Every finding on record at Cambridge Post Acute Care Center

Based on staff interview, record review, and facility policy review, the facility failed to ensure ongoing assessment and monitoring for complications before and after dialysis treatments were completed to ensure communication with the dialysis facility for one of two residents (Resident (R) 10) reviewed for dialysis of 32 sample residents. This failure had the potential to lead to uncommunicated and unassessed changes or complications for R10 and other residents receiving dialysis.Findings include:Review of the undated facility's policy titled, DIALYSIS, revealed Post Dialysis Monitoring: 1. Licensed nurse to obtain . Blood Pressure . Pulse . Presence/Absence of Bruit/Thrill as indicated . Licensed nurse will monitor for Signs/Symptoms of fluid overload/deficit . Dizziness . Neck vein distention . Remove pressure dressing from the shunt/fistula site upon return from Dialysis as indicated . Review of R10's admission Record located under the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses of end stage renal disease and dependence on renal dialysis. Review of R10's significant change Minimum Data Set (MDS) with an Assessment Reference Date of 11/26/2025 and located under the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) was not conducted due to severely impaired cognition. The MDS further indicated she received hemodialysis.Review of R10's physicians order located under the Orders tab of the EMR and dated 03/02/2026, revealed dialysis every Tuesday and Saturday. Additional physician's orders indicated to monitor for complications from dialysis one time a day every Tuesday and Saturday due to dialysis treatment, to monitor for complications from dialysis and to report to MD (medical doctor) or healthcare extender.Review of R10's care plan located under the Care Plan tab of the EMR, dated 08/14/2025 and last revised 03/17/2026, revealed The resident with ESRD [end stage renal disease] and hemodialysis to obtain vital signs per protocol and report significant changes in pulse, respirations, and blood pressure immediately. The care plan also indicated, Monitor/document/report to MD PRN [as needed] for s/sx [signs/symptoms] of the following: Bleeding, Hemorrhage, Bacteremia, septic shock . Changes in level of consciousness . heart and lung sounds .Review of R10's EMR under the Documents tab revealed no Dialysis Communication Form for the following dates R10 was scheduled for dialysis treatment: 03/07/2026, 03/10/2026, 03/14/2026, 03/21/2026, 03/24/2026, 03/28/2026, 03/31/2026, and 04/07/2026. During an interview on 04/10/2026 at 11:35 AM, Unit Manager (UM) 2 reviewed R10's medical record and looked at documents at the nurse's station and confirmed there were no Dialysis Communication Forms for dialysis treatments on the following dates: 03/07/2026, 03/10/2026, 03/14/2026, 03/21/2026, 03/24/2026, 03/28/2026, 03/31/2026 and 04/07/2026. UM2 stated when the resident returned to the facility after dialysis, the nurses were supposed to assess the resident and complete a Dialysis Communication Form. She stated the nurses were supposed to document their portion on the bottom of the form.vital signs and site assessment.

Based on observations, record review, staff interviews, and facility policy review, the facility failed to follow infection control guidelines during wound treatment for one of two residents (Resident (R) 10) reviewed for pressure ulcers and failed to follow infection prevention measures when an indwelling urinary catheter bag was placed on the floor for one of two residents (R10) reviewed for catheters of 32 sample residents. These failures had the potential to cause infections in the wound and the urinary tract for R10.Findings include:Review of the facility's policy titled, Dressings Non-Sterile, dated June 2025, revealed The purpose of this procedure are to provide guidelines for sterile dressing changes to protect wounds from injury and to prevent the introduction of bacteria . 20. Cleanse the wound. Use separate gauze for each cleansing stroke. Clean from the most contaminated area to the least contaminated area.Review of the facility's policy titled, Catheter Care, Urinary, dated June 2025, revealed The purpose of this procedure is to prevent infection of the resident's urinary tract . Be sure the catheter tubing and drainage bag are kept off the floor .1. Review of R10's Face Sheet located under the Profile tab in the electronic medical record (EMR) indicated R10 was admitted to the facility on [DATE]. R10's primary diagnosis was sepsis (life-threatening infection). Other diagnoses included septic shock, osteomyelitis (bone infection) of the sacral (base of the spine) and sacrococcygeal (base of spine and tail bone