Every finding on record at Bridgeview Center

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure that the residents environment remained as free of accident hazards as is possible by failing to 1) assess Resident #7 for smoking safety and 2) failing to supervise Resident #8 during smoking, from a sample of three residents reviewed for smoking, from a total sample of 7 residents who smoked.The findings include:1. On 8/4/25 at 3:45 pm, Resident #7 was observed smoking in the lobby. He was on oxygen via nasal canula, and his portable oxygen tank was at the back of his wheelchair. The receptionist was observed turning off the oxygen tank and removing the canula from the resident's nose. She then wheeled the resident to the designated smoking area near the lobby but left the oxygen tank at the back of his wheelchair.A clinical record review for Resident #7 indicated he was admitted to the facility on [DATE]. His diagnoses included Chronic Obstructive Pulmonary Disease (COPD), dementia, unspecified severity, with other behavioral disturbance, major depressive disorder, and recurrent, moderate.A review of the admission Minimum Date Set (MDS) with an assessment reference date (ARD) of 5/29/25 for Resident #7 indicated that he had a Brief Interview for Mental Status (BIMS) score of 08 out of 15, indicating moderate cognitive impairment. He exhibited physical and verbal behavioral symptoms directed to other. He also had other behavioral symptoms not directed to others.In an Interview on 8/4/25 at 3:50 pm, the Director of Nursing (DON) stated that that the facility was a smoking facility. She stated residents were allowed to smoke any time if they were deemed safe to smoke. She explained that residents were assessed for safe smoking on admission and quarterly. She was then directed to Resident #7 at the smoking area. She said, Oh my he is not supposed to have the oxygen tank, and he knows better. She walked to the resident and retrieved the oxygen tank. There were two other residents at the smoking area. The DON stated Resident #7 had another incident and was educated on safe smoking. He was notified to leave his wheelchair with oxygen at the lobby and walk to the smoking area. She was asked for a copy of the resident's smoking assessment.On 8/4/25 at 4:00 pm, the Regional Nurse consultant (RNC) provided the copy of Resident #7's assessment. He said, I'll be honest, there was a mistake the assessment indicates that the resident was not a smoker. He added that the facility would conduct a full house audit for smoking and initiate a performance improvement plan (PIP) on smoking. Review of the physician orders for Resident #7 dated 5/23/25 revealed the following:Respiratory-Oxygen: Encourage and assist resident to use oxygen at 2 Liters via nasal canula (NC) continuously for COPD.Respiratory-Oxygen Tubing Change: Change oxygen tubing/mask/bag weekly and as needed (PRN).Trazodone HCl Oral Tablet 100 milligrams (MG). Give one tablet by mouth at bedtime or Depression, Insomnia.Risperidone Tablet 0.5 MG- Give 1 tablet by mouth at bedtime for dementia, agitation.Risperidone Tablet 1 MG- Give 1 tablet by mouth in the morning for agitation, dementia.Duloxetine HCl Capsule Delayed Release Particles 30 MG- Give 1 capsule by mouth two times a day for depression.Lorazepam Tablet 0.5 MG- Give 1 mg by mouth three times a day for anxiety.A review of the care plan for Resident #7 initiated on 5/29/25 noted that the resident is at risk and/or have actual impaired cognitive function/impaired thought processes related to BIMS less than or equal 12 and diagnosis of dementia. The resident is at risk for altered respiratory status/difficulty breathing related COPD-Interventions included to Administer OXYGEN as ordered. Monitor O2 saturations as ordered/PRN. Change tubing per MD order and PRN. Notify MD as indicated. Resident #7 was not care planned for smoking. (Copy obtained) A review of the smoking assessment for Resident #7 dated 5/23/25 indicated that the resident did not smoke. (Copy obtained)Review of the interdisciplinary care plan meeting sheet dated 5/26/25 indicated that Resident #7 was educated on not taking oxygen outside to the smoking area due to risk of injury. Resident agreed to leave wheelchair and oxygen in the building. (Copy obtained) A smoking contract/policy was signed by the resident on the same day.2. A clinical record review for Resident #8 indicated he was admitted to the facility on [DATE] with re-entry on 5/10/25. His diagnoses included Sequelae of Cerebral Infarction, Moderate Protein-Calorie Malnutrition, gastrostomy status, iliotibial band syndrome, low back pain, critical illness myopathy, Vascular Dementia, Mild, With Anxiety, Unspecified Convulsions, Nontraumatic Subdural Hemorrhage, Unspecified and muscle weakness.Review of the physician orders for Resident #8 dated 5/10/25 revealed the following:Risperidone 1 mg by mouth two times a day for paranoia.Levetiracetam (Keppra) 100mg/ml. Give 5 ml via PEG tube every morning and at bedtime for seizure control.Valproic acid oral solution. Give 1000mg via G- tube at bedtime and 250 mg in the morning for mood disorder/ agitation.Review of the care plan for Resident #8 initiated on 11/25/24 indicated that the resident was at risk for complications related to chronic tobacco use. Nicotine dependence Encourage/remind resident to maintain smoking materials, including lighters, matches, etc. at the designated facility location. Offer and encourage the resident to utilize a smoking apron. Resident refused to utilize a smoking apron. Resident has a history of exhibiting the following behaviors: non- complaint with smoking apron, throwing things around including metal ashtray and calling residents by racial slurs. Revised care plan dated 3/15/25 indicated that the resident has a potential for activities of Daily Living ( ADL) self-care deficit related to ADL needs and participation vary, fatigue, chronic medical condition, dementia, impaired balance, history of cardiovascular accident (CVA).The Quarterly MDS with an ARD of 5/28/25 revealed that the resident had a BIMS score of 09 out of 15, indicating moderate cognitive impairment. Review of the smoking assessment for Resident #8 dated 5/10/25 section B (Mental and physical factors) noted that the resident had cognitive impairment and had dexterity/mobility limitations, therefore smoking supervision was required (Copy obtained).During an interview on 8/05/25 at 10:30 am, Resident #8 was observed in the hallway. He confirmed that he smoked unsupervised. He acknowledged that he had cigarettes in his pocket. However, he declined to answer if he had a lighter with him and self-propelled himself away.During a follow up interview on 08/05/25 at 11:16 am with the DON, she stated that residents are assessed on admission and quarterly. She said, All smoker are supposed to be safe smokers and do not require supervision. She mentioned that there were no designated smoking times, and smokers are supposed to give their smoking paraphernalia to the nurse after the smoking session. When asked how the nurses tracked the resident smoking paraphernalia's, she stated that the residents were educated to hand the over to the nurse after they were done smoking. She added that some residents were buying the smoking paraphrenias when they go out on LOA. She confirmed that there was no system in place to ensure that the residents do not possess them. She said, It's hard to track them since we cannot search them when they go out, it's their right, but we can revoke the smoking privilege if they don't follow the policy.On 8/5/25 at 1:05 pm, Certified Nursing Assistant (CNA) A was observed at the designated smoking area. She stated that she was asked to monitor residents as they smoke today. She mentioned that she had been in the facility for almost a year and residents were not supervised during smoking until today. She confirmed that Residents #7 and #8 were smoking cigarettes. She stated that she was not asked to take the smoking paraphernalia.A review of the facility's smoking policy tilted Smoking/vaping contract acknowledgement: updated on 1/27/2025 revealed the following:PURPOSE: To provide residents with the privilege of smoking/vaping and/or use of electronic smoking devices while maintaining their safety and the safety of others. Facility Policies:Resident smoking, vaping and/or use of electronic smoking devices is permitted only in the designated smoking area. All other areas of facility property are smoke free.2. All residents who smoke/vape and/or use electronic smoking devices will be assessed upon admission or at the start at such activity and as their cognitive and/or physical status mandates.3. Residents who require supervision will only use tobacco products and/or nicotine with supervision at the appointed smoking times (this includes electronic cigarettes). Residents who use tobacco products and/or nicotine with an electronic smoking/vaping device will have a care plan. 4. If determined the resident is unsafe when smoking and/or vaping, they will have supervision during such activity.5. Residents are to only smoke/vape the products that are purchased specifically for them. There is no borrowing or sharing of tobacco/nicotine products between Residents or Staff. If a Resident does not have tobacco products/nicotine they cannot smoke/vape.6. Tobacco products will be dispensed one at a time per resident request, with a limit of two cigarettes per supervised smoking break. Electronic smoking/vaping devices will be dispensed with prefilled cartridge.7. Absolutely no tobacco paraphernalia and/or tobacco products are to be kept in resident rooms. Electronic cigarettes, vaping devices including prefilled cartridges, nicotine, batteries, and/or charging elements for such devices are not permitted in a resident's room.8. If at any time, a resident is found with tobacco, nicotine and/or smoking/vaping materials (including lighters, matches, electronic cigarettes, prefilled cartridges, etc.) in his/her room or is found smoking, vaping, and or using an electronic smoking device (i.e. e-cig) in the room or inside the facility, such articles will be removed, smoking/vaping privileges will be revoked, and could result in Resident discharge from the facility. 9. If at any time this policy/contract is violated, smoking/vaping and/or tobacco/nicotine usage privileges will be revoked.10.Tobacco/Nicotine and smoking/vaping privileges may be revoked or limited at any time at the discretion of the facility administration.11. No resident may smoke/vape and/or use an electronic smoking device while on oxygen. 12. Smoking/Vaping paraphernalia for all residents will be secured by staff and labeled with individual resident names. 13. E-Cigarettes/Electronic Smoking Devices/Vaping Devices are considered the same as cigarettes and are subject to the same policies. 14. Any resident witnessed using/obtaining/storing illegal smoking/vaping materials and/or paraphernalia on facility property is subject to a 30-day discharge notice. Local Law Enforcement will be notified. PROCEDURE: A licensed nurse will evaluate residents who smoke, vape, or use electronic smoking devices upon admission or at the start of such activity and as cognitive or physical status changes warrant 2. Residents who smoke, vape, use electronic smoking devices are only permitted to do such activity in the designated smoking area. Residents will periodically be reviewed to reassess their ability to smoke/vape or use tobacco/nicotine safely.Residents will be offered and encouraged to use smoking aprons. I, ---------------------have reviewed and agree to the above smoking/vaping policy and procedure contract and further agree to abide by these guidelines in order to continue smoking/vaping privileges. I further acknowledge that my room or personal belongings may be searched for by facility staff at any time if I am suspected of violating any aspect of this smoking agreement.

