs were ordered to be placed on elevators (see facility observations below). Included in the Abuse/Adverse event investigation were audits of the basement doors for 2/23/22-3/1/22. The audits indicated all locks in the basement were in working order and locked during these dates during both morning and evening. Documentation also included all staff in service regarding missing persons. The training covered the urgency of finding missing residents with 12 follow-up questions related to the process for monitoring, reporting, and finding missing residents. The notes indicated this training was initiated on 2/24/22. The hospital notes from 2/24/22 were provided by the DON on 3/15/22 at 4:33 p.m. The notes indicated a fracture to the right humeral head (shoulder) and no abnormalities were observed in the head and the spine. She was given a sling for her right arm and discharged with follow-up to orthopedics as well as an order for [MEDICATION(S)]-acetaminophen 3-325 milligrams every eight hours for pain related to right arm. The 2/24/22 elopement risk indicated the resident was recently readmitted from the hospital, ambulated independently, had a history of elopement, wandered, and became agitated when diverted from exits. It indicated the resident was a risk for elopement. Interventions in the assessment included the same interventions marked in the elopement care plan (see below). The 2/24/22 fall risk assessment, completed at readmission, indicated a fall within the last 90 days. It indicated the resident ambulated without problems with devices and maintained position as required. Her score was marked as 13 with ten being a score in which fall interventions should be in place. -However, the resident had an unwitnessed fall on 2/23/22 where she sustained a fracture so she was at an increased fall risk. On 1/2/22 she was marked with a score of 16 and now after her fall she was scored lower with a score of 13. The social services director (SSD) provided behavior tracking forms on 3/15/22 at 2:45 p.m. The form indicated target behaviors of cussing at staff, exit seeking, yelling, and excess wakefulness. The form was dated for 10/31/2020 to 11/28/2020. A request for more recent documentation was made. The SSD provided additional documentation on 3/15/22 at 3:05 p.m. This included a behavior tracking form for March 2022. Target behaviors were listed as verbal aggression, wandering, and crying. -The tracking form did not denote any behaviors for the month. V. Facility observations and interviews Velcro stop signs were observed on the outside of the elevators on the unit where Resident #25 resided on 3/9/22 at 11:42 a.m. The sign was stretched across the elevator door frame. At 12:20 p.m., a staff member exiting the elevator asked LPN #3 why there was a stop sign. LPN #3 said it was for a male resident and Resident #25. For the remainder of the survey, until 3/15/22, the signs were not placed across the elevator door frame but hanging off to the side. The DON indicated the stop signs were implemented at night (see interview below). The basement was observed on 3/11/21 at 3:56 p.m. All doors were labeled and locked except for the employee break room. VI. Staff interviews The DON was interviewed on 3/14/22 at 4:53 p.m. She said staff that have been at the facility for years know Resident #25 well. She said Resident #25 had a history of wandering and looking for a white truck, her dogs, or her husband. The DON said when Resident #25 was looking for these things, staff would give Resident #25 a cold soda and snack and keep watch of her. The DON said on 2/23/22, Resident #25 was up and had stated she was looking for something. The DON said the certified nurse aide (CNA) that was working that night was unfamiliar with Resident #25 and did not know Resident #25's statement was indicative of elopement or wandering behavior. She said one CNA left the floor to take out the trash which left one other CNA and a nurse on the floor. The DON said around 9:50 p.m. the CNA was approached by a male resident who said he had sent Resident #25 down on the elevator because she was lost. The DON said the male resident had dementia so staff was unsure how accurate his statement was. The staff on the unit began to look for Resident #25 on the unit first and later began to search other floors since the male resident stated he helped Resident #25 onto the elevator. The DON said she was notified via phone at 10:40 p.m. and she asked the staff to report it as a missing person. The DON said the staff searched on all floors and outside. She said a licenced practical nurse (LPN) found Resident #25 in the boiler room with her walker. She said she was found about 10-20 minutes after she was called. She said Resident #25's hair turban and glasses were on the floor which indicated she may have fallen. She said Resident #25 was sent to the hospital because staff suspected she broke her arm. The DON said immediately after the event they began to educate staff on missing persons and all doors in the basement were checked. She said several doors in the basement were found to have broken locks and they were replaced by 2/24/22. The DON said she ordered stop signs to be placed on the elevator doors and they arrived on 3/10/22. She said they were to be used at night. She said she was unsure what could be done to ensure the male resident did not assist other residents off the floor in the elevator. Licensed practical nurse (LPN) #3 was interviewed on 3/15/22 at 11:44 a.m. She said Resident #25 would wander in the hallway and ask where her room or family was. She said she would redirect the resident. She said there was no set protocol on what to do besides redirect the resident. She said Resident #25 ambulated in her wheelchair since the fall because her balance was not as strong. She said she had not eloped since the accident. She said there is a behavior book on the unit to track behaviors. She said she did not use the book and instead marked behaviors in the resident's electronic health record. Certified nurse aide (CNA) #2 was interviewed on 3/15/22 at 12:10 p.m. She said Resident #25 would wander on the unit but usually did not want to leave the floor. She said she had received training on how to redirect the resident. She said the resident did not have triggers that would indicate elopement. She said the resident had not eloped since her accident because she would mostly be in her wheelchair. The DON was interviewed again on 3/15/22 at 2:40 p.m. She said would expect the care plan to be updated following an event such as a fall or elopement. She said she was unsure if Resident #25's care plan was updated and would follow up. She said when Resident #25 was first admitted she had numerous behaviors and was hard to redirect. She said the behaviors had been stable. She said her behaviors included wandering, verbal aggression, and weepiness. She said wandering was not necessarily a behavior but it needed to be monitored. She said the plan for Resident #25 was for her to move to a secured unit following her surgery. She said Resident #25 was not wandering in the unit and was using a wheelchair to ambulate. She said the facility did not have a wanderguard system. The DON was interviewed again on 3/15/22 at 3:22 p.m. She said Resident #25's care plan was not updated following the event. The DON said the staff focused on external factors that led to the event such as audits of the locks in the basement and training on missing persons. She said Resident #25 will transition to a locked unit after her surgery. VII. Facility follow-up The DON provided additional information on 3/15/22 at 4:33 p.m. It included orders from the nurse practitioner from 3/14/22. It noted the orthopedic consultation was reviewed and indicated a severely displaced right humeral fracture with a plan to proceed with surgery in one week. It included orders for preoperative lab work to be completed. The nursing home administrator (NHA) provided the quality assurance and performance improvement plan for the 2/23/22 event on 3/16/22 at 3:57 p.m. after facility exit on 3/15/22. It indicated corrective actions taken post event (2/23/22-2/24/22) included: -Resident #25 was assessed by a registered nurse (RN) and sent to hospital; -Interviewed all staff on duty regarding the event; -Reviewed camera footage for timeline of events; -Contacted resident's nurse practitioner to discuss secure placement and orthopedic follow up; -Contacted the elevator company to inquire about having a code to go to basement level; -Audit of basement doors completed and locks replaced; -Stop signs ordered for elevator doors; and, -Training provided to staff regarding missing persons. The plan indicated the facility will monitor the changes (start date of 2/24/22 and completion date of 3/31/22) by: -Audit tool for basement doors to ensure the doors are locked daily; -Elopement drills four times a year; and, -Audits of at risk binder at the front desk to be completed monthly for six months.

