Every finding on record at Brio of Johnston, LLC

Based on observation, clinical record review, manufacturer's recommendation and staff interview, the facility failed to administer insulin utilizing an insulin pen as recommended for 1 of 1 resident reviewed for insulin administration (Resident #4). The facility reported a census of 34 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had a Brief Interview for Mental Status (BIMS) of 13, indicating intact cognition. The MDS included a diagnosis of Diabetes Mellitus (DM). Resident #4's Physician Orders included an order dated 1/27/26 to inject 20 units of Basaglar KwikPen insulin subcutaneously daily. On 4/8/26 at 9:15AM, observed Staff A, Licensed Practical Nurse (LPN), inject 20 units of insulin into Resident #4's abdomen utilizing the Basaglar KwikPen. After the injection, Staff A removed the insulin pen prior to waiting a minimum of 5 seconds. Following the removal of the insulin pen, when asked how long the pen is to remain in place following the injection, Staff A reported a few seconds and then stated 5-10 seconds. Review of the manufacturer's recommendation for the Basaglar KwikPen documented the following:a. Insert the needle into the skin.b. Push the dose knob all the way in.c. Continue to hold the dose knob in. d. Slowly count to 5 before removing the needle. Review of the facility policy titled, Insulin Pen Use, effective April 2025 instructed to insert pen at 90-degree angle; press the injection button all the way down and hold for 5-10 seconds. During an interview 4/8/26 at 10:45 AM the Assistant Director of Nursing (ADON) reported she expected an insulin pen to remain in place a minimum of 5 seconds following administration when using an insulin pen.

Based on observation, staff interview, policy review, and the 2022 Food Code United States (U.S.) Food & Drug Administration (FDA), the facility failed to protect food from contamination during preparation as evidenced by 3 observed instances of improper glove use and potential cross-contamination. The facility reported a census of 34 residents.Findings include: On 4/8/26 at 10:30 AM: observed Staff B, Cook, preparing the pureed meals for lunch. Staff B removed lasagna from the oven with gloved hands. Without performing changing their gloves or performing hand hygiene, Staff B completed the following:Placed three servings of lasagna in the blender and added a piece of garlic bread to the lasagna with their left gloved hand.Attempted to pureed the lasagna in the blender, which cracked. Staff B wiped the side of the blender off with their right gloved hand.Transferred the pureed lasagna to a second blender and added one piece of garlic bread with their left gloved hand.On 4/8/26 at 12:13 PM: observed Staff B during lunch service preparing meals.Staff B wore a glove on their right hand.Observed Staff B throwing a piece of trash in the garbage and touch the lid of the garbage can with their gloved right hand. Staff B failed to remove the glove or perform hand hygiene.Staff B then removed a hamburger from the warmer, removed the wrapping, picked up the hamburger with the same gloved right hand, cut the hamburger in half, placed it on a resident's plate, and added fries using the same gloved hand.Review of facility policy titled, Food Safety for [NAME] Life, effective August 2025 directed to be aware of food-borne organisms including poor personal hygiene; poor hand washing practices. Review of the 2022 Food Code U.S. FDA, if used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation.During an interview 4/9/26 at 9:05 AM, the Certified Dietary Manager (CDM) reported she expected the staff to not touch surfaces while wearing gloves and then touch ready-to-eat food with the same gloves.

Based on observations, staff interviews, and policy review, the facility failed to securely store resident medications for 2 of 6 residents reviewed for medication administration. The facility reported a census of 34. Findings include:1. Resident #29's Minimum Data Set (MDS) assessment identified a Brief Interview for Mental Status (BIMS) score of 2, indicating severely impaired cognition. On 4/6/26 at 12:45 PM, on the Chronic Confusion or Dementing Illness (CCDI) unit, observed Resident #29's medication drawer wasn't securely locked. The drawer opened easily and contained Resident #29's medication administration cards.2. On 4/6/26 at 2:45 PM, on the CCDI unit, observed Resident #19's medication drawer wasn't securely locked. The drawer opened easily and contained Resident #19's inhaler and nebulizer medications.During an interview on 4/6/26 at 3:30 PM, the Director of Nursing (DON) witnessed and acknowledged the unlocked drawers in Resident #19 and Resident #29's rooms. The DON explained medication drawers shouldn't stay unlocked. If a drawer lock broke, the staff should move medications to a different drawer with a working lock. They should also initiate a work order immediately or alert the Administrator to initiate one.The Medication Storage in Resident Apartment/Room policy revised August 2024 directed prescription and non-prescription medications must stay in a designated locked area within the resident's room. The policy instructed that only authorized persons should have access to the medication supply.

Based on observations, staff interview, and policy review, the facility failed to apply infection control practices during wound care for 1 of 1 residents reviewed for pressure injuries (Resident #29). The facility reported a census of 34. Findings include: The Minimum Data Set (MDS) Assessment completed on 3/2/26 revealed Resident #29 with a Brief Interview for Mental Status score of 2, indicating severe cognitive impairment. Diagnoses include non-Alzheimer's dementia and stroke. The Care Plan, last revised on 4/6/26, reported Resident #29 developed an unstageable pressure injury (a deep wound where the base is completely hidden by dead tissue) to the right heel. During an observation on 4/8/26 at 10:00 AM, Staff F, Licensed Practical Nurse, entered Resident #29's room to initiate wound cares and immediately put on a gown and gloves. Hand hygiene was not observed before putting on gloves. After the old, soiled dressing was removed, Staff F cleansed the right heel, as ordered, and began to apply the new dressing. Staff F realized the dressing was not dated and placed Resident #29's heel on their sock while labeling the dressing. Once labeled correctly, the heel was removed from the sock and the dressing applied. Hand hygiene nor glove change was observed before placing the new, clean dressing. In an interview on 4/8/26 at 10:30 AM, Staff F acknowledged the lack of hand hygiene and glove change during wound cares. Staff F explained the cleansed heel should have been placed on a barrier, such as a clean absorbent pad, and not the resident's sock when they were labeling the dressing. The undated Dressing Change Competency procedure outlined the following: 1. Perform hand hygiene and put on gloves prior to starting cares and opening supplies 2. Remove old dressing and discard in a garbage receptacle 3. Remove and discard gloves 4. Perform hand hygiene and put on gloves 5. Cleanse the wound and apply skin protected and/or prescribed medications if ordered 6. Discard used supplies 7. Remove and discard gloves 8. Perform hand hygiene