area) vertebra (bones of the spine) regions, and a history of urinary tract infections. Review of R10's significant change Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 11/26/2025 indicated a Brief Interview for Mental Status (BIMS) was not conducted due to severe cognitive impairment. The MDS also indicated R10 had a stage four pressure ulcer and an indwelling urinary catheter.Review of R10's Physician Orders located under the Orders tab in the EMR revealed an order dated 04/03/2026, documented STAGE 4 PRESSURE WOUND [a severe, full-thickness wound extending to exposed muscle, tendon, or bone] SACRUM FULL THICKNESS . Sodium hypochlorite solution (dakins [sic]) and cover with ABD [abdominal] pad and secure with Tape (paper) apply once daily and as needed . if saturated, soiled, or dislodged for 30 days every day shift for wound for 30 days.Review of R10's care plan located under the Care Plan tab of the EMR, dated 03/20/2026, titled, STAGE 4 PRESSURE WOUND SACRUM FULL THICKNESS which indicated, . Provide wound care per treatment order. An additional Care Plan titled, The resident has pressure ulcer stage 4 to sacrum, with an initiation date of 09/27/2025, indicated . the resident's Pressure ulcer will . remain free from infection . During an observation of R10 in her room on 04/09/2026 at 11:05 AM, Unit Manager (UM) 2 provided wound care to R10's stage four sacral pressure ulcer. With gloved hands, UM2 adjusted R10's brief, placing her gloved hand in R10's perineal (between rectum and vagina) area and partially removed the brief. With the same gloved hands, UM2 proceeded to clean R10's sacral pressure ulcer. UM2 did not remove the soiled gloves or perform hand hygiene prior to cleaning the wound. Then, UM2 changed the gloves during the wound cleaning but did not perform hand hygiene. UM2 then continued to clean the sacral pressure ulcer and using a gauze pad wiped from the perineal area, up the left buttock and up to the sacral wound and around the wound edge from the six o'clock position to the twelve o'clock position of the wound.During an interview with UM2 immediately after the completion of the wound care observation on 04/09/2026 at 12:00 PM, UM2 confirmed she did not remove the soiled gloves, perform hand hygiene, and apply clean gloves prior to cleaning R10's sacral pressure ulcer. UM2 also confirmed she used the same gauze pad she used to clean R10's perineal area up the buttock and around the wound edge going from a dirty area to a clean area. UM2 confirmed she should not have cleaned from the perineal area up the buttocks to the sacral wound.During an interview on 04/10/2026 at 1:00 PM, the Infection Preventionist (IP) was asked what her expectations were for a nurse performing wound care to an open wound. IP stated after removing a resident's brief and before beginning wound cleaning, the nurse was supposed to put on clean gloves and wound cleaning was to be done from clean to clean and dirty to dirty. The IP stated it's not ok for the nurse to go from the perineal area up the buttocks and then around the wound edge. 2. Review of R10's Physician Order located under the Orders tab of the EMR,, dated 03/02/2026, indicated Change Indwelling catheter 16 FR [French = size] and Inflate with 10 CC [cubic centimeter - a unit of measure] of sterile water one time a day starting on the 28th and ending on the 28th every month.Review of the Care Plan located under the Care Plan tab of the EMR, dated 09/24/2025 and revised 01/15/2026, indicated The Resident has Indwelling catheter r/t [related to] wound healing of stage 4 pressure wounds to the sacrum. The goal was The resident will be/remain free from catheter-related trauma . Review of a Progress Note located under the Progress Notes tab of the EMR, dated 04/03/2026 at 11:20 AM, indicated STAGE 4 PRESURE WOUND SACRUM FULL THICKNESS . Wound Size (L x W x D [length by width by depth]): 8 x 13 x 1 cm.During an observation of R10 in her room on 04/09/2026, she was observed receiving a partial bed bath by Certified Nursing Aide (CNA) 5 and Certified Medication Aide Technician (CMAT) 1. While turning R10 from her left side to her right side, CNA5 removed the indwelling urinary catheter bag from hanging on the side of the bed and gave it to CMAT1 who was on the other side of the bed. CMAT1 then placed the Foley catheter bag on the floor. During an interview with CMAT1 immediately after the partial bed bath on 04/09/2026 at 12:21 PM, CMAT1 confirmed she placed the catheter bag on the floor and confirmed catheter bags should not be placed on the floor.During an interview on 04/10/2026 at 1:00 PM, IP was asked what her expectations were for placement of catheter bags. IP stated the catheter bag should be below the level of the bladder but not on the floor.