Based on observations, interviews, and record review, the facility failed ensure one (#58) of five out of 26 sample residents received the care and services necessary to meet their nutrition needs and to maintain their highest level of physical well-being. Resident #58 admitted to the facility for long term care on 11/8/21 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a BMI of 16.6 (underweight being 18.5 or less) when he was admitted to the facility, which indicated he was underweight. The resident had a loose fitting bottom denture causing chewing difficulty. According to the registered dietitian, she was aware the resident had weight loss prior to being admitted to the facility. The resident was at nutritional risk due to previous weight loss, malnutrition and with swallowing trouble. According to the resident's primary care physician, the resident had sustained weight loss but had increased intake when he ate with his family or had the food the family brought in for him, in addition had ordered speech therapy and a modified [MEDICATION(S)] swallow study for his swallowing problems. A nutritional supplement was ordered for the resident but was not evaluated when the resident had sustained significant weight loss. [MEDICATION(S)] was ordered on 1/28/22 to promote the resident's appetite, however, the resident started losing weight 2/27/22. The resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The interdisciplinary team failed to comprehensively address the resident's weight loss, ongoing nutritional risk and swallowing function in order to maintain the parameters of his nutritional status. Observations revealed the food the resident representative brought in was in the refrigerator for the resident to eat, however it was not offered to him consistently. The resident representative had been bringing in food and snacks for the resident since early January 2022. Due to the facility's failures, the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Furthermore, the resident was not offered speech therapy to address his swallowing problems to offer the least restrictive diet, exercise and compensatory strategies for his swallowing function. The resident was sent to the hospital on 3/13/22 for pneumonia and urinary tract infection. Cross-reference F688 due to the resident's decline in mobility, swallowing function and worsening contractures. Findings include: I. Facility policies and procedures A. The Modified Texture Diets and Hydration policy, revised 10/18/21, was provided by the director of nursing (DON) on 3/15/22 at 12:04 p.m. It read, in pertinent part, As the resident's swallowing/chewing ability changes, the diet can be progressed or regressed based on an assessment of the resident by a Speech/Language Pathologist (SLP). In case the SLP is not available, Nursing may downgrade a diet until the SLP has an opportunity to assess. B. The Hydration and Nutrition policy, revised 7/14/21, was provided by the DON on 3/15/22 at 12:04 p.m. It read, in pertinent part, An ongoing assessment of the ability to consume and assimilate food and fluid is conducted by nursing personnel and all concerns are reported to the nurse, to include: positioning needs, environmental and social consideration, ability of resident to feed self, ability of resident to chew, drink and swallow, amount of food lost in spillage, nutritional balance or imbalance of intake, weight loss or gain, signs of dehydration. Consultation with dietary and therapy personnel is performed on admission and as needed. II. Resident status Resident #58, age 70, was admitted on [DATE]. According to the March 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/5/22 minimum data set (MDS) assessment indicated the resident was not cognitively intact and unable to complete a brief interview for mental status. It indicated the resident's cognitive skills for daily decision making were severely impaired. It indicated the resident required extensive assistance for activities of daily living, including one person assistance for eating. It indicated the resident did not have difficulty swallowing and did not lose 5% of weight over the past month or 10% over the past six months. The MDS indicated the resident was on a mechanically altered diet. It indicated the resident did not have broken, loose, or partial dentures as well as no discomfort or pain with chewing food. He did not have any behaviors or rejection of care. III. Resident interview Resident #58 was interviewed on 3/9/22 at 2:48 p.m. He was tired and spoke in short sentences and answered yes/no questions. He said he had recent weight loss and that it sometimes hurt to swallow. He also said the food was usually good and he sometimes received snacks. He said his family brought food for him. IV. Resident representative interview The resident representative was interviewed on 3/10/22 at 9:07 a.m. The resident representative said Resident #58 had lost weight while he had been at the facility. He said he brought in homemade food weekly, since January 2022, because Resident #58 said he did not like the food. The resident representative said he also brought in snacks for Resident #58 though he was unsure if the staff provided these snacks to the resident. He said Resident #58 only wore his top dentures because the bottom ones did not fit and that it could make the resident's chewing difficult. The resident representative was interviewed again on 3/14/22 at 8:33 a.m. The resident representative said he was concerned because he was notified on 3/12/22 that Resident #58 had a fever and was vomiting and staff thought he had aspirated (had food or liquid go into lungs). He said Resident #58 was sent to the hospital on 3/13/22 in order to be assessed and have a chest x-ray and labs completed. He said the staff at the hospital said Resident #58 was dehydrated, malnourished, and had pneumonia. The resident representative said Resident #58 informed him that he did not always receive feeding assistance from staff. The resident representative said he was unsure if Resident #58 had a swallow assessment since he was admitted but knew he was initially on a ground diet texture and was downgraded to puree. He said Resident #58 returned to the facility on [DATE] and was not admitted to the hospital. He said brought homemade food to be provided to Resident #58 on 3/13/22. V. Observations Resident #58 was observed in the unit dining room on 3/10/22 at 12:21 p.m. Certified nurse aide (CNA) #5 was beside the resident and provided feeding assistance. At 12:56 p.m. Resident #58 ate 50% of his meal which consisted of puree meat, vegetable, and mashed potatoes and drank 12 ounces of coffee. The meal ticket was not sent up with the tray and CNA #5 was unable to report what specifically was on the tray. The meal did not consist of any additional items that were provided by the resident's representative. Tray line was observed on 3/14/22 at 11:32 a.m. Resident #58's meal was plated at 12:13 p.m. The meal consisted of puree chicken, broccoli, and rice. The meal was plated from the steam table. The meal did not consist of any additional items that were provided by the resident's representative. Resident #58 was observed in his room on 3/14/22 at 12:35 p.m. CNA #4 entered the room with the lunch meal and provided feeding assistance. CNA #4 finished providing assistance at 1:08 p.m. CNA #4 said he ate about 50% of his meal and drank 24 ounces of water. She said she was unsure what the puree meal was. She said Resident #58 required total assistance for meals and needed assistance with drinking because he had contractures. On 3/14/22 at 2:16 p.m. the homemade meals from Resident #58's representative were observed in the walk-in refrigerator located in the main kitchen. Ten containers of puree meals were observed. Dietary aide (DA) #1 said the resident's representative provided food the resident liked and it was prepared and sent to the unit in conjunction with the regular meal for both lunch and dinner. She said it was the cooks' responsibility to send it and she was unsure why it was not sent on that day. VI. Record review The March 2022 weights revealed the following: -93.6 lbs. on 11/9/21 -94.4 lbs. on 11/23/21 -90.6 lbs. on 12/7/21 -81.9 lbs. on 1/11/22 -80.5 lbs. on 1/16/22, 13.1 lbs. weight loss, 14.0% over two months -85.0 lbs. on 1/24/22 -86.3 lbs. on 2/13/22 -83.2 lbs. on 2/27/22 -83.2 lbs. on 3/2/22 -84.1 lbs. on 3/10/22, 9.5 lbs weight loss, 10.1% since admission over four months. -The resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The initial nutritional assessment was completed on 11/15/21. It indicated Resident #58 was on a ground meat texture diet with thin liquids. It indicated the resident received medical nutritional support with Med Pass supplemental shakes of 120 milliliters three times a day. It indicated the resident's weight was 93.6 lbs (pounds) and he was 63 inches tall, his BMI was 16.6 (underweight) and ideal body weight was indicated at 103-127 lbs. It indicated meal intakes were 51-75%. The quarterly