Based on observations and staff interview, the facility failed to provide services to protect residents from accident or hazards by transferring residents in a wheelchair without foot pedals for 3 out of 12 residents observed in wheelchairs (Residents #26, #31, and #29). The facility reported a census of 34.Findings include: 1. The Minimum Data Set (MDS) Assessment completed on 3/2/26 revealed Resident #29 had a Brief Interview for Mental Status score of 2, indicating severe cognitive impairment. The MDS reported Resident #29 utilized a wheelchair and required staff assistance to operate. During an observation on 4/6/26 at 12:55 PM, Staff D, Certified Nursing Assistant (CNA), pushed Resident #29 from the dining area to the common area without securing their feet on the attached foot pedals. Resident #29's feet dangled between the two pedals. 2. The MDS Assessment completed on 3/13/26 revealed Resident #26 had a BIMS score of 3, indicating severe cognitive impairment. The MDS indicated Resident #26 didn't use a wheelchair for ambulation but walked with staff supervision. The Care Plan, revised 4/1/26, noted Resident #26 ambulated with a walker with staff supervision. The Care Plan also noted Resident #26 recently began using a wheelchair for activities further away but used a walker for short distances. During an observation on 4/6/26 at 1:00 PM, Staff D pushed Resident #26 from the dining area to the TV area without securing their feet on the foot pedals. The wheelchair didn't have foot pedals attached. Resident #26's feet dangled during the transfer. 3. The MDS Assessment completed on 3/8/26 revealed Resident #31 had a BIMS score of 2, indicating severe cognitive impairment. The MDS reported Resident #31 utilized a wheelchair with staff assistance. The Care Plan, revised 9/18/25, noted Resident #31 required staff assistance with wheelchair mobility to and from their specific destination. The Care Plan also stated Resident #31 used the wheelchair independently at times. During an observation on 4/7/26 at 12:55 PM, Staff E, CNA, held Resident #31's hand and pulled the wheelchair along without securing their feet on the foot pedals. Resident #31 went to their room from another part of the unit. They didn't have foot pedals attached to their wheelchair. Resident #31's feet weren't in motion and dangled close to the floor during the transfer.In an interview on 4/7/26 at 4:00 PM, the Director of Nursing (DON) stated the staff should use foot pedals whenever transporting a resident in a wheelchair. In an email received on 4/8/26 at 2:00 PM, the Director of Social Services confirmed the facility didn't have a policy regarding transferring residents in wheelchairs.

Based on electronic health record review, staff interview, and policy review, the facility failed to document on the Behavior Assessment Record, as ordered, behaviors related to psychotropic medication use (drugs which alter a person's mental state, emotions, or behavior) for 3 out of 3 residents reviewed for unnecessary medications (Residents #17, #24, and #25). The facility reported a census of 33 residents. Findings include: 1. The Minimum Data Set (MDS) Assessment, dated 2/6/25, revealed Resident #17 with a Brief Interview for Mental Status (BIMS) score of 1, indicating severe cognitive impairment. Diagnoses on the MDS include Alzheimer's Dementia, anxiety, and depression. The MDS listed the use of an antidepressant and an antipsychotic medication. Summary of Physician Orders for Resident #17, obtained on 3/13/25, listed orders for Divalproex (anticonvulsant used as a mood stabilizer) 125 mg tablet two times daily, Olanzapine (antipsychotic) 2.5 mg tablet daily and Sertraline (antidepressant) 50 mg tablet daily. The Physician Orders direct staff to Monitor and document for behaviors related to psychotropic medication use. Refer to active Care Plan for target behaviors one time a day every Tuesday and one time a day every Friday. The Behavioral Assessment Record (BAR) revealed the following: a. In February 2025, behaviors were not recorded for 2 out of 8 days b. In January 2025, behaviors were not recorded for 4 out of 9 days c. In December 2024, behaviors were not recorded for 2 out of 9 days Review of Progress Notes in the electronic health record lacked documentation to address if behaviors had been observed or not on the days missing documentation on the BAR for Resident #17. 2. The MDS Assessment, dated 1/23/25, revealed Resident #24 with a BIMS score of 2, indicating severe cognitive impairment. Diagnoses on the MDS include Alzheimer's Dementia, anxiety, depression and senile degeneration of the brain. The MDS listed the use of an antianxiety, antidepressant, and an antipsychotic medication. Summary of Physician Orders for Resident #24, obtained on 3/13/25, listed orders for Buspirone (antianxiety) 7.5 mg tablet two times daily, Quetiapine (antipsychotic) 1.5-25 mg tablets two times daily, and Sertraline (antidepressant) 1.5-50 mg tablets one time daily. The Physician Orders direct staff to Monitor and document for behaviors related to psychotropic medication use. Refer to active Care Plan for target behaviors one time a day every Tuesday and one time a day every Friday. The Behavioral Assessment Record (BAR) revealed the following: a. In February 2025, behaviors were not recorded for 2 out of 8 days b. In January 2025, behaviors were not recorded for 4 out of 9 days c. In December 2024, behaviors were not recorded for 2 out of 9 days Review of Progress Notes in the electronic health record lacked documentation to address if behaviors had been observed or not on the days missing documentation on the BAR for Resident #24. 3. The MDS Assessment, dated 1/17/25, revealed Resident #25 with a BIMS score of 2 indicating severe cognitive impairment. Diagnoses on the MDS include Alzheimer's Dementia, anxiety, and depression. The MDS listed the use of an antipsychotic and antidepressant. Summary of Physician Orders for Resident #25, obtained on 3/13/25, listed orders for Duloxetine (antidepressant) 60 mg tablet one time daily, Quetiapine (antipsychotic) 12.5 mg tablet two times daily, and Trazodone (antidepressant) 1.5-50 mg tablets one time daily. The Physician Orders direct staff to Monitor and document for behaviors related to psychotropic medication use. Refer to active Care Plan for target behaviors one time a day every Tuesday and one time a day every Friday. The Behavioral Assessment Record (BAR) revealed the following: a. In February 2025, behaviors were not recorded for 2 out of 8 days b. In January 2025, behaviors were not recorded for 4 out of 9 days c. In December 2024, behaviors were not recorded for 2 out of 9 days Review of Progress Notes in the electronic health record lacked documentation to address if behaviors had been observed or not on the days missing documentation on the BAR for Resident #25. During an interview on 3/12/25 at 1:45 PM, Staff A, Licensed Practical Nurse, explained tasks, such as completion of the BAR, is flagged in yellow as a reminder. If the day is marked with a check-mark on the BAR, the specific question has been addressed and no behaviors observed. The initials NO on a day indicate behaviors not identified. During an interview on 3/12/25 at 2:00 PM, the Director of Nursing (DON), acknowledged the incomplete BAR documentation for Residents #17, #24, and #25. Upon further review, the missing documentation occurred on all the same days for the three residents. The DON explained the BAR is completed by nursing staff and flagged for completion during medication rounds throughout the day. Certified Medication Aides (CMA) were scheduled to pass medications on the undocumented days on the BAR. The CMA's do not have access to the BAR completion and are unaware of the task to alert nursing staff. The policy Adverse Effects Monitoring Process, revised 04/2024, stated professional team members should record if adverse effects are present as indicated on the order set at the triggered times.