Based on record review and staff interviews, the facility failed to ensure the completion of a Preadmission Screening and Resident Review (PASRR) for one (Resident #9) of two residents selected for PASRR review, from a total survey sample of 23 residents. The findings include: A review of Resident #9's medical record revealed that he was admitted to the facility on [DATE]. No PASRR was found for the resident's 1/17/2023 admission. Further review of the resident's record revealed that he was admitted with diagnoses including, but not limited to, dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance; major depressive disorder; schizoaffective disorder, bipolar type; brief psychotic disorder, and other specified persistent mood disorders. On 12/04/24 at 1:30 PM, the Director of Nursing (DON) was asked to provide Resident #9's admission PASRR. She provided a PASRR dated 2016. On 12/05/24 at 9:00 AM, the DON was asked if a more recent PASRR had been completed. She stated the facility had no PASRR for Resident #9 other than the one already provided and dated 2016. She was asked for the facility's policy for PASRR screening. No policy was received during the survey. On 12/05/24 at 11:56 AM, an interview was conducted with the Minimum Data Set (MDS) Coordinator and the DON. The MDS Coordinator was asked what she looked for when a PASRR had been completed by the transferring facility prior to the new resident's admission. She stated she did not check the PASRR for accuracy but when she had questions, she called the review organization for assistance. When asked about the facility's policy for PASRRs, she stated the facility did not have a policy for PASRRs. The DON was asked about the facility's policy for PASRRs. She also stated the facility had no policy for PASRRs. She stated, This one is on me. We did not do the screening.

Based on observations, interviews, record review, and facility policy and procedure review, the facility's failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections. The facility failed to follow isolation guidelines for COVID 19 for five (Residents #1, #2, #3, #4, and #5) of seven residents who were positive for COVID 19, from a total sample of 9 residents. Failure to follow proper infection control standards increases the risk of adverse health outcomes for facility residents, staff, and other facility occupants. The findings include: On 7/29/24 at 10:00 am, Licensed Practical Nurse (LPN) A was observed passing medication to Resident #1. A sign on the door noted Resident #1 was on droplet precaution. LPN A was observed wearing a surgical mask below her chin and had no gown or gloves. She was standing at the door interacting with Resident #1 who was sitting in his chair near the door less than one foot from LPN A. When LPN A, realized she was being watched, she pulled up her mask to cover her nose and mouth. During an interview on 7/29/24 at 10:10 am with LPN A, she was asked why Resident #1 was on isolation. She stated that she was not sure and had to look it up. After reviewing Resident #1's physician orders, she stated that the resident had tested positive for Covid on 7/20/24. When asked what personal protective equipment (PPE) she was supposed to use. She said, N95 respirator mask, face shield, gloves and gown. When LPN A was asked if the facility had enough PPE, she said, Yes. She went on to confirm that she should have been wearing a N95 when interacting with Resident #1, who was less than 5 feet away from her. On 7/29/24 at 10:20 am, Resident #2 was observed in room [ROOM NUMBER] sitting on Resident #3's bed. A sign on the door for room [ROOM NUMBER] indicated that Resident #3 was on Droplet precaution. On 7/29/24 at 10:25 am, an interview was conducted with Personal Care Attendant (PCA) B. She was asked if Resident #2 belonged to room [ROOM NUMBER]. She said no and entered room [ROOM NUMBER] to assist Resident #2 out of the room. PCA B was wearing a KN95 mask and did not don gloves or gown. She stated that Resident #2 was in room [ROOM NUMBER] and she was not on isolation (PCA B did not perform hand hygiene after exciting isolation room [ROOM NUMBER]). She was again asked if Resident #3 had a roommate, she said, Yes, Resident #4 is his roommate and is in activities. On 7/29/24 at 10:30 am, PCA A was observed entering room [ROOM NUMBER] A. She was wearing a KN95 mask and did not don gloves or gown. There was a sign on the door indicating that residents were on Droplet precaution. The PPE bag that was hanging on the door had no PPE. PCA A assisted Resident #5 to put on his pants. After dressing the resident, she walked outside the resident room holding Resident #5's hand and directed him to the activities room. Resident #5 was not encouraged to wear a mask. PCA A did not perform had hygiene. Before entering the activities room, she was stopped and asked what precautions Resident #5 was on. She said, I don't know, he is not my resident. She continued to enter the activities room where 15 other residents were seated having activities. In an interview on 7/29/24 at 10:34 am with LPN C, she confirmed that Resident #5 was on droplet precaution. She added that the resident tested positive for Covid on 7/22/24 and should be off of isolation on August 1. When asked if the resident was allowed to leave his room without a mask. She said, Resident are allowed to go anywhere they want we can't restrict them; he does not have any symptoms. She then asked the activities staff to offer a mask to Resident #5. During a follow-up interview on 7/29/24 at 10:45 am with PCA B, she stated that she was hired in May 2024. When asked if she had received any training on infection control and abuse/neglect she said, No. She added that she received video training upon hire. When asked how she identified what type of isolation and appropriate PPE to use, she said, Honestly I don't know. During an interview on 7/29/24 at 12:25 pm with the Assistant Director of Nursing (ADON)/Infection Control Preventionist, she stated that since the facility was in outbreak mode, all staff are supposed to wear surgical masks when in the resident areas and stay home if sick. Residents who are positive for COVID 19 should be encouraged to stay in their rooms or wear mask when they get out of their room. Staff are supposed to follow the standard precaution and isolation precautions. When asked how she ensured that staff implemented the infection control protocol, she said that she conducts random spot checks and hand hygiene observations. When asked how staff are supposed to differentiate isolation precautions, she said that isolation posters were color coded, and each poster included the appropriate PPE to wear. When asked how families and visitors are notified of an outbreak. She said, We are supposed to have an outbreak sign upon entrance, but I noted it was not there when you guys walked in. The ADON confirmed that staff are supposed to perform hand hygiene, don appropriate PPE before entering isolation rooms except when entering rooms on Enhanced barrier precaution (EBP). She stated that COVID 19 isolation requires an N95 mask, Face shield, gown and gloves. When asked how COVID 19 residents in semi-private rooms were isolated. She said, Normally we will get the negative resident out of the room, but residents who are positive for COVID 19 without symptoms can be placed in the same room, it's a case-by-case situation. When asked about Resident #3, she confirmed that resident was on isolation for COVID 19, and his roommate (Resident #4) was not on isolation. When asked why the two residents were not separated. She stated that there was no available bed. The ADON also confirmed that Resident #5 had no roommate. She could not explain why Residents #3 and #5 were not placed in the same room. A review of the facility' policy and procedure titled, Infection Control - Infection Prevention and Control Program - Revised 6/2023 revealed the following: Standard - An infection prevention and control program (IPCP) are established and maintained to provide a safe, sanitary and conformable environment and to help prevent development and transmission of communicable diseases and infections. Guideline- The infection prevention and control program is developed to address the facility-specific infection control needs and requirements identified in the facility assessment and the infection control risk assessment. The program is based on accepted national infection prevention and control standards in accordance with local, state and federal regulations and guidelines. Procedure: Elements (Page 2) 2. The elements of the infection prevention and control program consists of coordination/oversight/policies/procedures, surveillance, data analysis, antibiotics stewardship, outbreak management, prevention of infection, and employee health and safety. Outbreak management (Page 4) 1. Outbreak management is a process that consists of: a. determining the presence of an outbreak; b. managing the affected residents; c. preventing the spread to other residents; d. documenting information about the outbreak; e. reporting the information to appropriate public health authorities; f. educating staff and the public; g. monitoring the recurrences; h. reviewing the care after the outbreak has subsided; and i. recommending new or revised policies to handle similar events in the future. Important facets of infection prevention include: a. identifying possible infections or potential complications of existing infections; b. instituting measures to avoid complications or dissemination; c. educating staff and ensuring that they adhere to proper techniques and procedures; d. communicating the importance of standard precautions and cough etiquette to visitors and family members; e. enhancing screening for possible significant pathogen; f. immunizing residents and staff to try to prevent illness; g. implementing appropriate isolation precautions when necessary; and h. following established general and disease-specific guideline such as those of the centers for Disease Control (CDC) A review of the facility's policy titled, Infection Control: Transmission Based Precautions - Revised 02/2024 revealed the following: Guideline: All staff receive training on transmission-based precautions upon hire and at least annually. Procedure: 3. Droplet precautions- a. intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions (i.e. respiratory droplets that are generated by a resident who is coughing, sneezing or talking). b. Make decisions regarding private room on case-by-case basis after considering infection risk to other residents in the room and available alternatives. c. Healthcare personnel wear surgical masks for close contact with infectious resident. d. Residents on Droplet precautions who must be transported outside of their room should wear a surgical mask if tolerated and follow respiratory hygiene/cough etiquette.