nutrition assessment was completed on 2/7/22. It indicated Resident #58 was on puree diet texture with thin liquids. It indicated Resident #58's most recent weight was 85 lbs. It did not indicate if a significant weight change had occurred as nothing was marked on the assessment. It noted Resident #58's intake had improved since admission to 75% and greater and his family brought in food for him. -There were no additional nutrition assessments by the RD when the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The nutrition care plan, revised 1/18/22, was reviewed. It indicated Resident #58 had ongoing weight loss since admission and intake less than estimated needs. Interventions included: assistance with eating and drinking, preferences for Mexican food, potatoes, and soup as well as food brought in from family, puree diet, monitor weight per facility protocol and supplements as ordered. Progress notes from 11/8/21-3/15/22 were reviewed and revealed the following: On 11/12/21 a progress note was completed that indicated Resident #58 did not wear dentures and had difficulty chewing food. No coughing or swallowing difficulties were observed. On 12/29/21 a progress noted was completed that indicated Resident #58 only ate a few spoonfuls of both breakfast and lunch. It noted the resident did not verbalize if he wanted an alternative meal. It indicated the physician was notified of recent weight loss and physician mentioned a feeding tube may be indicated. On 1/7/22 a progress note was completed that indicated Resident #58 had poor intake and appetite at date. It noted he consumed three to four spoonfuls of breakfast and lunch and required prompting to open mouth and take medications during shift. It indicated intake of fluids was fair. On 1/11/22 a progress note was completed that indicated Resident #58's family brought in three meals and were left in the unit refrigerator. On 1/11/22 a progress note was completed that indicated Resident #58 reported difficulty swallowing both liquids and solids. It noted a CNA confirmed resident coughed on occasion with both liquids and solids and the nurse reported no difficulty with swallowing medications. The note indicated the physician was notified of weight loss and a swallowing evaluation was requested. On 1/12/22 a progress note was completed that indicated the resident's representative was notified of decreased intake. The note indicated the family reported they would continue to bring in food for the resident. On 1/15/22 a progress note was completed that indicated the resident's representative reported they were only interested in a feeding tube if it becomes necessary. On 1/16/22 a progress note was completed that indicated the resident's representative provided eight containers of pureed meals and were left in the walk-in refrigerator to be provided with lunch and dinner. On 1/17/22 a progress note was completed that indicated a weight warning of -5.0% change over the past 30 days. It indicated the results of a calorie count were available with average meal intake of 227 kilocalories and 7.3 grams of protein. It indicated the physician was notified of these results and the family was aware of current weight. It indicated the resident was at risk of continued weight loss and his current intake was not meeting estimated needs at this time. -However, no interventions were put in place when the resident had additional weight loss. The family were supplying meals as early as 1/11/22. On 1/18/22 a progress note was completed that indicated a CNA reported 100% intake of a lunch meal and the resident consumed all of the Med Pass as ordered. It indicated there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/28/22 a progress note was completed that indicated an increase in weight up 3% from previous with an improved appetite. It indicated the family continued to bring in food for the resident and he continued to take [MEDICATION(S)] for appetite and Med Pass supplements three times a day. -The [MEDICATION(S)] was ordered 12 days after the resident had a 13.1 lbs weight loss since admission to the facility. On 2/18/22 a progress note was completed that indicated an increase in weight up 5% over the past 30 days. It indicated the resident continued to eat well at meals and family continued to bring in meals. On 3/10/22 a progress note was completed that indicated a decrease in weight. It indicated weight fluctuated between 80-86 lbs. over the past two months. It indicated his intake was 50-100% of meals. It noted the resident received 120 milliliter of Med Pass supplement three times a day and staff assisted with meals, snacks, and supplements. -However, there were no additional nutritional interventions, the [MEDICATION(S)] medication and nutritional supplements were not evaluated when the resident started losing weight 2/27/22. On 3/13/22 a progress note was completed that indicated the resident had an elevated temperature and emesis and was sent to the emergency room for evaluation. On 3/13/22 a progress note was completed that Resident #58 returned from the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was prescribed [MEDICATION(S)] 500 milligrams every eight hours and [MEDICATION(S)] 100 milligrams two times a day. On 3/14/22 a progress note was completed that indicated the resident returned from the hospital after being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] The meal intakes were reviewed for 2/15/22-3/15/22. The intakes indicated the resident was typically consuming 50-100% of meals. -However, resident observations above indicate the food and snacks that the family representative provided were not included at meal time, with his intake estimated at 50% on 3/10/22 and 3/14/22. The director of therapy (DOT) provided physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The orders were faxed to the home health care provider on 11/18/21. Review of March 2022 CPO revealed the following: -House supplement, frozen, three times daily for malnutrition ordered 11/8/21 and discontinued 1/18/22; -A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -Regular diet, puree texture, and thin liquids ordered 1/18/22; -2 Cal Med Pass three times a day for malnutrition ordered 1/18/22; -[MEDICATION(S)] tablet of 7.5 milligrams one time a day for poor appetite ordered 1/28/22; and, -Weekly weights every Wednesday for weight loss ordered 2/3/22. The DON provided the hospital notes on 3/15/22 at 12:04 p.m. The notes indicated the resident was seen at the hospital on 3/13/22 with concerns related to cough, shortness of breath, and fever. The notes indicated the resident was on supplemental oxygen upon arrival though it noted the resident did not wear supplemental oxygen at baseline. The notes indicated the resident was on two liters of oxygen and was at 85% oxygen saturation. The staff increased to four liters and the resident reached normal oxygenation. The notes indicated pneumonia was observed on x-ray and the resident was able to be titrated back to room air. Specifically, the notes from the chest x-ray indicated patchy airspace disease in the right midlung. He was started on antibiotics including [MEDICATION(S)] and [MEDICATION(S)]. The director of therapy (DT) provided the speech therapy evaluation and plan of treatment on 3/15/22 at 2:00 p.m. The evaluation indicated the resident had mild oropharyngeal dysphagia (swallowing problems occurring in the mouth and throat). Recommendations included to continue with puree texture and thin liquids. Carryover of swallowing techniques included alternating liquids and solids, modification of size of bite, using tongue to clear oral cavity, upright position for all meals, and monitoring signs and symptoms of aspiration including coughing and throat clearing, changes in respiratory symptoms, and fever. -The speech therapy evaluation was completed on 3/15/22 despite the initial referral for evaluation on 11/17/21. In addition, the MBSS test for his swallowing trouble was ordered on 1/18/22. The MBSS test was not completed by the survey exit on 3/15/22. VII. Staff Interviews Licenced practical nurse (LPN) #3 was interviewed on 3/14/22 at 9:14 a.m. She said Resident #58 had a fever and emesis on the previous day and there were concerns for aspiration. She said he was sent to the hospital for evaluation and it was determined he had pneumonia and an urinary tract infection. The registered dietitian (RD) was interviewed on 3/15/22 at 9:23 a.m. She said Resident #58 had experienced weight loss since admission and from conversations with the resident's family, he was losing weight prior to admission. The RD said an intervention she added was Med Pass supplements three times a day on 1/18/22. -However, per the nutrition assessment 11/15/21, the resident was supposed to be receiving Med Pass three times per day to meet his estimated nutrition needs and this was not a new intervention when the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] She said Resident #58's family also brought in food for him