Based on observations, staff interview, and policy review, the facility failed to securely store resident medications for 1 of 6 residents reviewed for medication administration. The facility reported a census of 33 residents. Findings include: During an observation on 3/10/25 at approximately 10:00 AM, on the Chronic Confusion or Dementing Illness (CCDI) Unit, the medication drawer in Resident #18's room was not securely locked and was easily opened. The unsecured drawer was full of Resident #18's medications. During an interview on 3/10/25 at 10:05 AM, the Director of Nursing, DON, witnessed and acknowledged the unlocked drawer. The DON removed the medications and placed them in another drawer that was securely locked. The DON stated medication drawers are to be locked when actively filled with medications and supplies. The policy Medication Administration, Storage, Disposal, and Nurse Review, revised 09/2020, stated all prescription medications must be kept in a locked cabinet.

Based on observation, clinical record review, policy review and staff interview the facility failed to ensure the garden gate closed securely allowing 2 residents to leave the garden unnoticed. (Resident#1 and #2) The facility reported a census of 35 residents. Findings Include: 1. The Admission Minimum Data Set (MDS) dated [DATE] for Resident #1 documented a Brief Interview for Mental Status (BIMS) of 6 which indicated severe cognitive impairment. The MDS documented diagnosis including non-traumatic brain dysfunction, Alzheimer's disease and hypertension (high blood pressure). The MDS documented that the resident was independent with walking. The Care Plan for Resident #1 included a focus area of elopement risk/wanderer related to history of attempts to leave the facility and impaired safety awareness dated 5/2/24. The Care Plan interventions included use of wander guard, provide structured activities, redirect/distract when wandering and provide an assortment of nuts/bolts/washers for resident to sort. The Progress Note written on 6/2/24 at 2:59 PM documented Resident #1 was found outside the designated patio and was returned inside the facility within 5 minutes. 2. The Quarterly MDS for Resident #3 dated 4/3/24 documented a BIMS of 2 which indicated severe cognitive impairment. The MDS documented diagnosis including non-traumatic brain dysfunction, Alzheimer's disease and anxiety disorder. The Care Plan for Resident #3 included a focus area of elopement risk related to wandering and Alzheimer's disease dated 10/12/22. The Care Plan interventions included distract from wandering by providing diversional activity and identify purpose of wandering (looking for the bathroom). The Care Plan documented that the resident walked independently. The Progress Note written on 6/2/24 at 3:22 PM documented Resident #3 escaped through a locked gate on the patio and was found walking along the side of the building on the sidewalk. During an interview on 6/17/24 at 2:20 PM, Staff A, activities and Lifestyles Coordinator, explained she had worked the morning of 6/2/24. After she got off work, she went home and returned a short time later about 1:00 PM and had been fishing on campus. She had caught a good-sized fish. She took a picture and released the fish. There were residents sitting in the gated garden area. She entered the garden area using the key pad release from the outside. She showed a few residents the picture. There was a family member sitting outside with the residents but no staff present. Staff A continued, explaining when she left the garden gate, she heard it hit to latch but did not turn around to visualize the gate had properly latched. During an interview on 6/17/24 at 2:41 PM the Director of Plant Operations explained he conducted an inspection of the latch on the morning of 6/3/24. There was no explanation why the gate did not latch, there was nothing structurally or mechanically wrong with the latch. During an interview on 6/17/24 at 4:27 PM the Executive Director stated they take resident safety very seriously; the residents are safe. Review of the security camera footage at 4:38 on 6/17/24. The footage for 6/2/24 showed Resident #1 entering view in front of garage at 1:41:44 PM. Resident #3 entered into the view in front of garage at 1:42:25 PM and stood next to Resident #1. Both residents turn and walk up the sidewalk along the building. Both residents walk out of camera view at 1:45:45 PM. Team member comes quickly out of garage side door towards residents at 1:46:02. Facility document titled Elopement Precautions Policy last revised 4/22 directs that the electronic door alarms must remain active at all times. During an interview on 6/19/24 at 1:53 PM the Executive Director explained she would expect facility staff to follow facility policies.