Based on observations, staff interviews, record review, and review of the facility policy titled Resident Rights, the facility failed treat one of 9 sampled residents (R) (R9) in a dignified manner. Findings included:During an observation on 2/4/2026 at 1:15 pm, R9 was observed at the nurses' station in her self propelling in her wheelchair. The resident was verbalizing that she had to use the bathroom. As R9 proceeded to self-propel her wheelchair towards the A Hall, Certificed Nursing Assistant (CNA) AA approached R9 from behind her wheelchair, stopping the wheelchair and requesting to help move R9 in another direction. At that time, R9 pointed down the hall and stated, No. I am going that way. CNA AA told R9, No, you don't need to go down there. R9's tone elevated, and she began to hit the arm of her wheelchair, stating, No, no, no, no. I want to go that way, pointing towards A Hall. Staff AA grabbed the handles of R9's wheelchair and backed her up against the wall across from the nurses' station and locked the wheels on R9's wheelchair. A review of R9's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of five, which indicates R1 has a severe cognitive impairment. A review of the care plan dated 10/27/2025 indicated that R9 presented with dianosis of Alzheimer's Disease and goals included, but were not limited to, maintaining the resident's dignity and autonomy at the highest level through the next review date. Interventions included, but were not limited to, assessing R9 for coping strategies, respecting her wishes, and working with nursing staff to provide maximum comfort for the resident.During an interview on 2/4/2026 at 1:26 pm, CNA AA stated that she put R9 up against the wall so she would not go down the hall and go into other residents' rooms. During an interview on 2/4/2026 at 1:34 pm, the Director of Nursing (DON) confirmed that it is against the residents' rights and choices to restrict movement throughout the facility. She revealed the resident should be allowed to self-propel down the hall.During an interview on 2/5/2026 at 10:20 am, the Administrator revealed that residents have the right to wander anywhere in the building and that the residents are kept lined up in front of the nurses' station for more supervision.A review of the policy titled Resident Rights, dated July 2025, noted that each resident has the right to be treated with dignity and respect. When providing care services, each staff member respects each resident's individuality, as well as honors and values their input.

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled, Care of Central Venous Catheters including provide Peripherally Inserted Central Catheters (PICC Lines), the facility failed to provide appropriate treatment and services to one of 10 sampled residents (R) (RB). Specifically, PICC line dressing protocol was not followed, a chest x-ray was not ordered or performed and the PICC line was used without confirmation of placement, and dressing changes were not done according to facility policy and physician's orders.Findings include:Review of facility's policy titled, Care of Central Venous Catheters including Peripherally Inserted Central Catheters (PICC Lines) revealed under Policy Interpretation and Implementation: . 8. Change central line catheter site dressing every week transparent dressing (or as ordered by physician). Change central line catheter site dressing Q48 (every 48 hours) hours with gauze dressing (or as ordered by physician)Review of the electronic medical record (EMR) revealed RB was admitted with diagnoses of but not limited to the following: Intraspinal abscess and granuloma, infection following a procedure, candidiasis, chronic obstructive pulmonary disease, asthma, depression, muscle weakness.Review of RB's most recent quarterly Minimal Data Set (MDS) dated [DATE] revealed a Basic Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Section D (Mood)-RB has minor insomnia, feelings of depression and hopelessness, answered yes to Poor appetite or overeating. Section E (Behavioral Symptoms)-revealed no indication of Psychosis. Section GG (Functional Abilities and Goals)-RB2 is independent with bathing, dressing and using the toilet prior to admission. He uses a walker for ambulation and has only generalized muscle weaknesses in upper and lower extremities. He requires partial assistance with hygiene, substantial assistance with bathing, Supervision with dressing upper body and partial assistance with dressing lower body and footwear. Section J (Assessments)-Resident is on a pain management schedule.Review of the care plans for RB revealed the care plan was updated 8/16/2025 to include: Focus: Enhanced barrier precautions (EBP) for IV (intravenous) and wound care, Outcome: Resident will have no complications related to barrier precautions through next review date, Interventions: Enhanced barrier precautions per facility protocol/policy.Enhanced barrier precautions: wear gown and gloves for high contact resident care activities and perform hand hygiene. readmission on [DATE] with s/p transfusion status. 