which was to be served in addition to his lunch and dinner. She said she did not know why he was not served the extra food on 3/14/22 and confirmed it was in the walk-in refrigerator. She said he was not served the additional food on 3/10/22 because staff had served all the extra meals the family had brought in at that time. -However, during the 3/14/22 observation the resident had 10 containers in the refrigerator to provide to the resident and the staff did not provide him with the additional meals from the representative on 3/14/22 (see observation above). She said she did not believe Resident #58 had difficulty with swallowing. She said Resident #58 was admitted to the facility on a ground texture and was now on a puree texture. She said she did not know who downgraded his diet but it was changed on 1/18/22. She said if there was a swallow evaluation the DON may have notes. She said nursing staff may downgrade a diet and the speech-language pathologist would follow up later. She said his current diet was regular with puree texture and thin liquids. -However, the progress notes indicated the resident had difficulty swallowing with his meals and speech therapy and swallowing tests were ordered. She said she felt comfortable with the interventions the team had put into place related to weight loss and would speak to staff to ensure the meals the family brought in were served in addition to facility meals. She said she met with the DON once a week to discuss residents with weight changes. She did not indicate if she met with the interdisciplinary team. The DON was interviewed on 3/15/22 at 10:17 a.m. She said information related to a referral for a swallow evaluation was given to the director of therapy. She said Resident #58 had been observed coughing during meals and a nurse downgraded his texture to puree. She said nursing staff would downgrade a diet and have the speech-language pathologist follow up, as this was typical. She said the modified [MEDICATION(S)] swallow study (MBSS) was ordered because a feeding tube had been mentioned by the physician at one point due to weight loss. She said it did not fall on nursing staff to schedule the swallow evaluation. The DOT was interviewed on 3/15/22 at 10:40 a.m. He said he handled scheduling therapy evaluations as well as outside therapy-related evaluations such as a MBSS. He said the RD came to him and asked for Resident #58 to have a MBSS and the order was put in on 1/11/22. He said the physician did not sign the order until 1/30/22 and he was not notified the physician signed. He said since he was not notified, he did not follow up. He said Resident #58 had orders for a speech therapy evaluation dated 11/17/21 and he sent it out to the therapist that worked with the resident's payor source. He said he was told that the therapy company did not have a speech-language pathologist, so the evaluation was not completed. He said the facility's speech-language pathologist was going to see Resident #58 later that day. The DON was interviewed again on 3/15/22 at 2:40 p.m. She said she could not determine if the resident had aspiration pneumonia since the hospital notes indicate pneumonia. VIII. Facility follow-up The primary care physician was interviewed on 3/23/22 at 2:20 p.m. He said he had placed orders for speech therapy and a modified [MEDICATION(S)] swallow study for Resident #58, though he was unsure of exact dates when orders were placed. He said the resident had not been eating well since he was admitted to the facility. He said the resident's intake increased when he ate with his family or ate food the family brought in.

Based on observations, record review and interviews, the facility failed to ensure residents receive proper treatment and care to maintain vision for one (#46) of two residents reviewed for vision services out of 32 sample residents. The facilities failure to obtain vision specialist documentation and failure to implement recommendations from the specialist visit in March 2020 resulted in Resident #46 sustaining a decline in vision. Resident #46 who had a known [DIAGNOSES REDACTED]. The facility failed to ensure the specialist recommendations that were given in March 2020 were followed through and Resident #46 was not given weekly injections as recommended. Residents #46 sustained further eyesight decline from March 2020 to current date resulting in active choroidal neovascular membrane (growth of new blood vessels in the choroid) for both eyes along with presentation of retinal scar tissue. The facility's failures took away the resident's enjoyment of painting and watching television. Findings include: I. Facility policy and procedure Review of the Vision and Hearing Assistive Devices policy, dated 6/8/2020, provided by the director of nurses (DON) on 1/13/21 at 2:00 p.m. revealed in part Ensure residents receive proper treatment and assistive devices to maintain vision and hearing abilities. Review of the journal article by Agarwal, Aniruddha et al. An update on [MEDICAL CONDITION] choroidal neovascularization: epidemiology, multimodal imaging, and management. Journal of ophthalmic inflammation and infection vol. 8,1 13. 12 Sep. 2018, doi:10.1186/s -018-0155-6, revealed in part The most common cause of choroidal neovascular membranes (CNV) in the elderly is age related [MEDICATION NAME] degeneration .Given the propensity of untreated CNV to result in rapid irreversible central vision loss, the importance of characterizing risk factors for CNV and prompt [DIAGNOSES REDACTED]. II. Resident status Resident #46, age 72, was admitted on [DATE]. According to the January 2021 computerized physician orders [REDACTED]. [MEDICATION NAME] degeneration was not included in the list of diagnoses. The 12/10/2020 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. Vision was marked as adequate. Corrective lenses were marked as no. -The MDS was not accurate to include current vision deficiencies. The inaccurate information in the MDS resulted in the facility failure to initiate a care plan for the resident's care and services related to vision. III. Interviews An outside agency staff member was interviewed on 1/11/21 at 4:01 p.m. He said this resident had an eye appointment back in March 2020 for [MEDICATION NAME] degeneration. He said the vision specialist had recommended eye injections which were never completed. He said this resulted in full eyesight [MEDICAL CONDITION] for Resident #46. Resident #46 was interviewed on 1/11/21 at 4:08 p.m. He said his eyesight was bad. He said he went to the doctor last week and would be going again for a follow up visit in a month or two. A family member was interviewed on 1/13/21 at 10:29 a.m. She said she had been trying to get this resident to see a vision specialist since 2018. She said she had talked to the physician, nurse and social services. She said Resident #46 had inflamed eyes. She said she told them the saline eye drops were not working and needed to see a specialist. She said his eyes had gotten worse. She said the staff told her they would bring someone in to look at his eyes and it was not done. She said in July 2020, she had received an invoice from an eye specialist. She said she did not know about any eye specialist appointment. She said she contacted social services and they told her this appointment was not in the medical chart. She said she received another invoice in November 2020. She said she called the eye specialist about the invoice. She said she told the eye specialist that the facility told her Resident #46 did not have that appointment. She said the eye specialist told her they had a detailed report for the resident visit back on March 6th. She said Resident #46 had a new appointment this month and that was when she got the documentation from the March 2020 visit. She said Resident #46 was supposed to get eye injections after his March 2020 visit to help stop the progression of [MEDICATION NAME] degeneration. She said in March, the resident had shown initial signs of [MEDICATION NAME] degeneration, but nothing was done. She said his eyesight progression led to almost complete vision loss in that one eye. She said the resident's only pleasure was painting and watching television (TV). Resident #46 was interviewed again on 1/13/21 at 1:55 p.m. He said he used to have glasses a long time ago. He said he painted every day and was observed to have been watching TV. He said his eyesight was worse and blurry so was unable to see what things were. He said What else can I do? IV. Record review of specialist reports that were not in Residents #46's chart during the time of the survey. An eye specialist visit was completed in March 2020 which revealed the resident had decreased visual acuity and both eyes were dry. The resident was noted to have exudative (fluid leakage) age related [MEDICATION NAME] degeneration in his right eye with active choroidal neovascular membrane. The resident had a benign neoplasm (abnormal growth) in his right choroid. The resident was recommended