Based on observation, staff interviews and policy reviews the facility failed to ensure staff completed appropriate hand hygiene and glove usage prior to incontinence care for 1 of 1 residents (Resident #26) reviewed. The facility reported a census of 33 residents. Findings Include: A Minimum Data Set (MDS) for Resident #26, dated 4/5/24, included diagnoses of hypertension (high blood pressure), urinary tract infection in last 30 days, and anxiety disorder. The MDS identified the resident required partial to substantial assistance for transfers, toileting, and personal hygiene. The MDS documented the resident had a Brief Interview for Mental Status score of 9, indicating moderate cognitive impairment. Observation on 04/24/24 at 1:32 PM, Staff B, Certified Nurse Aide entered room to assist Resident #26 during toileting. Staff B washed hands, applied gloves, removed the resident's shoes and pants, applied a new attend, reapplied the resident's shoes, touched the dirty trash bag, and with the same gloves on proceeded to complete peri care on the resident. After cares completed, Staff B removed gloves and washed hands. Facility policy, Hand Washing and Hand Hygiene revised 6/2020 revealed hand hygiene must be performed after touching contaminated items and before providing personal cares for a resident (peri care). Interview on 4/24/24 at 4:00 PM, the Director of Nursing stated her expectation for staff to complete hand hygiene and apply new gloves before completing peri care.

Based on document review and staff interview the facility failed to provide Registered Nurse (RN) coverage eight consecutive hours a day, seven days a week. The facility reported a census of 33. Findings include: Review of facility's PBJ (Payroll Based Journal) Staffing Data Report (staffing numbers reported to Centers for Medicare and Medicaid Services) for the fiscal quarter of 2024 (October 1, 2023-December 31, 2023) identified a No RN hours trigger for 11/12, 12/9, 12/10, 12/23, and 12/24/23. Review of facility's schedule for the following dates revealed no RN scheduled to work: 11/12, 12/9, 12/10, 12/23, and 12/24/23. Interview on 4/23/24 at 2:42 PM, the Administrator confirmed the facility did not have 8 hours of RN coverage on the days reported on the PBJ report of 11/12,12/9, 12/10, 12/23, and 12/24/23. The Administrator stated there was a RN on call but not in the facility. The Administrator stated they do not have a policy for RN coverage that they follow the federal regulations for RN coverage 8 hours a day and her expectation for RN coverage 8 hours a day/7 days a week.

Based on staff interview, record review, and policy review the facility failed to follow a physician's order for one (Resident #26) of twelve residents reviewed. The facility reported a census of 33 residents. Findings include: A Minimum Data Set (MDS) for Resident #26 dated 4/5/24, included diagnoses of hypertension (high blood pressure), urinary tract infection in last 30 days, and anxiety disorder. The MDS identified the resident required partial to substantial assistance for transfers, toileting, and personal hygiene. The MDS documented the resident had a Brief Interview for Mental Status score of 9, indicating moderate cognitive impairment. Resident's Order Summary Report dated 4/24/24 documented the following current physician orders: 1. Clonidine (blood pressure medication) 0.1milligrams (mg) every 6 hours as need (PRN) for systolic blood pressure (SBP) (top number of BP) greater than 160 or diastolic blood pressure (DBP) (lower number of BP) greater than 100 starting 4/1/24. 2. Check BP every 6 hours and administer PRN clonidine per parameters every 6 hours related to hypertension starting 4/11/24. Resident's blood pressure summary report revealed the following dates and blood pressures: a. 4/6/24 8:00 AM - 161/71 b. 4/7/24 10:47 PM -169/97 c. 4/7/24 11:15 PM - 190/96 d. 4/8/24- 3:33 AM 181/93 e. 4/8/24 8:15 AM - 172/84 f. 4/8/24 11:15 AM - 175/85 g. 4/12/24 7:15 AM - 175/85 h. 4/17/24 7:27 AM - 168/93 i. 4/22/24 7:37 AM - 163/99 j. 4/22/24 6:42 PM - 163/99 k. 4/24/24 8:08 AM 180/100 Resident's Medication Administration Record for 4/1/24 - 4/30/24, revealed the clonidine PRN order had not been administered at all during those dates. Interview on 4/24/24 at 10:43 AM, Staff A, Licensed Practical Nurse stated the skilled residents' BPs are taken 2 times a day. Staff A further stated that she had taken the resident's BP about 8 AM and the resident's BP was 180/100. Staff stated she administered the resident's morning medications and did not give the clonidine PRN medication. Staff A stated she was not aware of the order for the resident's BP to be taken every 6 hours or the order for clonidine. Staff A stated she should have administered the clonidine based on the BP 180/100. Facility policy, Medication Administration revised 11/2022 documented the authorized person will ensure prescribed medication is administered per physician order. Interview on 4/24/24 at 11:05 AM, the Director of Nursing stated her expectation is to follow the physician's order.