8/16/2025 readmission with DX (diagnosis) of extraspinal abscess and granuloma, infection following procedure. Focus: Resident is receiving antibiotic/fluids intravenously via PICC related to sepsis. readmission on [DATE] with IV antibiotic therapy via PICC line for infection with status post spinal abscess of C2-C4 with s/p (status post) surgical procedure. 8/16/2025 readmission IV antibiotic therapy continue. Outcome: Resident will have a resolution in infection through next review date, Interventions: Administer Intravenous fluids as ordered per MD, Change IV site per facility protocol, Dressing changes to IV site per facility protocol. Monitor IV site for s/s of infection, Monitor/observe for adverse reaction to medication and report abnormal findings to MD (medical doctor)/RP/Resident, PICC line maintenance care as ordered.Review of the Physician's orders for RB revealed PICC line dressing 24 hours post insertion or on admission, then every week and prn (as needed). Reinsert PICC line for IV therapy written on 9/18/2025. On the 'name of company' IV company nursing form, an order for lidocaine was obtained by the facility but the requested chest x-ray to confirm PICC line placement is not present, and no results are in the chart.Review of the medication administration record, RB's PICC line dressing was changed on Monday September 22, 2025, but RB denies the dressing has ever been changed since September 19th, 2025 when the PICC line was inserted.An interview and observation with RB on 9/23/2025 at 1:28 pm revealed that the dressing on his PICC line had gauze under the transparent dressing and no date or time on the dressing. RB stated that the dressing was changed along with the new PICC line on Friday, 9/19/2025. He also stated that he told the nursing staff on Wednesday evening, 9/17/2025, that the tape was coming off and he was afraid the PICC line was going to come out. The PICC line came out on Thursday, 9/18/2025 in the morning, and he went without any of his IV medications for two days until the new PICC line was inserted on the afternoon of 9/19/2025.A telephone interview on 9/23/2025 at 2:12 pm with prior resident RA from complaint GA002580721 revealed the nurse told her that the facility was not equipped to handle PICC lines.An interview and observation on 9/24/2025 at 9:56 am revealed RB sitting in bed and stated that the PICC line dressing would not get changed until the tape came off, it had never been changed once a week. RB stated the dressing had not been changed since it was inserted on Friday, 9/19/2025. An interview on 9/24/2025 at 11:25 am with Unit Manager Licensed Practical Nurse (LPN) FF revealed that the Registered Nurses (RN)s did the PICC line dressing changes and if a PICC line became unusable for any reason, they called the doctor to get an order to reinsert. An interview on 9/24/2025 at 11:37 am with RN GG revealed when a PICC lines came out, they called the Doctor for an order for an x-ray before insertion to see what was going on then another order for x-ray after insertion. She stated that, we just wait until the PICC is inserted to restart the antibiotic. An interview on 9/24/2025 at 11:45 am with the Director of Nursing (DON) revealed her expectation when a PICC line was not usable for whatever reason, the nurse was to call the Doctor and request an alternative route for the medication. If there was no alternative, we got an order to reinsert and requested service and got an idea of when the PICC line could be re-inserted, this was considered a stat (immediate) procedure and notified the MD of the timeline. She also expected the dressing on the PICC line to be changed as ordered and per facility policy. An observation of RBs PICC line dressing change at 1:35 pm on 9/24/2025 with RN HH revealed masks were worn by the residents and RN HH. No gowns were used. RB did have an EBP sign on the room door. The resident was made comfortable and the bed raised, RN HH wiped down the bedside table with alcohol, removed the dressing with clean gloves, then removed gloves and performed hand hygiene and opened the sterile dressing change kit, then donned (put on) sterile gloves. RN HH broke the sterile field by touching RB's arm with her left hand while cleaning with her right hand. The Stat lock (Stabilization Device) was not changed, the antibacterial disk around the insertion site was not changed and was left in place. RN HH cleaned the site with alcohol and a chlorhexidine (antiseptic) swab, applied skin prep and a transparent dressing. The date and initials were written on the dressing.An interview on 9/25/2025 at 9:05 am with the Assistant Director of Nursing (ADON) verified that a follow up chest x-ray was not done after the PICC line placement on 9/19/2025 to verify PICC line placement and the line had been being used daily since insertion. An interview on 9/25/2025 at 9:28 am with dispatcher for the PICC line insertion company to get a message to the RN Supervisor for a return call to discuss the chest x-ray. At 9:49 am, the RN Supervisor and owner of the PICC line insertion company returned call and stated that they always requested that the facility call the provider and obtain an order for a chest x-ray, as the PICC line nurse could not write orders or call for a chest x-ray because they did not work for the facility.