Based on medical record review, interview, and facility policy review, the facility failed to ensure the resident care plan for one (Resident #1) of three residents reviewed for falls, was revised to reflect new interventions for risk of injury due to recent falls. Failing to revise care plans places the residents at risk of not receiving appropriate care. The findings include: A review of Resident #1's medical record revealed she was admitted to the facility on [DATE] with a re-entry on 12/5/23 with diagnoses of muscle wasting, unsteadiness on feet, unspecified dementia, and Parkinson's disease. Further review of Resident #1's medical record revealed she had falls in the facility on 11/8/23, 11/19/23, 12/4/23, and 1/9/24. A review of Resident #1's care plan initiated on 8/30/22 revealed she was at risk for falls with a goal to minimize risk for injury related to falls with interventions in place. However, interventions were noted to remain the same, and no documentation was found to support the facility had revised the resident's care plan, for effectiveness, following her falls on 11/8/23, 11/19/23, 12/4/23, and 1/9/24. (Photographic evidence obtained) On 1/18/24 at 2:22 PM, an interview was conducted with the MDS Coordinator, in the presence of the administrator. She was asked if Resident #1's care plan should have been updated or reviewed after the residents multiple falls in the facility due to her at risk for falls. The MDS Coordinator confirmed that although interventions were in place and the resident was appropriately assessed following each fall, the care plan did not reflect this. A review of the facility's policy titled, Care Plans, Development Baseline and Comprehensive issued on 11/2001, (revised on 5/2023) revealed: Comprehensive Care Plan 13. Assessments of residents are ongoing and care plans are revised as information about the residents' conditions change. (Photographic evidence obtained) A review of the facility's polity titled, Falls and Falls Risk, Managing issued in 2001, (revised on 3/2018) revealed: Resident-Centered Approaches to Managing Falls and Fall Risk 5. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. (Photographic evidence obtained)

Based on observations, interviews, and facility policy review, the facility failed to ensure eight (132, 126, 124, 125, 216, 212, 214, and 115) of thirteen resident bedroom privacy curtains observed were maintained to ensure a safe, functional, sanitary, and comfortable environment for residents. The findings include: 1. A visit to room [ROOM NUMBER] on 08/08/2023 at 10:28 AM, found the privacy curtain in the bedroom area to have multiple reddish-brown splatters on it. (Photographic evidence obtained) 2. A visit to room [ROOM NUMBER] on 08/08/2023 at 10:39 AM, found the privacy curtain in the bedroom area to have multiple reddish-brown splatters on it. (Photographic evidence obtained) 3. A visit to room [ROOM NUMBER] on 08/08/2023 at 10:44 AM, found the privacy curtain in the bedroom area to have multiple reddish-brown splatters on it. (Photographic evidence obtained) 4. A visit to room [ROOM NUMBER] on 08/08/2023 at 10:48 AM, found the privacy curtain in the bedroom area to have multiple reddish-brown splatters on it. (Photographic evidence obtained) 5. A visit to room [ROOM NUMBER] on 08/08/2023 at 11:06 AM, found the privacy curtain in the bedroom area to have multiple reddish-brown splatters on it. (Photographic evidence obtained) During the observation, Resident #2 was interviewed and stated she couldn't remember the last time the privacy curtain was cleaned or replaced. 6. A visit to room [ROOM NUMBER] on 08/08/2023 at 11:18 AM, found the privacy curtain in the bedroom area to have multiple reddish-brown splatters on it. (Photographic evidence obtained) 7. A visit to room [ROOM NUMBER] on 08/08/2023 at 11:22 AM, found the privacy curtain in the bedroom area to have multiple reddish-brown splatters on it. (Photographic evidence obtained) 8. A visit to room [ROOM NUMBER] on 08/08/2023 at 11:35 AM, found the privacy curtain in the bedroom area to have multiple reddish-brown splatters on it. (Photographic evidence obtained) During an interview with the Director of Environmental Services on 08/08/23 at 12:17 PM, he confirmed the privacy curtains listed above were stained. He explained that housekeeping was required to notify the floor technicians and maintenance when they came across a soiled or dirty privacy curtain. A work order should then be entered into the facility's work order system. The technicians and maintenance should clean and/or replace the privacy curtain upon notification of a soiled privacy curtain. His expectation was that work orders to replace a privacy curtain should be completed by the end of the business day. A review of the facility's policy titled: General Housekeeping, with effective date of 07/28/23 read, It is the policy of this facility to provide a clean, safe, orderly, comfortable and attractive home-like environment both indoors and outdoors. (Photographic evidence obtained)

Based on record review and an interview with the Social Worker, the facility failed to keep complete records of Notice of Medicare Non-coverage (NOMNC) and Advance Beneficiary Notice of Non-coverage (ABN) for two (Residents #30 and #40) of six sampled residents, discharged within the last six months, from a Medicare A-covered stay with benefit days remaining. The findings include: A review of six residents' records with remaining Medicare Part A days, revealed that two residents (#30 and #40) had missing signatures on both the NOMNC and ABN forms. (Copies obtained) The signature areas had no information or date on either form. The two residents' ABN forms did not have an Options box selected, a signature, or a date of contact on them. On the NOMNC forms for the two residents, the signature area and date areas were blank. This form had an additional information (optional) area filled out, but did not indicate whether the residents had declined, planned to appeal, or were not available to sign the forms. A receipt for certified mail was given, but there was no verification with signature or verification of forms sent with receipt. An interview was conducted with Social Services Director on 1/12/23 at 11:54 AM. She stated she went to the resident and let them know about their remaining days if they were their own responsible party. She would call the family about the benefits ending, and mail the forms if the resident was not their own responsible party. She stated she sent the form via Certified mail. when asked how she obtained the signatures for the forms, she produced a receipt for certified mail, but here was no verification with signature or verification of forms sent with receipt. She reported she either mailed them or verified by telephone. She reported she usually got a phone call from the representative/family to verify the forms were mailed. She stated if the representative did not send the form back, she didn't have a signature. She replied that she had done it this way for [AGE] years. A review of the form instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 and Medicare Claims Processing Manual Chapter 30 - Financial Liability Protections (update 1/21/2022) was conducted. The Regulatory instructions for ABN Signature and Date were as follows: The beneficiary or their authorized representative must sign the signature box to acknowledge that they read and understood the notice. The Skilled Nursing Facility (SNF) may fill in the date if the beneficiary needs help. This date should reflect the date that the SNF gave the notice to the beneficiary in person, or when appropriate, the date contact was made with the beneficiary's authorized representative by phone. If an authorized representative signs for the beneficiary, write (rep) or (representative) next to the signature. If the authorized representative's signature is not clearly legible, the authorized representative's name must be printed. If the beneficiary refuses to choose an option and/or refuses to sign the SNF ABN when required, the SNF should annotate the original copy of the SNF ABN indicating the refusal to sign and may list a witness to the refusal. The SNF should consider not furnishing the care. The regulatory instructions for NOMNC Signature and Date stated a Medicare provider or health plan (Medicare Advantage plans and cost plans , collectively referred to as plans) must deliver a completed copy of the Notice of Medicare Non-Coverage (NOMNC) to beneficiaries/enrollees receiving covered skilled nursing, home health (including psychiatric home health), comprehensive outpatient rehabilitation facility, and hospice services. The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily. Note: The two-day advance requirement is not a 48 hour requirement. The provider must ensure that the beneficiary or representative signs and dates the NOMNC to demonstrate that the beneficiary or representative received the notice and understands that the termination decision can be disputed. Use of assistive devices may be used to obtain a signature.

Based on observations, interviews, and record review, the facility failed to ensure one (Resident #231) of 39 sampled residents had access to the call light while in bed. The findings include: An observation was made of Resident #231 on 1/9/23 at 1:05 PM. She was in a double room in the bed nearest to the window and she had no roommate. No call light was seen near or next to the resident. She was asked where her call light was, but she was not able to locate it. During this time the call light was observed pinned to her privacy curtain. (Photographic evidence obtained) A second observation of resident #231's room on 1/9/23 at 2:20 PM. The call light was still hanging from the privacy curtain near the wall and out of the resident's reach. At this time Certified Nursing Assistant N was interviewed and reported that she had clipped the call light on the curtain 5 to 10 minutes ago. When asked where the call light should be in relation to resident, she stated, within reach of resident. On 1/11/23 at 12:25 PM, Resident #231's call light was observed on the floor out of reach of the resident. (Photographic evidence obtained) It was also observed that a red-colored drink had spilled in the resident's bed next to resident. On 1/11/23 at 2:10 PM, Resident #231's call light was seen hanging from the privacy curtain. (Photographic evidence obtained) The resident was asked how she got help without the use of her call light. She stated, I yell for it. She further stated if the call light was within reach, she would use it. An interview was conducted with Personal Care Assistant (PCA) P on 1/11/23 at 2:12 PM. She was asked how residents summoned for help when they were in their rooms. She reported, They use call light. She stated the call light should be next to the resident at bedside, next to their pillow. She confirmed that she did have Resident #231 on her assignment today, and the resident doesn't ask for help much. At this time PCA P was asked to enter Resident #231's room and check the call light. She confirmed that the call light was not within reach of the resident and reported, I don't know why its hanging from the privacy curtain. Housekeeping must have come in and moved it. PCA P confirmed that the resident did know how to use her call light and had used it in the past. PCA P was observed moving the call light within reach of the resident. A medical record review was conducted and revealed an admitted [DATE]. The resident's diagnoses included wedge compression fracture of unspecified lumber vertebra, unspecified encounter for fracture with routine healing; malignant neoplasm, bronchitis, anxiety disorder, unspecified fracture of sacrum, mild protein calorie malnutrition, and depression. A review of the facility's policy titled Answering the Call Light (Undated) was reviewed. The policy noted the purpose of this procedure was to ensure timely response to the resident's requests and needs. The policy's General Guidelines read, When the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident.