Based on clinical record review, staff interviews, facility policy review and Pharmacist interview, the facility failed to assure narcotic medication was in a secure location and not accessible to a dependent resident resulting in the possible ingestion of up to 18 Hydrocodone/APAP (Tylenol) 5-325 milligrams (MG) unsupervised in less than 24 hours for 1 of 1 residents with a history of drug seeking behavior (Resident #1). This failure resulted in 72 hours of monitoring of Resident #1 causing an Immediate Jeopardy (IJ) to the health, safety and security of the resident. The State Agency informed the facility of the IJ that began on April 27,2023 on September 13, 2023 at 4:30 PM. The facility staff removed the IJ on April 28, 2023 through the following actions: a. All team members from all departments will be educated as they come on for shifts starting immediately, including agency started 4/28/23 and ongoing. b. Daily huddles and shift to shift huddles- educate and obtain signatures with dates. Started 5/10/23 and ongoing. c. All team members in all departments will be educated if they note medications not properly stored in resident room in locked drawer or for narcotics double locked in medication room they are to notify their supervisor. Completed 4/28/23 and ongoing. d. All facility leaders will be educated by the Executive Director in the event of a concern with medication they are to immediately report to the Director of Nursing (DON) and Executive Director. Completed 4/28/23. e. Resident care plan updated to have an opioid substance disorder. Completed 4/28/23. f. Director of Social Services will meet with resident to establish psychosocial needs- she will offer Encounter Telehealth. Completed 5/2/23. g. Resident will be monitored for 72 hours for signs and symptoms of lethargy change in condition related to medication. Started 4/28/23. h. Nurse Practitioner documented routine pain medication and review, due to diagnosis of opioid dependence. Completed 5/9/23. i. Staff A, Registered Nurse (RN) was educated and received a corrective action. Educated 4/28/23, Corrective Action 5/1/23. j. Medication was replaced by the facility and the facility responsible for costs. Completed on 4/28/23. k. Continue to audit medication laptop cart and resident medication drawers. Started 5/1/23 and continues 3x weekly minimum and PRN. i. Created a binder with self-report, all policies, communication/education with team and signatures. Completed 5/4/23. The scope lowered from a J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility identified a census of 34 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) of 11 out of 15 indicating moderate cognitive impairment. The MDS further indicated the resident was independent with transfers, locomotion on the unit and in the corridor and had diagnosis including opioid dependence, anxiety disorder, depression, wedge compression fracture of second lumbar vertebrae and chronic pain syndrome. The MDS documented the resident received scheduled and PRN pain medication. The MDS also documented she received opioid pain medication 7 days of the last 7 day look back period. The Care Plan initiated 12/21/22 revealed Resident #1 was on pain medication therapy related to chronic pain and used as needed opioid (narcotic) pain and non-opioid pain medication. The Care Plan had a goal for the resident to be free of any discomfort or adverse side effects from pain medication and directed staff to administer analgesic medications as ordered by physician, monitor for increased risk for falls, monitor for adverse reactions to analgesic therapy including mental status, anxiety, constipation, depression, dizziness, lack of appetite, nausea, vomiting, pruritus (itching), respiratory distress, decreased respirations, sedation and urinary retention. The Care Plan initiated 4/28/23 documented Resident #1 was at risk for substance abuse disorder of opioids. The Care Plan directed staff as follows: -resident seeks out opioids and other analgesics. Monitor for seeking behavior. -remain non-judgmental. Be alert to changes in behaviors (restlessness, increased tension). -offer quiet space to reduce stimuli. The April 2023 Medication Administration Record (MAR) for Resident #1 documented the following orders: a. Acetaminophen (APAP) 500 MG 1 tablet three times a day *max 4 grams (GM)/24 hours start 3/7/23 6:00 AM. b. Hydrocodone/APAP tab 7.5-325 MG 1 tablet every 4 hours as needed for pain start 3/21/23 at 12:00 AM. The MAR documented the resident received Hydrocodone/APAP 7.5-325 mg at the following times: On 4/27/23 at 7:02 AM and at 2:20 PM. On 4/28/23 at 7:22 AM. Review of facility Incident Report #1083 dated 4/2023 revealed Staff B, the previous Assistant Director of Nursing (ADON) and the DON searched Resident #1's room and a missing narcotic card was found in the resident's dresser drawer folded up in fourths inside a pocket of a pair of jeans. The resident stated she had never seen the medication before and did not know what they were. Review of Resident #1's Progress Notes revealed the following documentation: -On 3/27/23 at 5:44 AM resident observed by nurse with at least 8-10 Tylenol tablets attempting to take them back to her room. Resident educated on not taking pills without the knowledge of the nurse. -On 3/27/23 at 6:23 AM resident observed by RN with a handful of Tylenol that she took from the medication cart attempting to take them back to her room. Resident stated she had a headache. PRN Hydrocodone 7.5 mg offered to the resident. Resident educated on the importance of asking for PRN medications instead of attempting to take them. DON and oncoming staff informed of the incident. Will continue to monitor resident. -On 4/28/23 at 7:50 PM Physician notified of 18 tabs of Hydrocodone/APAP 5-325 MG missing and possibly consumed by the resident and directed staff to monitor the resident and send to the hospital if necessary. -On 4/28/23 at 9:08 PM son made aware of stolen narcotics and possible consumption. Son voices understanding and denies questions or concerns. Review of facility policy titled, Controlled Substances Distribution and Administration, approved 7/2016, documented the purpose of the protocol was to ensure the proper distribution and administration of controlled substances (CIO medications) and revealed all controlled substances will be stored, distributed and administered in compliance with all applicable laws and regulations. Review of facility policy titled, Medication Administration, Storage, Disposal and Nurse Review, approved 9/2020, documented all prescription medication must be kept in a locked cabinet. All other medications must be stored in a locked area not accessible to persons other than employees responsible for administration and storage of medications. Narcotics shall be stored in a double locked area. During an interview on 9/13/23 at 5:27 AM, Staff A, RN revealed the pharmacy had delivered medications the evening of 4/27/23 around 8:30 PM while Staff A was in the middle of passing medications. Staff A revealed she delivered the medications to the locked cabinets in resident rooms around 10:00 PM and around midnight she was busy putting papers away when she checked the list of medications pharmacy had delivered that night and noticed a narcotic had been delivered. Staff A stated she checked the narcotic drawer and couldn't locate the narcotic that had been delivered. Staff A revealed she thought maybe she had misplaced the narcotic and went to every resident's room and checked every medication drawer and couldn't locate it. Staff A stated she then called the pharmacy to provide verification they had delivered the narcotic and she notified the DON. Staff A revealed she had set the medications that had been received from the pharmacy at the nurse's station unsupervised and unsecured for approximately one hour following their delivery. Staff A reported the normal protocol is to put narcotics in the locked medication room in a locked drawer in order to have the narcotics double locked. Staff A stated she had seen Resident #1 walking around when Staff A was looking for the narcotic around 1:00 AM or 2:00 AM after she had been looking for the narcotic and stated Resident #1 had a history of seeking out medication. Staff A reported the normal process for pharmacy deliveries is the pharmacy scans the medication on a mobile phone one at a time and then facility staff sign off after the medications are scanned. After signing, the pharmacy will fax a confirmation sheet of what had been delivered sometimes within 30 minutes and sometimes more than 30 minutes after delivery. During an interview on 9/12/23 at 12:22 PM, Staff D, Pharmacist revealed 4 GM of Tylenol in a 24-hour period of time would be the maximum dose. On 9/13/23 at 10:27 AM, the Clinical Quality Specialist revealed in April 2023 there were 6 residents that resided in the community of the facility where the incident occurred that wandered with purpose. During an interview on 9/13/23 at 12:59 PM, the DON reported the physician had reported to monitor Resident #1's breathing and somnolence (excessive drowsiness). The DON further revealed she was concerned the resident was going to go unresponsive and was thankful she had a high tolerance because of her history. During an interview on 9/13/23 at 1:13 PM, Staff B, the previous ADON stated she had general concerns for Resident #1's safety following the incident as it was very serious if someone ingests too many narcotics as they could overdose and die.