to have an injection in one week. -Recommendations from the eye specialist were not done. This resident's right eye declined to exudative with active choroidal neovascular membrane from January to March 2020 reports. The facility did not receive this report until the survey period resulting in physician orders [REDACTED]. The next eye specialist visit was not completed until in January 2021 which revealed the resident stated the vision in his right eye was black for the past six months. The resident had blurred vision in his left eye. He had exudative age related [MEDICATION NAME], bilateral, with active choroidal neovascularization. He had large retinal scar tissue present in his right eye and smaller retinal scar tissue present in his left eye. The resident was recommended to receive follow-up injections. -This resident's eyes declined further to exudative, active choroidal neovascular membrane for both eyes along with presentation of retinal scar tissue from March 2020 to January 2021 reports. The facility did not receive this report until the survey period. V. Additional record review current during survey The medical chart was reviewed during the survey and did not contain the eye specialist reports for the visits in March 2020 and January 2021. Physician notes were reviewed and did not contain any mention of [MEDICATION NAME] degeneration. No careplan for vision was found in the residents record. Review of the January 2021 CPO revealed: -Order date: 10/30/18: May have dental, podiatry, audiology, optometry care as needed. -Order date: 1/3/19: Artificial tears solution 0.4%: Instill one drop in both eyes four times a day for dry, red eyes. Review of the January 2020 Optometrist report revealed: -Plan and Treatment: 1) Retinal [MEDICAL CONDITION], nonexudative (dry) age-related [MEDICATION NAME] degeneration, bilateral, intermediate dry state, Drusen- (small, yellowish deposits of cellular debris) ([MEDICAL CONDITION]) of macula, bilateral- [MEDICATION NAME] degeneration- both eyes (OU)- with mild drusen without choroidal neovascular membrane (growth of new blood vessels in the choroid)- OU- [MEDICATION NAME] right eye (OD) noted today- refer for retinal eval .- monitor six months/ as needed (prn). 2) Age related nuclear cataract, bilateral- [MEDICAL CONDITION]- OU- mild/stable- not visually significant- no treatment indicated at this time- monitor six months. 3) [MEDICATION NAME] supplements help reduce the rate of age related [MEDICATION NAME] degeneration (AMD) progression or advanced AMD one eye .4) Dry eye syndrome- currently using tear therapy- continue artificial tears four times a day (QID)- poor adherence to meds and poor candidate for other treatment as previously attempted OU- monitor in three months/ prn. Physician orders: Please schedule retinal specialist evaluation . Review of the March 2020 eye specialist report, faxed 1/12/21 at 5:09 p.m., revealed: -Glasses: Yes -History of present illness: Patient states visual acuity (VA) is reduced right eye (OD) > left eye (OS). Patient states that OS>OD have been red for at least two years. Patient states both eyes (OU) feel dry . -Impression/ Plan: Assessment: Exudative (fluid leakage) age related [MEDICATION NAME] degeneration, right eye, with active choroidal neovascularization. Assessment: Nonexudative (dry) age related [MEDICATION NAME] degeneration, left eye, intermediate dry stage. Assessment: Benign neoplasm (abnormal growth) of right choroid .Plan: Encourage diet rich in green leafy vegetables and two servings of fish/ week; encourage .formulation eye supplements; encourage patient not to smoke cigarettes; discuss use of Amsler grid weekly and to notify us of any changes; treat with Lucentis 0.5 in one week. -These recommendations from the eye specialist were not done. This resident's right eye declined to exudative with active choroidal neovascular membrane. This documentation was not in the residents record see director of nursing (DON) interview below. Review of the January 2021 eye specialist report, faxed 1/13/21 at 3:18 p.m., revealed: -Glasses: Yes -History of present illness: Patient presents today for retinal evaluation. Patient notes vision OD has been black for the last six months and notes very blurred vision OS. Patient denies any eye pain roday OU. Patient denies any new flashes or floaters in either eye today. Patient's OU have been very red and gooey for the last two years. -Impression/ Plan: Assessment: Exudative age related [MEDICATION NAME] degeneration, bilateral, with active choroidal neovascularization. Assessment: Age related nuclear cataract, bilateral. Assessment: Benign neoplasm of right choroid. Plan: Patient presented 3/2020 with exudative age related [MEDICATION NAME] degeneration (EAMD) right eye and intermediate EAMD left eye was scheduled for Lucentis 0.5mg right eye following week, but lost to follow -up since. Today re-presents with large disciform scar (retinal tissue is replaced with scar tissue) right eye and worse subretinal fluid as well as new smaller disciform scar left eye with new subretinal fluid. Guarded prognosis for visual rehabilitation, but treatment indicated to prevent further loss of vision. Start treatment today with intravitreal anti-vascular endothelial growth factor (VEGF) injections. Lucentis 0.5 mg OU treat and extend discussed with patient and sister (power of attorney) post injection instructions given to patient/sister .Follow up: four weeks. This resident's bilateral eyes declined to exudative, an active choroidal neovascular membrane with the presentation of retinal scar tissue. VI. Staff interviews The DON was interviewed on 1/12/21 at 11:26 a.m. She confirmed the March 2020 eye specialist documentation was not in the medical chart. She said the resident's family member was going to be faxing it over. The social services director (SSD) #1 was interviewed on 1/12/21 at 1:22 p.m. She said they used to have an in-house service but they now work with the transport coordinator (TC) to schedule any needed appointments. She said paperwork usually came back with the resident, after appointments. The SSD #2 was interviewed on 1/12/21 at 1:31 p.m. She said if a resident needed an eye appointment, they would schedule with the TC. She said the TC would go with the resident to the appointment and get any paperwork. At 3:19 p.m., she said any documented refusals from the resident were shredded and unavailable. She said something happened on that March 2020 appointment and the resident did not want the doctor to do anything with him. She said this resident was receiving some eye drops. The DON was interviewed again on 1/13/21 at 9:23 a.m. She said she did not know who at the facility was in charge of ensuring they received the eye specialist reports. She said they would usually fax the documents to the facility. At 10:03 a.m., she said when this resident left the facility, his family would meet him at the appointment with the TC. She said the TC would have received the paperwork from the physician. She said she talked to registered nurse (RN) #3 and he said he only received a handwritten note from the family. The DON confirmed the nurses could have called the eye specialist for the reports. She said she did not realize this was not done. -At 10:12 a.m. she said she just received the documentation from the eye specialist visit from March 2020. She acknowledged there were some items that should have been put in as orders. She confirmed the orders and recommendations from the eye specialist were not done. RN #3 was interviewed on 1/13/21 at 10:56 a.m. He said the residents would have given the nurse their paperwork when they got back from appointments. He said if the resident did not receive the documents, then the TC would. He said this resident had an appointment the previous week. He said they only received a note from the family, a post injection care note and a grid. He said no other information was received. The DON was interviewed for a third time on 1/13/21 at 11:30 a.m. She said the resident had gotten the flu in March 2020. She acknowledged again they did not receive the orders from his March 2020 appointment. She said he had the flu the following week. She said the TC went to the March 2020 appointment with the resident. She said the resident was very upset during the appointment and maybe that was why the paperwork was missed. She confirmed the family had contacted the social worker (SW) regarding the invoice she received and there was no noted appointment scheduled. She said the only documentation they received after the January 2021 appointment was an appointment follow up date and a grid. She acknowledged the process needed improvement. She said she was going to initiate a communication envelope for outside appointments. She confirmed the facility needed the documentation from the doctor's office. The TC was interviewed on 1/13/21 at 12:23 p.m. She said back in March 2020, she had received a stack of referrals from the optometrist and she had put in a referral