Based on record review, interview, and facility policy review, the facility failed to implement abuse investigation and reporting policies and procedures related to reporting an injury of unknown origin within the required timeframe to the State Survey Agency for one (Resident #2) out of four sampled residents. The findings include: Record review of the facility's policy titled, Abuse Investigation and Reporting, dated 2001, revised July 2017, revealed: Reporting, 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following person or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative (Spouse) of Record; d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's Attending Physician; and g. The facility Medical Director 2. A alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse or has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury. (Copy obtained) Review of Resident #2's medical record revealed he was a [AGE] year-old male admitted on [DATE] with a readmitted [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Entry Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 10 (indicating moderately impaired), with periods of inattention, disorganized thinking. Resident required extensive assistance times 1-2 persons for all Activities of Daily Living except for eating. Resident #2 was discharged on [DATE] secondary to a fall and transfer to the emergency room . Review of progress notes dated 3/24/22 at 4:26 PM, revealed Employee A, Licensed Practical Nurse (LPN) documented, Follow up with Primary Care Physician (PCP) office in regard to radiology report and they stated a physician will be here 3/25/22 for evaluation per [NAME]. On 3/25/22 at 4:09 PM, the Director of Nursing (DON), documented, This nurse spoke with Employee B, an Advanced Practice Registered Nurse (APRN) post exam of Resident #2 and review of x-ray. Plan of care is to consult Orthopedic Surgeon. Patient remains without pain. On 3/31/22 at 1:41 PM, Employee C, LPN documented, Customer sent to the emergency room (ER) for uncontrolled pain to left hip. Guardian called and made aware, message left for sister to call back for update. On 3/31/22 at 5:53 PM, Employee C, LPN documented, Customer was admitted to Advent Daytona Beach for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 9/15/22 at 9:30 AM, a review of the investigation into the injury of unknown origin was conducted with the DON. The investigation revealed on 3/23/22 during therapy, Resident #2 complained of pain to left hip. An x-ray was obtained and revealed a left femoral head fracture, nondisplaced, indeterminate age. The resident was interviewed, denied pain, and gait was within normal limits and was ambulating on the unit. The PCP was called and on 3/25/22 the APRN came to see the resident. The Medical Director did not feel this was emergent and set up an appointment with ortho and to continue therapy. On 3/31/22 the resident complained of pain 10 out of 10 on the pain scale, the physician was notified who ordered the resident be sent to the ER for evaluation. The resident was admitted for a nonacute unhealed comminuted displaced fracture. The hospital recommendation was for non-surgical repair due to Resident #2's multiple comorbidities. Upon family consultation the surgical option was exercised. The Resident was scheduled for an Open Reduction and Internal Fixation (ORIF) of the left hip. The resident returned to the facility on [DATE] for post-surgery recovery and physical therapy. On 9/15/22 at 9:52 AM, an interview was conducted with the DON who stated in hindsight she realized she should have reported the hip fracture as an injury of unknown source.

Based on record review and interviews, the facility failed to provide a refund for one (Resident #1) of four residents sampled for refunds, within the required timeframe of 30 days, for the residents' pre-paid portion of the monthly service rate after the residents' expiration. The findings include: A closed record review for Resident #1 revealed that he was admitted on [DATE] as a private pay resident and expired on [DATE]. During a phone interview with Resident #1's responsible party on [DATE] at approximately 9:43 AM, she expressed that the resident had died on [DATE]. The responsible party stated that her dad paid the facility $7,500 for the 1st month rent, but unfortunately, he was only at the facility for 5 days. She talked to the office manager on [DATE] about a refund who told her if she didn't get a refund check within 2 weeks to call her back. On [DATE]th, she received an invoice in the mail which showed a total due of $0, which she didn't understand. She stated that it was her understanding that the facility was supposed to refund the credit balance back to her within 30 days. She confirmed at the time of the interview that she had not received a refund from the facility. A review of the financial statement for Resident #1's dated [DATE] revealed that on [DATE] the room and board rate period from ,d+[DATE] to [DATE] indicated 5 days/units at 250 dollars. The total amount equaled 1250.00 dollars. On [DATE], the statement line read: Payment #4995 7,500. Balance -6,250.00. On [DATE], the statement line read, Payment -6,250.00 and Balance 0.00. During an interview with the Administrator on [DATE] at 2:45 PM, she stated that refunds should be issued in about 30-days, and refunds are issued according to the regulations. On [DATE] at approximately 3:23 PM, the facility provided a copy of a check showing pay to the order of Resident #1's daughter/responsible party for $6,250, dated [DATE], 79 days after discharge.

Based on record review, observation, and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices related to skin care for one of 43 residents. (Resident #28) The findings include: Record review for Resident #28 revealed he was admitted to the facility on [DATE] with his most recent readmission on 5/15/2020. A review of the care plan, revised on 5/20/2021, revealed the following: Focus: Resident is at risk for alteration in skin integrity related to hygiene issues, incontinence, dementia, diabetes, dandruff on scalp, boil on abdomen. Goal: Will receive appropriate services and treatments to minimize potential skin breakdown, and will implement interventions to minimize the risk of skin impairment through next review, and facial rash will continue to improve within two weeks. Interventions: apply moisture, observe skin with ADLs (activities of daily living) and report abnormalities. Report localized skin problems (dryness, redness, pustules, inflammation, etc). [MEDICATION(S)] cream .5% (can be used to treat topical [CONDITION(S)] skin lesions), apply to face topically, daily, every evening shift for facial rash. Weekly skin check by licensed nurse. On 05/26/2021 at 11:28 AM, Resident #28 was observed sitting in the open lounge area in the center of the facility. Multiple staff members were also present in the area. Other aides and a nurse were observed passing by the resident, and some stopped to greet the resident. During this observation, small scaly white flakes were observed on the resident's shoulders, collar and the chest area of his dark blue shirt. The scaly white flakes were also observed on areas of the resident's forehead, eyebrows and in his hair. The resident also had multiple dry, white skin spots on his right hand and forehead. The resident acknowledged that he had dry skin, and advised that he used to have a cream for his skin, but he hadn't received it in some time. On 05/27/2021 at 8:31 AM, an observation was made of Resident #28 seated in the lounge area with multiple areas on his shirt covered with scaly, white flakes. Various staff members were in the area at the time of the observation. On 05/27/2021 at 10:25 AM, Resident #28 was observed in the facility lounge watching television. There were noticeable scaly, white flakes on his chest, collar and the sleeves of his shirt. There were also visible scaly white flakes on his forehead and eyebrows. During an interview with Employee H, Licensed Practical Nurse (LPN), on 5/27/2021 at 3:34 PM, she acknowledged that she was familiar with Resident #28. She confirmed he had a rash and dry skin. He was ordered [MEDICATION(S)] cream, but that was discontinued some time in February 2021. She stated the skin assessments were not assigned, and the skin check orders were not being completed as they should be. She acknowledged the presence of the scaly white flakes in the resident's hair and on his face. She stated the certified nursing assistants (CNAs) were responsible for providing ADL care and the nurses were responsible for providing treatments. On 05/28/2021 at 9:47 AM, Resident #28 was observed seated in the lounge area in the center of the facility. White, scaly flakes were on the resident's dark blue shirt. During an interview with Employee F, Registered Nurse (RN), on 5/28/2021 at 12:36 PM, she stated she was familiar with Resident #28 and was responsible for completing and reviewing the Minimum Data Set (MDS) assessments, including the section for skin assessments. She reviewed the treatment records and a licensed nurse completed the skin assessment weekly. A CNA was expected to evaluate the resident's skin while providing care, and the nurses were responsible for looking for dry skin, boils etc. when they did the skin checks. Employee F stated there were currently no orders for skin treatments for Resident #28, although the care plan was revised on 5/20/21 and indicated the use of [MEDICATION(S)] cream. She stated there had been an order in the past, but she could not provide any information as to why it was discontinued. Review of the Skin Sheet for Resident #28, dated 05/27/2021, documented no concerns. Employee F was asked if she had observed the condition of the resident's skin and the scaly white flakes. She responded yes, stating the nurse who completed the skin check should have documented the observation of dry skin and the scaly white flakes on the resident's shirt. She stated if the nurse had indicated the skin issues, orders could have been put in for treatments. On 05/28/2021 at 12:59 PM, Employee J, RN/Unit Manager, stated she was familiar with Resident #28. She acknowledged that she observed the resident covered in scaly white flakes. She stated he had received a shower and the CNAs should have been applying lotion to the resident after his showers. She confirmed that the care plan was revised on 05/20/2021. She stated that the cream was discontinued and was not re-started, but that it should have been. She confirmed that the Care Plan could not have been followed if the cream was not present. She stated that it should have been updated and/or the cream should have been re-ordered. During an interview with Employee K, RN, on 5/28/2021 at 3:28 PM, she stated she was familiar with Resident #28, and acknowledged that she completed the skin check dated 5/27/2021. She stated the process for performing a skin check was new, and she was not very familiar with it. She confirmed that she had observed dry skin and scaly white flakes on the resident' skin, and stated she gave him some over-the-counter lotion for the dryness. She acknowledged that she could have documented her observations on the skin sheet. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review, observations and staff interviews, the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident #2) The findings include: A record review for Resident #2 revealed a [AGE] year-old female admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission nursing note revealed she had a peripherally inserted central catheter (PICC line) to the mid-right arm for administration of intravenous (IV) antibiotics. A review of a 5/10/2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Also change the PICC line dressing every 5-7 days. A review of the May 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the MAR found that the PICC line dressing change order, dated 5/10/2021, had not been entered into the the record until 5/21/21. There were no further entries for the PICC line dressing change. An observation was made of the PICC line dressing for Resident #2 with Employee I, Licensed Practical Nurse (LPN), on 5/28/21 at 12:45 p.m. When the nurse was asked who was responsible for changing the PICC line dressing, she said a Registered Nurse (RN). She was asked when it was last changed, and she did not know. She said the dressing should be dated when changed. When asked how often did the nurses observe the PICC line site, she said every time you hang an IV medication. She was asked if there was a date on the dressing, but she did not see a date. When asked if the dressing was clean and intact, she said it wasn't dirty, but had loosened and needed to be secured. Also observed was IV [MEDICATION(S)], 1 gm at 250 ml hanging on IV pole. The tubing was running through an IV pump. The pump was set at 250 cc/hr. Observation of the IV bag containing the antibiotic [MEDICATION(S)] was found to have solution remaining in the bag and the pump was still running. An interview was conducted with Employee I on 5/28/21 at 1:20 pm. Regarding the time she hung the [MEDICATION(S)] for Resident #2, she said it was scheduled for 8:00 am, but not hung until 10:00 am due to a lab drawn this morning and the need to call the pharmacy to get authorization to hang. She said the [MEDICATION(S)] trough had been running high and had to be held for 2 days. She received the ok from the pharmacy and hung the bag at 10 am. When asked how long it usually takes for [MEDICATION(S)] to infuse, she said if the pump is working right, about an hour. She was asked if there was a reason why it had not completed infusing, and she said the pump kept occluding and had to keep resetting. She also said she used the gravity flow the other day and it too was very slow. An interview was conducted with Employee H, LPN, on 5/28/21 at 1:30pm. When asked how often the PICC line dressings were changed, she said weekly but only the RN can change. Regarding the duration for the IV antibiotics for Resident #2 to infuse from the time hung, she said it should only take about 30 minutes, but it often takes several hours when the tubing becomes occluded and the pump needs to be reset. She said perhaps the PICC line itself may need to be changed. When asked if the physician had been notified, she said she would call today. On 5/28/21 at 1:50 pm, the Director of Nursing was asked where the nurses document the PICC line dressing changes. She would need to review the record as they had a change in their computer system and some information did not come over. When she reviewed the records, she confirmed the original order for PICC line dressing changes on 5/10/21, did not appear on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . She confirmed that no dressing changes had been performed prior to 5/21/21 or after. When asked if she was aware of a problem with the IV pumps infusing slowly and delaying optimal effect of antibiotics, she said the pharmacy supplies the pumps and they are outdated. The pharmacy has purchased new pumps; however, the new pumps are not yet available to the facility.