Based on Resident interviews, staff interviews and record review the facility failed to answer call lights in a reasonable amount of time (15 minutes or less) for 3 of 8 residents interviewed (Res#30, Res #37 and Res#236) . The facility reported a census of 34 residents. Findings included: Interview on 01/30/23 at 12:14 PM Resident #30 relayed she used the call light and waited a half an hour while sitting on the toilet and another time waited 55 minutes in the morning for staff assistance. Resident #30 relayed she has a clock in her room and that is how she monitors time. Resident #40 relayed feelings that there is not enough staff. Interview on 01/30/23 02:00 PM Resident #236 voiced waited 10 -30 minutes, relayed she used her cell phone to look at the length of time staff responded. Interview on 01/31/23 08:49 AM Resident #37 voiced she used her calllight when needing assistance, waited at times over 20 minutes. Record review of facilities call light system logs provided by the Director of Nursing (DON) on 2/1/23 at 03:40 PM documented time over 15 minutes Res#30, Res #37 and Res#236. Review of 5 days log for residents interviewed from 1/25/23 to 1/30/23: for Resident #30 call light record documented a.01/25/23 at 2:13 PM - 50 minutes b.01/25/23 at 2:17 PM - 30 minutes c.01/26/23 at 7:03 AM - 25 minutes d.01/27/23 at 7:47 AM - 62 minutes e.01/27/23 at 7:37 AM - 38 minutes f.01/27/23 at 8:02 PM - 22 minutes g.01/28/23 at 2:07 AM - 21 minutes h.01/28/23 at 9:07 AM - 29 minutes i.01/28/23 at 4:09 PM - 24 minutes For Resident #37 call light record documented: a.01/27/23 at 11:32 AM -17 minutes b.01/27/23 at 6:38 PM - 21 minutes c.01/28/23 at 7:18 PM - 36 minutes d.01/29/23 at 4:09 PM - 18 minutes e.01/29/23 at 8:03 AM - 30 minutes f.01/29/23 at 8:53 Am - 20 minutes g.01/30/23 at 4:39 AM - 63 minutes h.01/30/23 at 4:47 AM - 28 minutes 01/30/23 at 6:02 AM - 18 minutes For Resident #236 call light record documented: a.01/25/23 at 12:24 PM- 37 minutes b.01/25/23 at 2:48 PM - 24 minutes c.01/25/23 at 6:21 PM - 26 minutes d.01/26/23 at 9:36 AM - 27 minutes e.01/26/23 at 12:11 PM- 35 minutes f.01/27/23 at 8:31 AM - 22 minutes g.01/27/23 at 2:33 PM -19 minutes h.01/29/23 at 1:14 PM - 23 minutes i.01/29/23 at 10:20PM - 29 minutes j.01/30/23 at 11:24 AM - 23 minutes Interview with the Administrator on 02/02/23 at 02:30 PM voiced expectation, relayed call lights to be answered within 15 minutes or sooner. Interview with the Director of Nursing (DON) on 02/03/23 at 03:00 revealed expectation for call lights to be answered in 15 minutes or less. Requests made throughout the survey for a Call light policy, not provided.