to a specialist. She said she did take him to the appointment. She said they usually gave the paperwork to her, the resident or they faxed it to the facility. She said the resident got upset when they were talking about a follow up appointment. She was unable to remember the paperwork. She said the resident's family met them at the January 2021 appointment. She said she remembered the family had paperwork and she had assumed the family was going to give to the doctor. She confirmed there was no consistent procedure for the paperwork after a doctors appointment. The MDS coordinator (MDSC) and DON were interviewed on 1/14/21 at 9:39 a.m. They said the MDSC was not full time and the MDSC had other duties along with MDS. The MDSC said she gathered her information from talking to the resident, nursing and family if the resident could not communicate. She said social work usually completed the vision section. She said she thought Resident #46 received eye drops. She said she was not aware of this resident having any vision problems. The DON acknowledged that they had missed follow ups resulting in information not available in the chart. She said there were no calls from the eye specialist to the physician. The DON acknowledged there was a breakdown in the process and they planned on correcting it. She said the eye specialist documentation was currently in the resident's chart and the resident's physician was currently informed of everything.

Based on record review and family/resident/staff interviews, the facility failed to ensure two (#1 and #2) of four sample residents received adequate supervision and assistive devices to prevent accidents. Specifically, the facility: 1. Failed to secure a physician's order prior to administering electrical stimulation treatment (EST) to resident #2's left lower extremity (LLE). -The resident sustained [REDACTED]. -Physician notification was delayed. -Nursing initiated treatment without physician orders. -Later when the physician was notified, the physician changed the treatment. -The facility failed to re-train all nursing staff regarding timely physician/family notification related to injuries. -The resident was overheard notifying her family of her injuries. 2. Failed to ensure resident #1 did not sustain injuries to his stump while trying to position himself at the dining table. The facility failed to consistently implement identified staff supervision (specifically higher table and compression device ... for sample resident #1 after ... on 6/8/10). The resident ran into the table again without identified intervention in place on 2/3/11, sustaining additional stump injuries without initiation or implementation of addition precautions. The findings include: A. Administration of EST resulting in 2nd degree burns for resident #2. Resident #2's closed medical record was reviewed. The resident was [AGE] years old. The resident was originally admitted to the facility for rehabilitation treatment on 11/6/10, status [REDACTED]. The resident was discharged to home on 12/10/10. According to the 12/10 computerized physician's orders (CPO), the resident had [DIAGNOSES REDACTED]. According to the Initial Data collection tool, dated 11/6/10, the resident had no short-term or long-term memory problems and the resident was independent with daily decision-making. The resident was able to communicate her needs. The resident was able to reposition herself in bed and needed standby assistance only for ambulation. The resident used a wheelchair for mobility and understood the need for waiting for assistance. The resident needed assistance of one staff for toileting, dressing and hygiene. The resident was continent of bowel and bladder. The resident had lacerations and a recent incision. The resident had acute and chronic pain daily. Review of the computerized physician orders (CPOs) and telephone orders (TO), dated 11/10 through 12/10, revealed there was no documented evidence of orders for EST. Review of a pain management care plan revealed no indication of EST as an intervention for the resident's pain management. Review of PT notes and a Witness interview statement form, dated 11/14/10 both indicated the patient was treated with EST for pain and sustained burns related to the treatment. The Witness interview statement form revealed the incident occurred on 11/14/10 at 9:30 a.m. Review of PT notes, dated 11/14/10 at 12:58 p.m. read, in pertinent parts, "Performed IFC (EST with interferential current) X (for) 8 minutes with constant attendance for decreasing (L) left knee pain. Patient (resident #2) did not report any discomfort during the treatment." However, review of physician orders revealed no indication of EST for the resident. PT notes for that date further read, "After removal of 2 of the electrodes, this therapist (PT) noted burn marks on patient's skin. Notified nursing immediately. Patient denies pain, but stated it felt like a burn. Recommended d/c (discontinue) of e-stem (EST)," although review of CPOs and physician TOs, dated 11/10 through 12/10, revealed no orders for initiation or d/c of EST. A typed form completed by the PT who performed EST, dated 11/16/10, read in pertinent parts, "On November 12, 2010, I (PT) reviewed (name of resident #2's) noting that she had a right transfemoral amputation and had limited with standing tolerance due to left knee pain. I (PT) entered (resident #2) at approximately 8:45 a.m. to start therapy. I (PT) asked if she still had knee pain. (Resident #2) reported she did have knee pain and was taking pain medications. I suggested that we also try electrical stimulation for decreasing the left knee pain. I explained the treatment to (resident #2) and asked if she had a pacemaker or a history of cancer. (Resident #2) reported that she did not have a pacemaker, but stated she had [DIAGNOSES REDACTED] many years ago. (Resident #2) agreed to the treatment." Again, there was no indication that the resident's physician ordered EST or that the physician was consulted regarding EST for the resident's pain management. Those PT notes further read in pertinent parts, "I turned the electrical stimulation unit on, asking (resident #2) to notify me when she first feels tingling and then tell me when it is/was comfortable for her. When (resident #2) stated the sensation was comfortable, I started the treatment. I stayed with (resident #2) throughout the treatment ... (Resident #2) stated she was not feeling the treatment as much as she did initially, so I turned the intensity up slightly and (resident #2) stated she could not feel it again ... (Resident #2) mentioned she had an infection in her left extremity and also stated her pain had decreased to 4 out of 10. Because of these two factors, I decided to stop the treatment early after 8 minutes of treatment. When I removed the electrodes, I noted a blackened area about 1.5 cm in length where the upper medial electrode had been and five blackened areas where the upper lateral electrodes had been ... (Resident #2) reported no pain over the area of irritation, denied any discomfort, but run her fingers over the area and stated it felt like burn. I immediately notified two nurses (the RN and LPN) of the blackened areas. Both nurses responded immediately and inspected the area ... At the conclusion of physical therapy treatment, this therapist inspected the blackened areas again ... the areas appeared unchanged." The notes further indicated that on 11/17/10, the PT included more information regarding the incident, which read in pertinent parts, "(PT name) forgot to mention two issues that were relevant to the case ... When (PT name) initially started the Electrical Stimulation procedure the machine showed an error message of 'overcurrent' which caused the machine to terminate the session immediately as a safety precaution ... At second attempt to start the procedure the machine no longer showed any error messages and the treatment was started without any indication of possible problems." The form further read, "On 11/15/10, (PT name) confirmed she had used electrodes for the electrical stimulation procedure on (resident #2) that had been used on another patient before," which was an infection control issue. A form entitled Corrective Action Form, dated 11/16/10, read in pertinent parts, "On 11/14/10 a patient (resident #2) developed a burn wound on her left leg resulting from the application of Electrical Stimulation provided by (PT name) ... she used electrodes that had been used on another patient ... She (PT) failed to adequately ensure that good contact between electrodes and patient's dry skin. Further (PT name) failed to write a clarification order (no physician orders were obtained prior to administration) in the chart to notify that Electrical Simulation was added to the patient's treatment plan." The form indicated that it was a second warning. Although the resident suffered burn injuries on 11/14/10, between 8:45 a.m. and 9:30 a.m., with breach of infection control issues, the PT, LPN