Based on observation, record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, by failing to document skin conditions to ensure the provision of care and services for two (Residents #87 and #95) of five residents reviewed for risk for skin conditions, in a total sample of 43 residents. The findings include: 1. On 5/28/2019 at 1:00 PM, Resident #87 was observed in her room, lying in bed with her legs uncovered. Several round reddened areas were observed on the underside of her left leg. A record review on 5/28/2019 for Resident # 87 found she was admitted to the facility on [DATE] with her most recent readmission on 3/27/2019. She was diagnosed with [REDACTED]. Further review of Resident #87's computer and paper medical record found no documented evidence of the reddened areas that were observed. The weekly skin checks revealed the two most recent skin checks, dated (MONTH) 23, 2019 and (MONTH) 16, 2019, revealed in Section B: Are there any new areas identified?, was documented as no. Resident #87 was care planned for risk of skin alteration with approaches including skin checks weekly. Staff were also to observe skin during activities of daily living (ADL) care and report abnormalities. Positioning and knee splints were also on the care plan. During an interview on 5/30/2019 at 10:53 AM with Resident #87's nurse, Employee B, she was asked if Resident #87 had any wounds. She stated that Resident #87 had marks on her legs from her braces, and that Resident #87 was on a pause from the braces and the certified nursing assistants (CNAs) were applying barrier cream. The 200 Wing Unit Manager joined the interview and stated that Resident #87's skin check was due today, and that the skin issues would not have been on the 5/23/2019 skin check, as they were reported on Monday. The Unit Manager was asked for any documentation related to the newly identified skin condition. The Unit Manager stated she contacted the doctor and called the family, but did not write a progress note. During an interview on 05/30/2019 at 2:21 PM, with Resident # 87's CNA, Employee A, she was asked if Resident #87 had any skin problems. She stated she had areas on her right knee and under the left knee on the right side. She stated she noticed the areas on Monday (5/27/2019) and reported them to the Unit Manager. She stated she was putting skin repair cream on the area. She was asked if it was on the CNA care plan (Kardex) or anywhere in the computer so the other caregivers would know. She confirmed that it was not on the Kardex or the care plan they had access to. During another interview on 5/30/19 at 2:42 PM, with Resident #87's nurse, Employee B, she stated she had completed the skin check for Resident #87, and she had three scabs on her right knee and an intact blister behind the left lower knee near her calf. She added that the treatment was the repair cream, and that the CNAs were applying it. The 200 hall Unit Manager was listening in on the interview and was asked if the treatment was on the CNA Kardex. She pulled up the Kardex in the computer and it had not been added. She also pulled up the care plan, and the treatment was not added, nor was the brace removed or put on hold. She stated she would do it herself and was observed updating the care plan in the computer. A review of the weekly skin check, dated 5/30/2019 at 10:00 AM, revealed Resident#87 was assessed as having three scabbed areas, no drainage to the right knee (front) and a small intact blister to her left lower leg (rear). On 5/30/2019 at 10:59 AM, Customer noted to have areas to bilateral lower extremity. Doctor and power of attorney notified. New orders for skin repair cream every shift and hold braces until healed. New orders for skin cream to bilateral lower extremities (BLE) were entered in the facility computer as an order on 5/30/2019 at 3:00 PM. The hold on the knee splints was entered as an order on 5/30/2019 at 2:13 PM. (Photographic evidence obtained) 2. A record review for Resident #95 revealed the four most recent weekly skin checks, dated 5/5/2019, 5/12/2019, 5/19/2019 and 5/26/2019, indicated under 1. A: Current skin condition had no skin conditions identified. Under Question B. Are there any new skin areas identified? No was marked. Question C. Check box if skin intact (no bruising, redness, open areas, cuts, lacerations etc.) 0. Skin intact was not marked on any of the skin checks. The progress notes for 5/12/2019, 5/19/2019 and 5/26/2019 had no findings listed for the skin checks. Further record review of the progress notes for Resident #95 revealed that on 5/24/2019, the nurse documented Resident #95 had a skin tear to her right hand. There was also a note on 5/18/2019 that Resident #95 had a skin tear to her right hand and notes on 5/8/2019 indicating that the resident had a skin tear to her right wrist. During an interview with Resident # 95's nurse (Employee B) on 5/30/19 at 11:12 AM, she stated Resident #95 had an area near her right shoulderblade that would reappear. Skin checks were done weekly and documented in the computer. She stated that she was not the nurse who completed Resident #95's skin checks. She had not seen the resident's skin and was not aware of any concerns with her skin. During an interview on 5/30/2019 at 11:20 AM with Resident #95's, CNA (Employee A), she stated Resident #95's back was a little bit red near her shoulder blade and she was putting the cream on. During an interview on 5/31/2019 at 11:49 AM with the 200 Hall Unit Manager, she stated that under question B, the No to new areas was how the nurses were trained to document. She was asked about the question regarding skin intake being left blank on all of the skin assessments. She stated that left blank would mean the resident's skin was not intact. The (MONTH) progress notes were reviewed with the Unit Manager, and she confirmed they did not document any skin concerns on the dates of the assessments. She was notified that Resident #95's CNA (Employee A) stated Resident #95 had a reddened area near her left shoulder blade that she had been applying cream to, and that Resident 95's nurse was not aware of. During further interview on 05/31/19 11:59 AM, with the 200 Hall Unit Manager and an interview with Resident #95's Nurse Practitioner (NP), the Unit Manager stated they had both looked at Resident #95's skin and she was going to put the repair cream on the CNA computer care plan (Kardex) for the CNAs to apply the repair cream on each shift. The NP stated she would follow the resident.