Based on observations, resident and staff interviews, and review of the facility's policy titled, Medication Delivery Expectations-Nurses, the facility failed to keep one of six residents (R) (RB) free from significant medication error.Findings include:Review of the facility's policy titled Medication Delivery Expectations-Nurses last revised June 2025 documented under Protocol: .8. Notify the physician if medication will be given late or obtain an alternative order or different start time, if appropriate.Review of the electronic medical record (EMR) revealed RB was admitted with diagnoses of but not limited to intraspinal abscess and granuloma, infection following a procedure, candidiasis, chronic obstructive pulmonary disease (COPD), asthma, depression, and muscle weakness.Review of RB's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive deficits.Review of the care plans for RB revealed the care plan was updated 8/16/2025: readmission on [DATE] with s/p (status post) transfusion status. 8/16/2025 readmission with DX (diagnosis) of extraspinal abscess and granuloma, infection following procedure. Focus: Resident is receiving antibiotic/fluids intravenously via PICC related to sepsis (life-threatening reaction to an infection). readmission on [DATE] with IV antibiotic therapy via PICC (peripherally inserted central catheter) line for infection with status post spinal abscess of C2-C4 (cervical vertebrae) with s/p (status post) surgical procedure. 8/16/2025 readmission IV antibiotic therapy continue. Outcome: Resident will have a resolution in infection through next review date. Interventions: Administer Intravenous fluids as ordered per MD (medical doctor). Change IV site per facility protocol. Dressing changes to IV site per facility protocol. Monitor IV site for s/s (signs/symptoms) of infection. Monitor/observe for adverse reaction to medication and report abnormal findings to MD/RP (responsible party)/Resident. PICC line maintenance care as ordered.Review of the Physician's orders for RB revealed an order for Micafungin Sodium-NaCl sodium chloride) intravenous Solution 100-0.9 mg (milligram)/100 ml (milliliter)-% (percentage) use intravenously every 24 hours for antibiotic therapy until 10/05/2025 23:59. Cefazolin Sodium injection solution reconstituted 2 GM (grams) Use 1 dose intravenously every eight hours for abscess to cervical spine until 10/6/2025.Review of the Medication Administration Record (MAR) for September 2025 for RB revealed Cefazolin doses were missed on 9/18/2025 at 1400 (2:00 pm), and 2200 (10:00 pm), 9/19/2025 at 0600 (6:00 am), and 1400 (2:00 pm), and on 9/22/2025 the dose at 1400 was missed. Number eight (8) was inserted in the MAR for these dates meaning the medication was not given. Micafungin Sodium-NaCl Intravenous solution 100-0.9 mg/100 ml dose was missed on 9/18/2025 and 9/19/2025. An interview with Registered Nurse (RN) GG on 9/24/2025 at 11:37 am revealed when a PICC line came out, we just wait until the PICC is inserted to restart the antibiotic. An interview on 9/24/2025 at 11:45 with the Director of Nursing (DON) revealed her expectation when a PICC line was not usable for whatever reason was the nurse was to call the Doctor and request an alternative route for the medication, if there was no alternative, we got an order to reinsert.