and RN were aware of the resident's injuries, there was no indication that the resident's physician (MD) or Medical Power of Attorney (MPOA) were notified of those injuries until 6:00 p.m., that night. In fact, the LPN initiated treatment without physician orders as she indicated in an interview on 2/7/11. Registered nurse's (RN) notes, dated 11/14/10 at 4:45 p.m., more than seven hours after the resident sustained [REDACTED]. (daughter) notified of physical therapy tx (treatment) this morning. Res received electrical stimulation (EST) with Interferential current X 8 mins (for 8 minutes) to (R) knee. Upon removal of electrodes, Res sustain a total of 7 burns, raised black areas, 1/4-1/2 cm. Res denies pain to site. Res ate well. F/U (follow up) ... (with) PT on Mon (Monday) 11/15/10." Furthermore, a letter, dated 11/16/10, from that RN (who was notified of the incident of 11/14/10) to the DON read in pertinent parts, "I just happened to be on the floor when (PT name) informed (LPN name) that (resident #2) had sustained a burn from the electrodes during her therapy. I (RN) went with (LPN name) to assess the site. We (RN and LPN) noted 3-4 separate burn sites on both the lateral and medial side of the resident's left knee ... I informed (PT name) that she would have to write a statement of the incident since she told me she would not be responsible for IDA (incident reporting report). This all (incident) happened at 930 (9:30 a.m.), but I did not get the report late afternoon (4:45 p.m., as indicated by nursing notes written by the RN). LPN had notified the physician (6:00 p.m., as indicated by LPN notes on that date) and obtained a treatment order, but had not notified the daughter. I spoke to the daughter and completed the IDA, nursing notes ... care plan and pain assessment around 1700 (5:00 p.m.) after I read (PT name) statement." Licensed Practical Nurse (LPN) notes, dated 11/14/10 at 6:00 p.m., eight and 1/2 hour after the resident suffered burn injuries from EST, read in pertinent parts, "Notified (physician's name) of resident sustaining sm (small) burn areas to above knee as previously noted (per RN notes at 4:45 p.m., on that date) - ordered to cleanse & apply dry dsg (dressing) ... (change) PRN (as needed ... to monitor for blistering or any open areas. No open areas at this time ... no acute ... (changes) ... Addendum - Left msg (massage) for wound RN (nurse) to see res (resident)." Staff interviews: On 2/7/11 between 3:00 p.m. and 3:30 p.m., the LPN was interviewed in presence of the Assistant Director of Nursing (ADON). In the interview, the LPN acknowledged that she failed to notify the MD of the resident's injuries in a timely manner. The LPN stated, "Usually I notify the MD immediately but I did not notify the MD until later that afternoon (6:00 p.m., according to LPN notes dated 11/14/10) ... The nurse supervisor (NSRN) was there when PT told me (according to NSRN letter dated 11/16/10, PT notified NSRN and LPN of resident's burns at about 5:00 p.m. on that date) ... The supervisor did not notify the MD (at time 5:00 p.m.) ... The expectation is that MD and family be notified as well ... I was waiting for the PT statement before notifying the MD ... to know exactly what happened before calling the MD ... I was expected to call the MD and get an order ... I never called the MD immediately (called MD at 6:00 p.m. see LPN notes) ... The resident called her family herself ... I did not call the family." The ADON clarified that it was the responsibility of nursing staff to timely notify the physician, of resident injuries. On 2/7/11 between 4:00 p.m. and 4:30 p.m., the Restorative Manager PT (RMPT) was interviewed in the presence of the ADON. The RMPT stated, "there were no physician orders to use electrical stimulation when the PT applied treatment to the resident ... Treatment requires physician orders ... PT/OT orders must be clarified with MD ... It was a mistake by PT (application of EST) ... It was PT error ... investigation indicated no malfunction of equipment ... all staff was educated ... nursing was educated to report incidents timely." During that interview, the RMPT gave the surveyor documentation of the facility Quality Assurance and Performance Improvement Plan (QAPIP) regarding EST and burn management for therapy and nursing department. On 2/7/11 between 4:00 p.m. and 4:30 p.m., the surveyor reviewed the QAPIP in the presence of the ADON and RMPT. In pertinent parts the QAPIP read, "Observations ... Delay of notification of the MD, family and DON (Director of Nursing) ... Action ... Individual Education will be provided to the nurse on duty at time of occurrence ... Evaluation Method ... 1:1 (one on one education) ... Goal or Measure of Success and Date ... Completed 11/16/10 ... Education to all nurses on reporting guidelines for incidents and timely notification of MD ... Goal or Measure of Success ... Will be completed 11/19/10." The QAPIP further read in pertinent parts, "Observations ... Nursing documentation following incident does not provide detailed description of incident ... Action ... Education to all nurses on expected documentation in nurses notes following an incident ... Goal or Measure of Success ... Will be completed 11/19/10." The facility provided incidence management in-service materials and staff sign in sheets, dated 11/20/10. The 11/20/10 in-service meeting included incidence management training and read in pertinent parts, "IDA must be entered into computer ... Family notification required on all incidents. If the resident is their own MDPOA (Medical Power of Attorney) then you must ask the resident if they would like their family notified. You must chart the family was notified or wether or not the resident wants family notification (when the resident is their own MDPOA) ... Pain and Fall assessment sheets need to occur after each incident, regardless of the type of incident ... Update care plan immediately and include all interventions ... Time and date ... care plan with your initials ... Care plan and documentation must be timely ... continue follow-up charting for 72-hours ... All above actions must be documented when they are done." Thirty-six nursing staff (both RNs and LPNs) were identified for in-service, however, nine of those nurses reviewed no in-service by the end of the survey on 2/7/11. There was no documentation that indicated the nine nurses completed that in-service. The findings were shared with the ADON and RMPT during the meeting of 2/7/11 between 4:00 p.m. and 4:30 p.m. The ADON stated that she would look elsewhere to see if she could locate possible further in-service for nursing staff. In a subsequent interview with the ADON and DON on 2/7/11 at 6:30 p.m., the ADON stated, "I only had one incident management in-service for staff since the incident (EST resulting in burns for resident #2) ... I have not done extra incident management in-service for nursing ... We did the training together with (the DON). No further documentation was faxed after exit as requested. B. Resident #1 Resident #1 was originally admitted to the facility on [DATE]. The resident was [AGE] years old. The resident had [DIAGNOSES REDACTED]. According to the admission minimum data set (MDS), dated [DATE], the resident had no short or long-term memory loss and was independent with daily decision-making. The resident was understood by others and others understood the resident. He required supervision for bed mobility and transfers, and needed limited assistance or supervision with most activities of daily living. His primary mode of mobility was an electric wheelchair. The resident had no impairment with range of motion (ROM) in bilateral upper extremities and was impaired with mobility in bilateral lower extremities (BLE). Review of nurses' notes, dated 6/8/10, read in pertinent parts, "Pt (resident/patient) has abrasion on Rt (right) stump. Pt stated that he was trying to get under DR (dining room) table (resident trying to park himself at DR table, while in electric w/c) and hit stump. 