Based on observations, record review and interviews the facility failed to provide oxygen as ordered by the physician for one (Resident #21) of one sampled residents reviewed for respiratory care, out of a total of 43 residents in the sample. The findings include: A record review was conducted for Resident #21 on 5/30/19, which noted an admission date of [DATE]. [DIAGNOSES REDACTED]. A review of the current physician's orders [REDACTED]. An observation was made on 5/29/19 at 9:54 AM of the resident in his room. He was alert with oxygen attached to a concentrator infusing at 2 liters via nasal cannula. The resident was hard of hearing and was unable to answer questions about his oxygen. An observation was made on 5/30/19 at 9:00 AM of the resident in his room, awake and sitting up in bed. He was just finishing breakfast, and his oxygen was infusing at 3.5 liters per nasal cannula via the concentrator. An observation was made on 5/30/19 at 1:10 PM of Resident #21 in his room. Oxygen was infusing at 3.5 liters via a nasal cannula through a concentrator. An observation was made on 5/30/19 at 2:50 PM of Resident #21 in his room. Oxygen was infusing at 4 Liters via nasal cannula through a concentrator. An interview was conducted with the Unit Manager/Registered Nurse (RN), of the 200/300 halls at 2:50 PM on 5/30/19. When the Unit Manager was asked to check the oxygen level on the concentrator for Resident #21, she reported the oxygen setting was on 4 liters. The RN took the oxygen off the resident, and reported the setting should be at 2.5 liters while sleeping. She stated, I will check the order to make sure. An interview was conducted with the Unit Manager, RN, at 2:56 PM on 5/30/19 concerning the oxygen order for Resident #21. She confirmed the physician's orders [REDACTED]. An interview was conducted with the Director of Nurses (DON) on 5/30/19 at 4:05 PM, concerning her expectation for Resident #21 receiving oxygen. The DON reported her expectation for staff was to follow the physician's orders [REDACTED]. An In-service/Education Roster was provided on 5/31/19, which stated, When orders are received for oxygen continuous and as needed, please make sure this order includes parameters for the liters, and oxygen delivery device. Please make sure to include an order to check oxygen saturations every shift. For any customer on oxygen, the nurse is responsible to make sure the oxygen is infusing at the correct liters as ordered by the physician.

Based on observations and interviews, the facility failed to provide dignity for two (Residents #81 and #64) of two residents reviewed for dignity out of a total sample of 28 residents. Resident #81 was not provided appropriate incontinent care, and Resident #64 was not provided privacy and dignity with the foley catheter bag. The findings include: 1. On 2/21/18 at 11:39 AM, an observation was made of Resident # 81 during medication administration. Employee E , Licensed Practical Nurse (LPN), approached Resident #81 in the TV room (Caring Corner), and asked the resident to please come to their room for medication. Employee E took the resident by the arm and was walking the resident back to the room. A second employee, Employee F, Certified Nursing Assistant (CNA), was passing juice in the hallway. Employee F looked at the back of Resident #81's pants and stated, Oh, and continued to pass juice. The surveyor looked at Resident #81 to see what Employee F was referring to. Resident # 81 was noted to have a large brown liquid area (resembling stool) on the back of the pants. Employee F never stopped passing her juice and did not say anything to Employee E. Employee E then took Resident #81 into the room to administer the medication. Employee E sat Resident #81 on the bed and started to gather the necessary supplies to administer Resident #81's medications via gastrostomy tube ([DEVICE]). Resident #81 got up from the bed and started to go out into the hallway, however Employee E redirected the resident back to bed (A foul odor was noted in the room at this time.). Employee E administered the medication, and then got the resident up off of the bed to return to the TV room (there was a moderate amount of brown substance on Resident #81's bedspread). Employee E then walked Resident #81 back to a second chair in the TV room and sat Resident #81 down. Resident #81's [DEVICE] was noted to be hanging out from the bottom of the resident's shirt. Surveyor then had to intervene and ask the nurse to please get someone to complete care on Resident #81. Employee E stated, Oh, I am sorry, I did not see that. On 2/21/18 at 12:05 PM, an interview was conducted with Employee F (CNA) regarding why she did not provide any care for Resident #81 and/or notify the nurse of what she had seen. Employee F stated, I just thought it was something from the [DEVICE], because she is always making a mess. Employee F then started walking away and the surveyor asked her to please get housekeeping for the chairs. Employee F did not respond. This surveyor stood in the TV area and made sure no other residents/visitors sat in either of the chairs. The North Wing Unit Manager came to the TV room with bleach wipes, and cleaned the chairs. 2. A record review for Resident #64 found an admission date of [DATE]. Resident #64's [DIAGNOSES REDACTED]. On 2/19/18 at 12:15 PM, the resident's catheter tube was observed on the floor at the bottom of the wheelchair during dining. On 2/20/18 at 9:45 AM, Resident #64's Foley catheter bag was observed. Resident #64 was lying in bed on her back, with her bed in the lowest position. Her Foley catheter was lying directly on the floor, and there was no dignity bag covering it. (Photographic evidence obtained) On 2/20/18 and interview was conducted with Employee C, Licensed Practical Nurse (LPN), regarding Resident #64 ' s Foley catheter bag lying on the floor. Employee C stated, Yeah, I see that. It should not be on the floor. I will get the Certified Nursing Assistant (CNA).

Based on record review and staff interview, the facility failed to provide assistance with eating for a resident with significant weight loss for 1 (Resident #64) resident reviewed for nutrition from a total sample of 28 residents. The findings include: A record review for Resident #64 found an admission date of [DATE]. [DIAGNOSES REDACTED]. Observations were conducted in the front dining room on the secure unit on 2/21/2018 at 11:35 AM. Resident #64 was sitting at the second table on the left with three other residents. The resident's eyes were closed. The resident appeared to be sleeping. The meal was in front of her, still covered and on the plate warmer. The resident was served pureed peas, bread, potatoes, Salisbury steak, dessert, milk, tea, and a health shake. At 11:37 AM, Employee P, the certified nursing assistant (CNA), came over to the resident. She took the plate off the plate warmer and removed the cover. She asked the resident to wake up and eat. The resident opened their eyes. The CNA put a spoon in ther hand and then returned to the first table to assist other residents. The CNA's back was to Resident #64. The resident put the spoon into the pureed peas and then to her mouth. The resident did not eat anything. The resident put the spoon on the table and then placed her hands on her lap. At one point, the resident picked up a napkin and put it down. The resident picked up the tea and drank some. The resident then put the cup of tea on the plate in the mashed potatoes. The resident drank about 3/4 of the tea. At no time did anyone say anything to Resident #64 or the other resident who was playing with their food at the table. There were six tables in the dining room with 19 residents. Two tables did not have a staff member. One table had two staff members. The staff members in the dining room were Employee Q, Certified Nursing Assistant (CNA), Employee L, CNA, Employee M, CNA, Employee N, Licensed Practical Nurse (LPN), and Employee P, CNA. An interview was conducted with Employees P and Q on 2/21/2018 at 11:50 AM. Both stated they usually had the same amount of staff in the dining room. On 2/21/2018 at 11:53 AM, Employee P moved Resident #64 from the table in order to get by and let another staff member go behind the first table to assist another resident. Resident #64 remained about two feet from the table. The CNA left the dining room. At 11:57 AM, a second CNA Employee Q, CNA, after assisting another resident, washed her hands and proceeded to wheel Resident #64 out of the dining room. At no point did anyone speak to the resident or cue her to eat after first time the spoon was given to her. Employee Q, CNA, was interviewed on 2/21/2018 at 11:59 AM. She stated when the resident put the cup down, the resident was done eating and would spit everything out. She was informed that no one tried to get the resident to eat or assist beyond just handing her a spoon. Employee Q stated she thought Employee P had spent a minute with the resident and tried to get her to eat. The nurse, Employee N, LPN, brought Resident #64 back into the dining room. Employee C, LPN, came into the dining room at noon and sat down next to Resident #64. She tried two different food items, but the resident stated she did not want to eat. She was able to get the resident to drink half of the health shake. During an interview with Employee C, LPN, on 2/21/2018 at 12:10 PM, she stated the resident was usually a better eater in the morning. She stated, You have to get the resident at the right time. She went on to say that this resident had no problems in the mornings accepting the Medpass nutritional supplement. The resident would drink a cup of water, then the Medpass and take the pills. Employee D, Unit Manager, was there during the interview. She added at one point that the resident's dentures would no longer fit due to weight loss. They had gotten new dentures hoping the resident would eat, but that had not happened. The nurse stated that the resident's daughter had visited and did not want the resident tube fed. She stated the husband came sometimes, but it was very difficult because he could not see to drive. On 2/21/18 at 2:59 PM, Employee L, CNA, stated that when you tried to assist resident #64 with meals she would say 'I am hungry.' The resident would take about five spoonfuls, three sips of her beverage, and then did not want more. The resident would say 'I do not want more.' If you tred to get her to drink or eat more, the resident would become agitated. She would drink her liquids. She liked sweets like juice or a shake, but would not drink all of the beverage. Today it was apple juice and milk. Liquids were of regular consistency and foods were pureed. The CNAs documented in the kiosk. Today at lunch Resident #64 refused, so Employee L wrote zero percent intake in the kiosk. Employee L went on to say that the CNAs did not record the amount of liquid intake; only how many times the resident was offered a beverage. Drinks do not have the percent. During an interview with the dietitian on 2/22/18 at 9:30 AM, she stated she had been following Resident #64 since 3/9/2017. She did assessments on 3/23, 5/23, 6/15, 9/14, 9/27, 11/3, and 12/14/2017 and on 1/18/2018. The resident's record was reviewed with the dietitian. On 1/18/2018 there was a high risk nutritional assessment completed. This assessment noted the resident was 91 pounds on 1/9/2018, and was 61 inches tall. The resident's ideal body weight (IBW) was between 94 and 116 pounds. The weight change in 30 days was 1.5%, in 90 days was 19%, and in 180 days was 22%. Nectar-thickened liquids, sugar-free house shakes three times daily, and sugar-free Medpass nutritional supplement, 120 cc (cubic centimeters) four times daily was ordered. The summary indicated a significant weight loss over the last 3-6 months. The resident also currently had a Stage III pressure ulcer. She ate poorly and often refused supplements. Supplements provided 1560 kcal/58 grams (kilocalories per 58 grams) of protein/24 (every 24 hours) with 100% consumption. The care plan meeting was held with the family, they were aware of the weight loss, and chose palliative care. Further decline was anticipated. The dietitian did not make any changes. She said on 12/27/17 they had a care plan meeting with the family, Director of Nursing, Social Services Director, Nursing, Activities and the culinary assistant. They had a special care plan meeting for residents that continued to lose weight despite all interventions. The also had the physician's assistant involved. He had spoken to the daughter regarding the decline. They spoke about the feeding tube and she declined. They decided on palliative care. They would continue to give supplements. She would get combative if you tried to feed her. She would eat on her own, but did not have an interest in food. She had dysphagia, so she had nectar-thickened liquids and a pureed diet. Effective 12/26/2017, orders in the computer stated no IVs, weekly weights, and do not send to hospital unless there was trauma. The dietitian provided evidence that they had tried [MEDICATION NAME]/[MEDICATION NAME] on 9/13/2017. It had no effect. Psychiatric services had also followed. They liberalized her diet as she was diabetic. She was a good breakfast eater so they were giving her double portions at breakfast. She had a ground/thin diet. On 1/18/2018 a dietitian's note indicated the following: Basically palliative care. Still supplements in place and encourage her to eat. Care plan mechanically altered diet. [MEDICATION NAME]. Palliative care. Still on Med Pass and House shakes. Family desires to keep comfortable.