Based on staff interviews, physician interview and record review the facility failed to notify the physician of resident change in condition for 1 of 3 residents (Resident 36) reviewed. The facility reported a census of 34 Residents. Findings include: The MDS dated [DATE] documented a Brief Interview of Mental Status (BIMS) as 15 indicating no cognitive impairment. The MDS also documented the need for extensive assistance of one person with bed mobility, transfers, dressing, toilet use and personal hygiene. The MDS documented diagnosis of benign prostatic hyperplasia, renal insufficiency, obstructive uropathy, urinary tract infections, acute kidney failure, acute cystitis, diabetes and heart disease. The care plan dated 5/27/21 documented residents indwelling catheter, interventions/tasks included to monitor, record and report to the doctor signs and symptom of infection, included , report no urine output. Record review of urinary output documented 1/4/2022 to 1/10/2022 On 1/4/2022 - day shift 450, evening shift 950, night shift 200 On 1/5/2022 - day shift 1000, evening shift 600, night shift-blank no documented On 1/6/2022 - day shift 600, evening shift 425, night shift-blank not documented On 1/7/2022 - day shift-blank not documented, evening 450, night shift -blank ON 1/8/2022- day shift- blank not documented, evening shift 600, night shift 300 On 1/9/2022 - day shift 600, evening shift 650, night shift 300 On 1/10/2022- day shift 250, evening shift 0 (zero), night shift blank resident at the hospital. Progress note dated 2/11/2022 at 02:15 AM documented assessed resident, appears pale, lethargic, blood pressure documented 66/40. Continued to have no output in catheter. Resident was sent to the emergency room and hospitalized . Interview on 02/02/23 at 02:38 PM 02/02/23 02:38 PM nurse, staff D, relayed the output in the computer is the only place that catheter output is documented, should be documented by all shifts. Interview on 02/02/23 at 02:49 PM Staff E, Director or nursing (D.O.N.) relayed the expectation is a CNA notifies the nurse if there is no urine output in the catheter bag, generally the doctor is notified if there is no output in 6 hours, the doctor should of been notified if there was no urine output in a shift, that would be abnormal and the physician notification is needed. Interview on 02/02/23 at 09:42 AM Physician, Staff F reviewed resident record, acknowledged resident had no urinary output in the catheter for an entire shift, relayed a report to the doctor would be warranted with no urine out put in a shift, stated no urine output in the catheter bag for an entire shift is not normal.

Based on testing logs, policy review, and staff interview, the facility failed to test 1 of 3 staff members reviewed during an outbreak. The facility reported a census of 34 residents. Findings include: 1. Review of Covid-19 Test Consent Forms between the dates of 12/14/22 through 02/02/23 revealed the facility tested Staff A on 12/14, 12/15, and 12/19/22. The facility also provided an undated, untitled, handwritten document that contained 2 additional testing dates for Staff A: 12/27/22 and 1/25/23. Review of the undated Covid Positive Residents List identified Resident #27 tested positive on 12/23/22. Resident #27's Survey Report v2 Report for December 2022 revealed Staff A assisted the resident with activities of daily living on 12/22/22. The facility lacked further documentation to show any additional tests for Staff A during this time period. The undated facility document Covid Positive Resident identified 3 additional residents tested positive on 12/28/22, 12/29/22, and 1/7/23. The Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 9/23/22, directed facilities to perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. The recommendations stated if additional cases were identified, strong consideration should be given to shifting to the broad-based approach. As part of the broad-based approach, testing should continue on affected unit(s) or facility-wide every 3-7 days until there are no new cases for 14 days. The facility policy, COVID 19 Clinical Update revised 11/2022, documented if a community was not able to identify all close contacts, they should perform testing for all residents and staff on the affected units as soon as possible. During an interview on 2/2/23 at 11:50 a.m., the Director of Clinical Excellence stated if a resident tested positive, they would test everyone in the household. During an interview on 2/2/23 at 1:30 p.m., the Director of Clinical Excellence reported if a staff member was exposed to a Covid positive staff member but was wearing a mask, she would not need to test. She did not have the documentation available, but said she would look for CDC Guidance to support this and subsequently submit it to the Department.

Based on observation, record review and staff interviews the facility failed to prevent possible accidents/injuries when staff pushed 1 of 4 residents reviewed in a wheelchair that lacked foot pedals (Resident #23). The facility reported a census of 34 residents. Findings include: The Minimum Data Set (MDS) Assessment tool dated 7/10/21 revealed Resident #23 scored 0 of 15 possible points on the Brief Interview for Mental Status (BIMS) test, which meant the resident displayed severe cognitive impairment. Active diagnoses listed on the MDS included Alzheimer's disease, unspecified lack of coordination, and other abnormalities of gait and mobility. The Care Plan dated 8/5/2021 documented Resident #23 as at risk for major injury related to history of falls due to dementia with lack of safety awareness, weakness, irritability with redirection, and instability. Observation on 08/24/21 at 11:47 AM revealed Staff A, Certified Nursing Assistant (CNA), pushed Resident #23 approximately 15 feet from an activity table to a lunch table in a wheelchair without foot pedals attached. Observation on 08/24/21 at 01:00 PM revealed Staff B, Lifestyle Coordinator asked the resident if he would like to go to yoga. Resident #23 lifted his legs and Staff B then pushed Resident #23 down the hall with no foot pedals attached to the chair in front of other staff members. Observation revealed none of the staff members that witnessed Staff B push the resident without foot pedals intervened. In an interview on 08/25/21 at 1:44 PM, the Director of Nursing (DON) stated she expected staff to attach pedals to the wheelchair when transporting a resident in a wheelchair. Section 5 of the facility's Wheelchair Use policy directed staff to lower footrests and place the resident's feet on the footrest if used.

Based on clinical record review and staff interviews, the facility failed to complete an accurate quarterly assessment using the Resident Assessment Instrument (RAI) specified by CMS for 2 of 2 Residents reviewed (Residents #10 and #25). The facility reported a census of 34 residents. Findings Include; 1. The quarterly Minimum Data Set (MDS) assessment tool dated 5/28/21 identified Resident #10 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented staff administered Resident #10 an anticoagulant on 7 days during the 7 day look back period. The May 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . 2) According to the MDS dated [DATE], Resident #25's medication regimen included an anticoagulant. Review of the July 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 08/26/21 at 10:53 AM, the Director of Nursing (DON) and Corporate MDS Coordinator both reported they expected staff to code and complete the MDS correctly.