Based on observations, staff interviews, record review, and review of the facility's policies titled, Infection Control and Dressings, Non-Sterile, the facility failed to follow infection control practices related to Enhanced Barrier Precautions and consistent hand hygiene when providing wound care for two of 16 residents (R) (R4 and R15) receiving wound treatment. The deficient practice had the potential of transmission of communicable diseases and infections.Findings include: Review of the facility's policy titled, Infection Control dated June 2025 revealed in Section Enhanced Barrier Precautions (EBP): .4.b. All residents with any of the following conditions should use enhanced barrier precautions.2) Wounds and/or indwelling medical devices (e.g., central line, urinary catheter.) regardless of MDRO (multi drug resistant organisms) colonization status who reside on a unit.c. During high-contact resident care activities:1) Dressing 2) Bathing/showering 3) Transferring 4) Providing hygiene 5) Changing linens 6) Changing briefs or assisting with toileting 7) Device care use: central line, urinary catheter, feeding tube, tracheostomy/ventilator.d. Gloves and gown prior to the high-contact care activity. e. Perform hand hygiene and change PPE before caring for another resident. Review of the facility's policy titled Dressing, Non-Sterile, dated June 2025, revealed: This procedure may involve potential or direct exposure to blood, body fluids, infectious diseases, air contaminants, and hazardous chemicals. Protective Barriers That May Be Needed: Handwashing/Alcohol-based hand rub (ABHR), Gloves, Gown (as indicated), Designated Waste Disposal, Mask, Goggles (as indicated), Face Shield (as indicated). Steps in the procedure: .15. Put on clean gloves.17. Cleanse the wound. Use separate gauze for each cleansing stroke. Clean from the most contaminated area to the least contaminated area. 18. Use dry gauze to pat the wound dry. 19. Wash hands or sanitize hands with ABHR (if not visibly soiled) and apply new gloves.22. Remove gloves and discard into the designated container.26. Wash hands or sanitize hands with ABHR (if not visibly soiled). 1.Review of R4's electronic medical record (EMR) revealed that R4 was admitted with diagnoses that included, but were not limited to Alzheimer's disease, vascular dementia, anemia, insomnia, major depressive disorder, cerebral amyloid angiopathy, hypertension, a stage 4 pressure ulcer of the right hip, and peripheral vascular disease. Review of R4's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 0, indicating significant cognitive impairment. Review of the care plan dated 6/15/2024 revealed R4 is on Enhanced Barrier Precautions (EBP) for wound care, with interventions to keep EBP per facility protocol: wear gown and gloves, perform hand hygiene. Review of R4's physician orders included the following related to a wound: Enhanced Barrier Precautions (EBP) related to wound care. Pressure Wound, Right Hip: Clean with NS or wound cleanser, pat dry, apply calcium alginate, and cover with bordered island gauze every Tuesday, Thursday, Saturday, and as needed for soilage/dislodgement. Further review of R4's EMR revealed that R4 was followed by 'name of wound practice' wound physicians. On 9/18/2025, documentation revealed: Focused Wound Exam (Site 3): Stage 4 pressure wound of the right hip, full thickness. Dressing treatment plan: calcium alginate applied once daily and gauze island with border applied once daily. The physician documented the wound's progress as improved, evidenced by decreased surface area and decreased undermining (separation of the wound edges from the surrounding healthy tissue). Observation during wound care for R4 on 9/24/2025 at 11:32 am, the surveyor observed LPN AA perform a dressing change on the resident's right hip. The nurse followed infection control practices for EBP, including donning a gown and performing hand hygiene. However, no barrier was used for the supplies, and items including a large bottle of wound cleanser used for multiple residents were placed directly on the bedside drawer in the resident's room. After completing the dressing change, LPN AA returned the cleanser bottle to the treatment cart without sanitizing it. 2. Review of R15's EMR revealed diagnoses that included, but were not limited to, severe protein-calorie malnutrition, seizures, encounter for palliative care, local infection of the skin, severe sepsis, and pressure ulcers. Review of the Significant Change MDS assessment dated [DATE] revealed a BIMS score of 7, indicating severe cognitive impairment. Review of R15's care plan dated 4/20/2025 revealed a focus on Enhanced Barrier Precautions (EBP) for wound care and Foley catheter care, with interventions including wearing a gown and gloves for high-contact resident care activities and performing hand hygiene per facility protocol. The resident has an infection of the sacral wound, with interventions to maintain precautions when providing care. The care plan also identified the potential for further skin impairment related to fragile skin, impaired mobility, altered skin integrity, and incontinence. Review of R15's physician's orders revealed the following: Sacrum wound: Cleanse with wound cleanser once daily and as needed if saturated, soiled, or dislodged, for 12 days. Apply alginate calcium once daily and as needed if saturated, soiled, or dislodged, for 12 days. Secondary dressing: foam with border (silicone-sacrum) once daily and as needed if saturated, soiled, or dislodged. Left and right hip wounds: Primary dressing sodium hypochlorite solution (Dakin's) three times per week and as needed if saturated, soiled, or dislodged. Secondary dressing: gauze island with border three times per week and as needed if saturated, soiled, or dislodged. Enhanced Barrier Precautions (EBP): Related to wound