Based on observations and interviews, the facility failed to provide 3 (Resident #32, #109, and #68) of 3 residents reviewed for accidents, out of a total sample of 28 residents, an environment free of accident hazards. The findings include: 1. Resident #32 is an [AGE] year old female, admitted to the facility on [DATE]. Resident #32 resides in the locked memory care unit due to severely impaired cognition. On 02/20/18 9:56 AM Resident # 32 was observed lying in bed. As this surveyor was entering Resident # 32's bathroom to check for concerns, an open tube (cap was missing) of Zinc Oxide was observed lying on a gauze pad on the dresser beside the television. This surveyor immediately notified the nurse. Employee H , Licensed Practical Nurse (LPN), entered the room and confirmed the Zinc Oxide tube was in Resident # 32's room. (Photographic evidence obtained) Employee H stated, I do not know why this is in here. There is no one in B bed, and Resident # 32 does not get this from me. Maybe on the night shift. This surveyor asked whether the medication should have been in the room, and Employee H stated, No, it should be locked up in the treatment cart. Progress notes were reviewed, and indicated that the resident ambulated ad lib (as she wished), and wished to stay in her room. 2. Resident #68 was a [AGE] year-old male, admitted on [DATE], and who resided in the locked memory care unit due to severely impaired cognition. Resident # 109 was an [AGE] year-old male, admitted on [DATE], and resided in the locked memory care unit due to severely impaired cognition. On 2/19/18 at 1:37 PM, Resident #68's and #109's shared bathroom was observed with a toothbrush and a razor in a spit basin in the sink. Record reviews were conducted for Resident's #68 and #109, and they both were documented as ambulating ad lib (as they wished). On 2/19/18 at 2:07 PM, and interview was conducted with Employee G, Certified Nursing Assistant (CNA), regarding the razor that was left sitting on the sink in the spit basin. Employee G confirmed the razor was there, and stated, I threw it in the sharps container, because it is not supposed to be there. I noticed it when I looked to see what you were looking at. I did not know it was there before that. I am agency, and they must have left it there this morning. A review of the facility's Policy and Procedure for handling sharps revealed: Needle Handling and Sharps Injury Prevention; dated 5/1/2003, and revised on 10/20/16; page 2 under Process; 6. Sharps Disposal: 6.2 Safety razors, although not contaminated, must be placed in sharps disposal containers. DO NOT replace razor blade guards.

Based on observations, staff interviews and record reviews, the facility failed to administer gastrostomy medication in accordance with accepted standards of practice for 1 (Resident #81) of 1 sampled residents reviewed for gastrostomy tubes, out of a total sample of 28 residents. The findings include: Resident #81 was a [AGE] year-old female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 2/21/18 at 11:41 AM, an observation of medication administration was conducted with Employee E, Licensed Practical Nurse (LPN), and Resident #81. The resident was administered [MEDICATION NAME] (anxiety medication) 0.5 mg (milligrams) via her gastrostomy tube ([DEVICE]). Employee E, Licensed Practical Nurse (LPN), removed the [MEDICATION NAME] from the medication cart and crushed it, then mixed it in a medication cup with 10 cubic centimeters (cc) of water. Employee E then entered the resident's room, placed a tray with the medication on the bedside table, shut the door, and then went back out to the medication cart to get water for the flush. She returned to the room, left the door open, pulled the curtain, and auscultated for placement. The nurse did not check for residual. She then flushed the tube with 10 cc of water, drew the medication up in the syringe, and pushed the medication into the [DEVICE] with the syringe piston. She drew up 60 cc of water with the same syringe and pushed it with the syringe piston into Resident #81's [DEVICE]. Employee E forced water into the tubing with the piston. She stated to Resident #81, Do not push on your stomach. The nurse then drew up 60 more cc of water, and pushed it into Resident #81's [DEVICE] with the piston of the syringe. Employee E stated to Resident #81,Try not to push on your belly, okay? Employee E then laid Resident #81's [DEVICE] on her lap, and stated, I have to get more water. The nurse left the room and went to the medication cart just outside the door to get water. The nurse stated, This is my first day ever in this building, You can tell I have not worked in nursing homes much. She then returned to Resident #81's room, drew up 60 more cc of water, and began forcing it into Resident #81's [DEVICE]. As Employee E was pushing the water in, the tube opened and water went everywhere. Employee E dropped Resident #81's [DEVICE] back on her lap and stated, I need to get a towel. Resident #81 got up and started out the door, and Employee E wiped the resident's front with the towel. Employee E then took Resident #81 back to the TV room and placed her in a chair. Resident #81's [DEVICE] was observed to be hanging out of the bottom of her shirt. On 2/21/18 at 12:17 PM, and interview was conducted with Employee E, Licensed Practical Nurse (LPN), regarding the administration of the medication to Resident #81. Employee E was asked whether she normally pushed the medications and water into a resident's gastrostomy tube ([DEVICE]), and Employee E stated, Yes, I always push medications into the [DEVICE]. Employee E was then asked whether she had received any training in the facility prior to being placed on the medication cart this morning, and she stated, No, I did not get any training, and this is the first time I have ever been in this building. A review of the facility's policy and procedure for [DEVICE]s was conducted and it revealed the following: Enternal Tube Medication Administration Specific; dated 3/1/2008, and revised 7/8/2016; Procedures: 1) b. Aspirate stomach contents with syringe; L. Remove plunger from the 60 milliliter (ml) syringe and connect the syringe to the clamped tubing; M. Flush the tube with the specific amount of water prior to medication administration. Clamp tubing after the syringe is empty, allowing water to remain in the tube; N. 2) Allow medication to flow down tube via gravity.

Based on observations, interviews, and facility record reviews, the facility failed to provide sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 (Employee E, Licensed Practical Nurse (LPN) of 1 agency staff member reviewed. The findings include: On 2/21/18 at 11:41 AM, an observation of medication administration was conducted with Employee E, Licensed Practical Nurse (LPN), and Resident #81. The resident was administered [MEDICATION NAME] (anxiety medication) 0.5 mg (milligrams) via her gastrostomy tube ([DEVICE]). Employee E, Licensed Practical Nurse (LPN), removed the [MEDICATION NAME] from the medication cart and crushed it, then mixed it in a medication cup with 10 cubic centimeters (cc) of water. Employee E then entered the resident's room, placed a tray with the medication on the bedside table, shut the door, and then went back out to the medication cart to get water for the flush. She returned to the room, left the door open, pulled the curtain, and auscultated for placement. The nurse did not check for residual. She then flushed the tube with 10 cc of water, drew the medication up in the syringe, and pushed the medication into the [DEVICE] with the syringe piston. She drew up 60 cc of water with the same syringe and pushed it with the syringe piston into Resident #81's [DEVICE]. Employee E forced water into the tubing with the piston. She stated to Resident #81, Do not push on your stomach. The nurse then drew up 60 more cc of water, and pushed it into Resident #81's [DEVICE] with the piston of the syringe. Employee E stated to Resident #81,Try not to push on your belly, okay? Employee E then laid Resident #81's [DEVICE] on her lap, and stated, I have to get more water. The nurse left the room and went to the medication cart just outside the door to get water. The nurse stated, This is my first day ever in this building, You can tell I have not worked in nursing homes much. She then returned to Resident #81's room, drew up 60 more cc of water, and began forcing it into Resident #81's [DEVICE]. As Employee E was pushing the water in, the tube opened and water went everywhere. Employee E dropped Resident #81's [DEVICE] back on her lap and stated, I need to get a towel. Resident #81 got up and started out the door, and Employee E wiped the resident's front with the towel. Employee E then took Resident #81 back to the TV room and placed her in a chair. Resident #81's [DEVICE] was observed to be hanging out of the bottom of her shirt. On 2/21/18 at 12:17 PM, and interview was conducted with Employee E, Licensed Practical Nurse (LPN), regarding the administration of the medication to Resident #81. Employee E was asked whether she normally pushed the medications and water into a resident's gastrostomy tube ([DEVICE]), and Employee E stated, Yes, I always push medications into the [DEVICE]. Employee E was then asked whether she had received any training in the facility prior to being placed on the medication cart this morning, and she stated, No, I did not get any training, and this is the first time I have ever been in this building. On 2/22/18 at 3:23 PM, an interview was conducted with the Director of Nursing (DON) regarding the training checklist that was provided to the surveyor for agency staff. The DON stated that the unit managers/supervisors were to complete the checklist before the agency staff started working on the floor. The DON was asked for all checklists for all agency nurses that were working this week. The DON was asked again for the facility's policy and procedure for education of agency staff prior to providing care, and the DON confirmed that the facility did not have a policy and procedure for agency staff education. On 2/22/18 at 5:27 PM, the Director of Nursing (DON) was asked a second time for the check-off list for agency nurses, and she stated that she contacted the staffing person, but she had not called her back yet. On 2/22/18 at 6:33 PM, an interview was conducted with the Director of Nursing (DON), and she confirmed that they did not have a competency check list for Employee E, Licensed Practical Nurse (LPN). 2/21/18 was the first day that Employee E, LPN, provided care in the facility. Employee E did not provide [DEVICE] medication administration per facility protocol and/or the accepted standards of practice. Employee E was unaware that the facility had a locked memory care unit, and residents should not be let out of the unit. The facility failed to orient Employee E, LPN, to the building and/or its practices of care in the facility. The facility's policy and procedure was reviewed for New Team Member Orientation and it revealed: New Team Member Orientation; dated 5/1/2003, and revised on 11/30/2015; Policy: All team members will be provided with an orientation to centers and its practices. Purpose: To assure that the new team member will be provided appropriate information to do their jobs. Process: Section one of the New Team Member Orientation checklist will be completed and signed by the administrator/designee and forwarded to the Learning Specialist/Sr Learning Specialist prior to attendance of the new team member at orientation. 1. All newly hired personnel must attend the New Team Member Orientation on the FIRST day of employment. 2. The orientation program includes but is not limited to: 2.1 A tour of the center, which includes: 2.1.1 Location of Personal Protection Equipment (PPE), Material Safety Data (SDS) Material, Biohazardous/Biomedical Waste Storage Areas, supply areas, major department areas, and team member break areas; 2.1.2 A demonstration of the use of the customer call light system and intercom systems: 2.1.3 General Safety Management (O.S.H.A. required training) 2.2 Instruction in procedures to be followed in an emergency, which include: 2.2.1 Unusual occurrences with customers (i.e.: wandering, missing, etc.) 2.2.2 Fire Safety 2.2.3 Disaster Preparedness 2.2.4 Accident Prevention 3. In addition to New Team Member Orientation, the new team member will be oriented to his/her department's policy and procedures and the responsibility of their position. The facility failed to provide any training to Employee E, Licensed Practical Nurse, on 2/21/18 prior to assigning her to pass medications to residents in the facility. Employee E was not provided a tour of the facility, and had to ask one surveyor about letting a resident out of the locked unit. She asked a second surveyor where the soiled linen room was located.