0 s/s (no signs/symptoms) of infection noted, 0 drainage or pain observed. Dr's (MD) office called, family friend notified." Review of Incident follow up and recommendation form, dated 6/6/10, revealed that resident #1 had skin injury after he bumped his knee on a table in dining room, which resulted in a skin tear. The recommendations included in pertinent parts, "RECOMMENDATION/ACTION TAKEN: look at table ht (height) in dining room. Education to resident to ensure table ht is appropriate & careful not to bump into obstacles ... FOLLOW-UP: Resident would wear stump socks and education of benefits ... Skin tears has healed over ... (with) 0 issues Res (resident) wearing shrinkers to protect skin. Table ht adjusted." A witness interview/statement form, dated 6/9/10 at 9:30 a.m., about the incident of 6/8/10, indicated resident #1's interview read in pertinent parts, "I scraped my knee on the table, it was not high enough ... It's high enough now (6/9/10 at 9:30 p.m.) someone raised the table. I wear the shrinkers socks but right now I'm letting my scab air out but I will be leaving later and I'm going to put them on. I have two pairs but I could use two more pairs so I have a couple to change out and wash." Review of the care plan for falls, indicated that it was updated on 6/10/10 after the resident bumped into a DR table, then again on 6/25/10 and on 1/26/11. The care plan documented the following problems in pertinent parts: "resident at risk for injuries from falls due to decreased mobility and transfer, hx (history) of syncope and collapse ... pain to knees/at risk for injury r/t (relate to) safety awareness." The goal for the care plan indicated the resident was to remain free of (falls/injuries) through next review (4/19/11). The approaches to the care plan read in pertinent parts, "educating resident on w/c (wheelchair) use ... Educate him (resident#1) to fragile skin and encourage, and educated to importance of w/c gloves on 7/14/10. Resident educated on safely awareness on 6/10/10 ... Stump shrinkers to be worn BLE (bilateral lower extremities) as tolerated to Res (resident) ... 6/10/10. Resident educated about benefits of wearing shrinkers to stump & that this could help prevent skin tears... PT to eval (evaluate) tx (treat) to ...(increase) safety ... check table height to decrease ... (resident #1's) bumping into table - 6/9/10." The care plan further indicated that although the resident was generally alert oriented X3, the resident experienced cognitive changes related to dialysis and fluid imbalance. The care plan read in pertinent parts, "At times his (resident #1) confusion affects his short term memory." The goal indicated less distress from cognitive loss through 4/11/11. Approaches to the care plan read in pertinent parts, "Staff will remind (resident #1) of recent details when he is in distress due to confusion. Staff to observe for changes in cognition and report to nursing supervisor and social services." Resident Initial Interview: On 2/7/11 between 2:00 p.m. and 3:00 p.m., during a group interview for alert and oriented residents as identified and assembled by the facility, resident #1 stated, "I rammed into the DR table ... about two weeks ago ... I have a sore on the (L) knee ... The wound nurse (WCRN) has been caring for it ... I am diabetic and I have to be careful." Review of nurses' notes, dated 2/3/10 at 12:00 p.m., read in pertinent parts, "This resident told wound nurse (WRN) ... about he bumped a table ... (with) his (L) knee in the dining room last Friday (1/28/11). His small trauma wound (abrasion) size: 0.6 X 0.7 (cm) wound, bed (wound bed) dry ... with thin red scab, no drainage." Furthermore, review of nurses notes revealed no 72 hour follow up every shift as indicated by in-service of 11/19/10. Specifically, nursing documentation revealed the abrasion was initially observed on 2/3/11 at 12:00 p.m., then documented again on that date at 2:00 p.m. and 10:00 p.m. The abrasion was next documented on 2/4/10 at 1:45 p.m. By 2/7/11, the last nursing documentation was dated 2/4/11 at 10:30 p.m. and addressed no abrasion. There was no documentation that the abrasion was resolved by 2/4/11 at 1:45 p.m. (a period of about 25 hours after the injury was first noted). Although the WCRN initiated an acute care plan for wound care, there was no indication that an investigative process was initiated for follow up or identification of actions for prevention of further accidents, as indicated by the facility policy. There was no indication that the care plan was reviewed in regards to interventions to prevent further accidents with injuries when the resident positioned himself at the DR table after the 2/3/11 accident with injuries to the resident's stump. On 2/3/11, an acute care plan which only addressed the abrasion care was initiated after the resident suffered another abrasion to his knee while positioning himself at the DR table. In pertinent parts, the acute care plan read, "Problem: abrasion wound on (L) knee ... Goal Wound healed ... (without) infection ... Change wound dressing as Dr (MD) order ... Educate him (resident) of ... (increased pain ... measure wound ... weekly ... If wound condition not improving within 14 days need to report Dr." Although the Care plan addressed treatment of [REDACTED]. There was no evidence that indicated the facility followed up to see if identified precautions, specifically that the resident was still educated on w/c (wheelchair) use, that he was aware of his fragile skin that further education on safely awareness was provided. It was unclear if the resident consistently wore stump shrinkers to his BLE as identified in the care plan or if the resident was reminded about benefits of wearing shrinkers to stump for prevention of skin tears. Furthermore, there was no indication that PT was notified of the 2/3/11 incident for evaluation of the safety of the DR table height to decrease possible bumping into table. For a resident who was identified with confusion with short-term memory at times, there was no indication that staff was alerted to remind or supervisor of the resident regarding prevention of injuries related to DR table positioning. The investigative process for the 2/3/11 incident was requested from the facility on 2/7/11 and none was initiated as indicated by the facility in-service which was completed on 11/19/10. Observations: On 2/7/11 at 6:14 p.m., the DON observed the resident as up in his electric w/c, which was parked at the DR table. The DON interviewed the resident who confirmed that he had injured his stump after he ran into the table. The resident stated that when he ran into the table, the table was not high enough to clear the w/c last week. The resident stated that since then, the table was raised up and presently he was able to get his w/c under the table without bumping any of his stumps. The resident stated that he was not wearing his stump shrinkers at that time and had not worn them for a while. Staff interviews: On 2/7/11 at 4:00 p.m. and 4:30 p.m., the Restorative LPN (RLPN) in the presence of the ADON, stated that she was responsible for following up on all incidents. In the interview, the RLPN stated, "Incident reports are supposed to be completed immediately ... at the time of the incident or at least within 24 hours of the incident." The RLPN stated that they (other staff) called today at 3:00 p.m. regarding the incident in which resident #1 sustained a recent injury to his knee stump on DR room table. The RLPN stated, "It (incident) is not in the computer system (IDA) as of now (2/7/11). In that same interview on 2/7/11 between 4:00 p.m. and 4:30 p.m., the ADON stated, "No incident report was turned in on 2/3/11 regarding (resident #1) to make sure we follow up with investigative process so we start education. Action plan would be to educate nurses ... We would have followed up the next day (2/3/11) but there was no incident report in the computer for follow up." The WCRN was interviewed on 2/7/11 at 4:45 p.m., in the presence of the DON and the administrator (NHA). In that interview, the WCRN stated, "He came to me (on 2/3/11) and showed me the skin on his stump. He said last week in DR he bumped into the table while positioning his w/c so he could eat at the table. I notified MD ... I didn't know I had to complete an incident report ... Because I think it is a small wound, I usually think I can handle it." The WCRN stated she was pretty new to the facility. The WCRN acknowledged that she was not in-serviced in regards to completion of incident report or notification of other staff/family in regards to accidents or injuries associated with accidents. Furthermore, review of in-service records and staff interviews revealed that the WCRN was one of the nine facility nurses who received no in-service in regards to appropriate follow up of incident by 11/19/10 or 2/7/11 (exit date of survey). On 2/7/11 at 5:30 p.m., the DON was interviewed. In the interview, the DON stated, "When the nurse (WCRN) discovered the abrasion, she should have entered the incident into the computer system ... Follow-up would include asking for PT (physical therapy) evaluation (regarding table height and positioning of electric chair to avoid accidents with injuries) ... update care plan totally ... We need to educate all nurses." On 2/7/11 at 6:00 p.m., in the same interview with the DON and ADON, the ADON acknowledged that all nurses were not in-serviced regarding follow up of accidents and injuries as indicated by the facility QAPIP, which indicated that nursing staff education was completed by 11/19/10. On 2/7/11 at 6:20 p.m., in a subsequent interview the DON stated, "We will educate the WCRN on following up on incidents, specifically, reporting timelines and guidelines." On 2/7/11 at 6:25 p.m., in another interview with the RMPT, he stated, "After we were notified today, PT followed up on w/c mobility and safety ... We re-educated resident on being aware of objects around him."