care and Foley, every 12 hours. Hospice admission: [DATE] with diagnosis of unspecified severe protein malnutrition. Heel protector: While in bed. Right inner heel wound: Cleanse with normal saline or wound cleanser and apply hydrocolloid every third day. Foley catheter: Inserted on admission, with orders to change monthly and as needed. Observation of a dressing change for R15 on 9/24/2025 at 11:42 am, LPN AA entered R15's room to perform a dressing change. A sign for EBP precautions was posted on the door; however, LPN AA and Wound Tech II did not wear gowns prior to or during the procedure. When treating the right hip wound, LPN AA removed the soiled packing but did not change her gloves before applying Dakin's solution to gauze and covering the wound with a new bordered gauze island dressing. While still wearing the same contaminated gloves, she reached into her pocket to retrieve a marker to date the dressing and then returned the marker to her pocket without cleaning it. The same practice was observed during the sacral dressing change, when she again retrieved the marker from her pocket while wearing contaminated gloves and then returned it to her pocket. When changing the dressing on the left hip, LPN AA changed gloves after removing the soiled dressing from the right hip; however, hand hygiene was not performed after glove removal. In an interview following the observation, the surveyor asked LPN AA why she wore a gown for one resident prior to a dressing change but did not wear one for R15. LPN AA stated she forgot to do it and acknowledged she ignored the EBP signage on the door, explaining that there were no PPE supply boxes or a cart at the doorway to remind her. Wound tech II also confirmed that gowns should have been worn when providing high-contact care to the resident, but acknowledged they failed to do so. In an interview with the Infection Preventionist (IP)/Staff Development Nurse on 9/24/2025 at 12:33 pm, she stated that staff were frequently educated on EBP and the use of gowns during high-contact care to residents with wounds or catheters, both to protect residents and to reduce the risk of infection. In an interview with the Director of Nursing (DON) on 9/24/2025 at 12:35 pm, she stated her expectations were that staff consistently followed infection control practices, including frequent hand hygiene, sanitizing hands when changing gloves since glove changes do not substitute for hand hygiene, and adhering to EBP precautions for residents with wounds, central lines, or catheters.

Based on observation, staff interview, and review of the facility's policy titled Giving a Bed bath, the facility failed to ensure residents' basins, urinals, and bedpans were labeled and covered for 11 of 69 shared rooms (D2, D5, D18, D16, C9, C15, B16, B5, A15, A5, and A11). These failures had the potential to expose patients to infections due to cross-contamination. Findings include: A review of the facility policy, Giving a Bed bath, dated April 2022 under the section titled Steps in the Procedure revealed, 23. Clean washbasins, be sure the resident's name is written on the wash basin, place in a clean plastic bag and store it in the resident's bathroom, closet or nightstand and return any other supplies to designated storage areas. Observation of rooms on halls A, B, C, and D with the Infection Control Preventionist (ICP) on 2/9/2024 from 4:40 pm through 5:05 pm revealed the following: Room D2, bathroom, shared by two residents, revealed two basins in a clear plastic bag. Neither of the basins was labeled with a resident name. Room D5, a bathroom shared by two residents, revealed one basin on the floor, which was unbagged and unlabeled with a resident name. Additionally, two bedpans in a clear plastic bag and two basins in a clear plastic bag were observed. None of the items were labeled with a resident's name. Room D18, a bathroom shared by two residents, revealed two bedpans in a clear plastic bag and one basin in a clear plastic bag. None of the items were labeled with a resident name. Room D16 bathroom, shared by two residents, revealed one urinal attached to the toilet assistance bar. The urinal was not labeled with a resident name. Additionally, a clear plastic bag contained one bedpan and one basin. Neither of the items was labeled with a resident name. Room C9, a bathroom shared by two residents, revealed two bedpans in a clear plastic bag. Neither of the items was labeled with a resident name. Room C15, a bathroom shared by two residents, revealed one basin on the floor. The basin was not bagged or labeled with the resident's names. Room B16 bathroom, shared by two residents, revealed three unlabeled and unbagged urinals. Room B5, a bathroom shared by two residents, revealed two basins and one bedpan. The items were labeled with the resident's names and placed together in one clear plastic bag. Room A15 bathroom, shared by two residents, revealed one unlabeled and unbagged basin sitting on the floor. One basin and one bedpan were also observed in a clear plastic bag. Neither item was labeled with a resident name. Room A5, a bathroom shared by two residents, revealed two basins in a clear plastic bag, which were not labeled with a resident name. Room A11, a bathroom shared by two residents, revealed two basins in a clear plastic bag, which were not labeled with a resident name. During an interview with the Infection Control Preventionist (ICP) on 2/9/2025 at 4:48 pm, she stated the Certified Nursing Assistants (CNAs) were supposed to check all the resident's rooms to ensure all basins, urinals, and bedpans were off the floor. All items were to be bagged in a clear bag and labeled with the resident name. The ICP confirmed that numerous bathrooms contained unlabeled and unbagged items. She acknowledged several items sitting directly on the floor, unbagged and unlabeled.