Based on observation and interviews, the facility failed to store/label medications in accordance with currently accepted professional principles, and ensure that there were no expired medications available for use with residents. The deficient practice was observed in the rain forest shower room, room [ROOM NUMBER] on the memory care unit, room [ROOM NUMBER], caring way unit medication room's refrigerator, medication cart #2 with Employee D, medication cart #4 with Employee K, and the 300 hall medication room's refrigerator with Employees I and J. The findings include: On 2/18/2018 at 1:30 PM, observations were made of Remedy Cream (skin repair cream containing Dimethicone 1.5%, a medication cream) in the rain forest room (shower room) in caring way (locked memory care unit), and Remedy Cream in the bathroom in room [ROOM NUMBER] (memory care unit). A disinfectant bottle was sitting on top of the locked cabinet in the rain forest room (shower room) in caring way (locked memory care unit). On 2/18/18 at 2:45 PM, an interview was conducted with Employee D, Licensed Practical Nurse (LPN), regarding observations made of Remedy Cream in the shower room, in room [ROOM NUMBER], and the disinfectant bottle was observed in the shower room on top of the cabinet. Employee D was asked about the Remedy Cream, and she stated that it should not be in those locations. The nurses were to keep it locked up on the treatment carts, and then give the certified nursing assistants (CNAs) a cup of it as needed, because in this building CNAs can apply it. Employee D was asked about the disinfectant bottle and she stated, I just don't know why they can't take the time to lock it up. On 2/20/2018 at 9:37 AM, a Zinc Oxide tube (uncapped) was found in room [ROOM NUMBER]. On 2/20/18 at 9:56 AM, Resident # 32 was observed lying in bed. As this surveyor was entering Resident # 32's bathroom to check for concerns, an open tube (cap was missing) of Zinc Oxide was observed lying on a gauze pad on the dresser next to the television. This surveyor immediately notified the nurse. Employee H, Licensed Practical Nurse (LPN), entered the room and confirmed the Zinc Oxide tube was in Resident # 32's room. (Photographic evidence obtained) Employee H stated, I do not know why this is in here. There is no one in B bed, and Resident # 32 does not get this from me. Maybe on the night shift. This surveyor asked whether medication should have been in the room, and Employee H stated, No, it should be locked up in the treatment cart. On 2/21/18 at 2:37 PM, Remedy Cream was left in the basket in the rain forest room (shower room) across from room [ROOM NUMBER]. (Photographic evidence was obtained for all concerns listed above.) On 2/22/18 Medication storage observations were conducted and revealed the following: The medication room on the caring way unit: Observation was conducted with Employee D, Licensed Practical Nurse (LPN), and the refrigerator temperature was 32 degrees. The surveyor asked what the temperature should be, and she stated, It should be 38 degrees at least. I don't know what happened. They checked it last night and it was fine. Employee D then turned up the refrigerator dial from 3 to 3.5, and stated, I will put it in TELS for maintenance to follow up with. Medication cart observation was conducted for Cart # 02 with Employee D, and there were expired nasal sprays and eye drops on the cart. (Photographic evidence obtained) Employee D confirmed and verified that the medications were expired. The Director of Nursing (DON) and Regional Risk Manager approached the cart and asked what was wrong. They were told of the expired medications. The Regional Risk Manager asked, How do you know they are expired?, and the surveyor repled, because of the dates. The Regional Risk Manager then reviewed the medications and confirmed that they were expired. Employee D was asked how long the nasal sprays were good for after opening. She reviewed the book on the medication cart and stated, They are good for 35 days after opening. Photographic evidence was obtained. Cart #4 was observed on 2/22/18 at 9:11 AM With Employee K, Registered Nurse (RN), and expired eye drops and nasal sprays were discovered. Employee K stated that she would reorder the medications right away. (Photographic evidence obtained) On 2/22/18 at 9:25 AM, an observation was conducted of the medication room on the 300 hall with Employees I, Registered Nurse (RN) and Employee J, Registered Nurse/Unit Manager. It was discovered that the refrigerator temperature was 48 degrees. Employee J stated, It is because we just opened it. This surveyor had the door open for approximately 30 seconds, and the temperature elevated to 60 degrees. Employee J reached over and turned on the extension cord on the counter and stated, It is because that got turned off. Now it should work. The surveyor checked the cord that was attached to the refrigerator and confirmed that it was not plugged into the extension cord. Employee J picked up the cord attached to the refrigerator and confirmed that it was not plugged in to the extension cord. Employee J then stated to Employee I, You need to contact the pharmacy and get all these medications reordered. The surveyor then requested a list of all medications that were having to be replaced from Employee J. On 2/22/18 at 2:37 PM, Employee J brought in the list of medications that had to be replaced, and 11 residents were affected by the elevated refrigerator temperature. On 2/22/18 at 5:32 PM, an interview was conducted with the DON regarding medication storage, and she was asked for a copy of the refrigerator logs for both medication rooms. On 2/22/18 at 6:23 PM, an interview was conducted with the DON regarding the temperature logs for the medication room refrigerators that she brought in to surveyor. The DON stated that the one form was the incorrect form because it was a food refrigerator log. The DON was asked whether she was aware of the refrigerator on the 300 unit being broken and all of the medications having to be reordered. She replied, Yes. The DON and this surveyor reviewed the temperature log sheets, and the DON confirmed multiple dates of out of range temperatures being documented (2/2/18, 2/7/18, 2/8/18, 2/9/18, 2/10/18, and 2/15/18 on medication refrigeration temperature log). A second log of temperatures was documented over the entire month on the wrong form. They were utilizing a dietary temperature form.

Based on observation and interviews, the facility failed to maintain infection prevention protocols designed to provide a safe, sanitary and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections. This impacted one (Resident #64) of 28 sampled residents and one medication cart in the facility. The findings include: 1. An observation was made on 2/20/18 at 9:45 AM with Resident #64 of her Foley catheter bag. Resident #64 was observed lying in her bed on her back, with her bed in the lowest position. Her Foley catheter was lying directly on the floor, and did not have a dignity bag covering it. (Photographic evidence was obtained) On 2/20/18, an interview was conducted with Employee C, Licensed Practical Nurse (LPN), regarding Resident #64's Foley catheter bag being on the floor. Employee C stated, Yeah, I see that. It should not be on the floor. I will get the Certified Nursing Assistant (CNA). 2. On 2/21/18 at 9:07 AM, an observation was made of Employee E's medication cart, and Employee E's personal bag was noted to be sitting on the medication cart in the side pocket on top of gloves and other supplies. (Photographic evidence obtained) An observation was also made of Employee E's personal cell phone in the top drawer, lying on the insulin needles. On 2/21/2018 at 11:37 AM, an interview was conducted with Employee E, Licensed Practical Nurse (LPN), regarding her personal bag being on the side of the medication cart. Employee E stated, I am looking for my bag right now, because somebody moved it. I guess I am not supposed to keep it there.