Based on observations, staff interviews, and policy review the facility failed to comply with current infection prevention and control standards. The facility reported a census of 48 residents. Findings include: 1. During observations on 8/12/20 at 12:30 P.M., 8/17/20 at 5:30 P.M., and 8/18/20 at 11:45 P.M., 12-14 residents were observed in the dining room seated at 3 tables and a bar. Four to six residents were seated at the table tops that measured 90 inches X 42 inches. Two to three residents were seated at the table tops that measured 36 inches X 36 inches. No residents were observed wearing masks and no masks were visible on the tables. The residents were not maintained at a distance of 6 feet apart to adhere to social distancing requirements. 2. During an observation on 8/18/20 at 11:30 A.M., Staff C, Licensed Practical Nurse (LPN) placed clothing protectors on several residents and touched each resident. The LPN proceeded to ask several individual residents what kind of juice they wanted to drink, pour the juice from a carafe into a glass, and give the glass to each resident. The LPN touched each resident on the shoulder or back while talking to them. The LPN failed to sanitize her hands after touching each resident and then touching the carafe and glasses for each resident. Review of a facility policy dated 2008 titled Hand Washing and Hand Hygiene stated hand hygiene must be performed with specific examples of before and after touching medication or food to be given to a resident and between contacts with different residents in high risk areas. During an interview on 8/18/20 at 1 P.M., the DON verified staff should sanitize their hands between touching residents and the glasses.

Based on clinical record review and staff interviews, the facility failed to document care plan interventions for 2 of 9 care plans reviewed (Residents #4 and #5). The facility reported a census of 28 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #4 showed an admission date of [DATE] and a Brief Interview for Mental Status (BIMS) score of 15, which meant the resident demonstrated intact cognition. The MDS revealed the resident had [DIAGNOSES REDACTED]. The MDS documented Resident #4 required assistance of staff for transfers. An incident report revealed a fall occurred on 7/30/20 at 8:00 pm when the resident attempted to transfer independently from the recliner to the bed. The resident sustained [REDACTED]. On admission, the care plan identified the resident as a fall risk and contained interventions to prevent falls, including assistance with transfers; however, staff did not list a care plan intervention for the 7/30/20 fall until 8/12/20. On 8/13/20 at 08:45 am, Staff E, Licensed Practical Nurse (LPN) reported not placing an intervention on the care plan the shift of the fall on 7/30/20. On 8/13/20 at 10:25 am, Staff D, Registered Nurse (RN) could not recall a fall intervention being implemented when working the two days following the fall (7/31/20 and 8/1/20). On 8/18/20 at 03:45 pm, the Minimum Data Set (MDS) Coordinator produced a note by the DON, dated 7/31/20, with the incident report stating the resident was forgetful at times and signage posted in the room for a reminder to use the call light. The DON, on 8/13/20 at 10:45 am, said he placed the intervention on the care plan on 8/12/20 following a review where he recognized the reminder sign had not been put on the care plan at the time the intervention had been implemented. 2. The MDS assessment dated [DATE] for Resident #5 showed an admission date of [DATE] and a BIMS score of 4, which indicated the resident displayed severe cognitive impairment. The MDS reveled the resident had [DIAGNOSES REDACTED]. Incident reports reveal the resident fell on [DATE], 5/21/20, 5/24/20, and 5/29/20. Interdisciplinary notes document the falls from 5/5/20 to 5/29/20 and do not indicate any interventions to prevent them in the future. The care plan identified the resident as at risk for falls and included interventions to prevent falls. However, the resident fell four times between 5/4/20 and 6/5/20, but did not contain any interventions to address those falls. On 8/18/20 at 03:45 pm, Staff C, LPN, stated that the nurse writing an incident report for a fall does not devise an intervention as that is left to the Director of Nursing (DON). On 8/13/20 at 03:45 pm, the MDS Coordinator stated that an interdisciplinary team meets Monday through Friday to discuss falls and determine an intervention to be placed on the care plan, although over the weekend, the on-call nurse might update the care plan. The facility's Fall Checklist revised 8/5/19 directed staff there must be a new intervention to prevent a fall added to the care plan and documented in the interdisciplinary notes. On 8/19/20 at 01:00 pm the DON stated the expectation is for the nurse writing the incident report to update the care plan with a fall intervention.

Based on observation, clinical record review, and staff interview, the facility failed to ensure staff provided oral care/personal hygiene for one (Resident #9) of two residents observed. The facility reported a census of 48 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #9 dated 7/18/20, included [DIAGNOSES REDACTED]. The MDS identified the resident needed extensive assistance of two staff for bed mobility, transfers, dressing, toilet use and personal hygiene. An observation on 08/19/20 at 11:38 AM revealed the resident lying in bed. Staff A, Certified Nurse Aide (CNA) and Staff B, CNA proceeded to provide incontinent care, dress the resident, transfer her to a wheelchair and push her to the dining room for lunch. At that time, the resident's hair stuck out in the back and on the sides. Staff did not offer or provide any personal hygiene (washing of face, hands, chest, arm pits; deodorant; hair grooming) or oral care. During an interview on 08/19/20 at 11:50 AM, Staff B, CNA, verified the resident did not get up for breakfast and was getting up for the first time that day. CNA stated the resident usually sleeps in and then staff assist her up for lunch. During an interview on 8/19/20 at 12 P.M., the Director of Nursing (DON) stated the expectation for resident's personal hygiene and oral care to be completed in the morning before breakfast or when getting up for the day. The DON stated the cares to be completed are perineal care, oral care, and washing of face, hands, and chest/armpit areas. He also stated staff should apply deodorant and brush/comb the resident's hair. The DON verified even if resident often refuses, staff should offer personal hygiene cares.