Based on observations, staff and resident interviews, record review, and review of the facility's policy titled Self-Administration of Medication Program, the facility failed to ensure that three of 56 residents (R) (R45, R113, and R432) did not have unauthorized and unsecured medications at the bedside. This failure created the potential for medication errors and unauthorized access to medications by other residents. Findings include: Review of the facility's undated policy titled, Self-Administration of Medication Program, revealed under the Policy statement, It is the policy of the facility to allow the resident and or legal representative of that resident the right to self-administer medication when it has been deemed by the interdisciplinary team (IDT) that it is clinically appropriate. Under the section titled Procedure revealed, (5) If a resident request to self-administer drugs, it is the responsibility of the IDT to determine it is safe for the resident to self-administer drugs, before the resident may exercise that right. (6) When determining if self-administration is clinically appropriate for a resident, the IDT will at a minimum consider the following .(c)The resident's cognitive status, including the ability to correctly name medications and know what conditions they are taken for (7) The admitting nurse or designee will complete the Self-Administration of Medication Evaluation and report the findings to the Unit Manager or designee. (8) The interdisciplinary team must also determine: (a) Who will be responsible (the resident or the nursing staff) for storage; if medications are stored at the resident's bedside, a lockbox or locked drawer must be used to store the medications 1.Review of R45's Face Sheet indicated the resident was admitted with diagnoses that included but not limited to essential (primary) hypertension, hyperlipidemia, type 2 diabetes mellitus without complications, peripheral vascular disease, and gastroesophageal reflux disease without esophagitis. Review of R45's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed for Section C (Cognitive Pattern) a Brief Interview for Mental Status (BIMS) score of 6 (six), which indicated moderate cognitive impairment. Review of R45's care plan dated 3/29/2023 revealed, the resident has an HX (history) of alteration in gastro-intestinal status r/t (related to) infectious, gastroenteritis and colitis, GI (gastrointestinal) bleeding, abd (abdominal) pain. There was no documented evidence of interventions for self-administration of medications. Further review of the care plans lacked a care plan for self-administration of medications. Review of R45's Orders Summary Report dated 2/9/2025 lacked orders permitting the resident to self-administer medication. Review of the Self Administration of Medication assessment dated [DATE] revealed, R45 was not capable for self-administration of medication. Observation on 2/8/2025 at 10:39 am in R45's room revealed [Name] fast melts tablets (OTC medication used to treat indigestion) on the resident's bedside table. The resident stated she was unaware that she was not allowed to have medications at the bedside. Observation on 2/8/2025 at 12:34 pm revealed Certified Nursing Assistant (CNA) GG exiting R45's room. Upon inquiry, CNA GG stated she was unaware of whether R45 could self-medicate and would verify. Observation on 2/8/2025 at 12:42 pm with the Assistant Director of Nursing (ADON) revealed, R45's [Name] fast melts tablets were observed on the bedside table. ADON informed the resident that she was not permitted to self-medicate and removed the medication. R45 stated she was unaware of this rule and that her son had provided the medication. 2. Review of R113's Face Sheet indicated the resident was admitted with diagnoses that included but not limited to type 2 diabetes mellitus, cognitive communication deficit, anxiety disorder, hyperlipidemia, benign prostatic hyperplasia, insomnia, and depression. Review of R113's Quarterly MDS assessment dated [DATE] revealed for Section C (Cognitive Pattern) a BIMS score of 6, which indicated moderate cognitive impairment. Review of R113's care plan dated 9/19/2024 revealed, At Risk for Decreased Cardiac Output r/t HTN (hypertension), hyperlipidemia, DM 2 (diabetes melilites). There was no documented evidence of interventions for self-administration of medications. Further review of the care plans lacked a care plan for self-administration of medications. Review of R113's Order Summary Report dated 2/8/2025 lacked orders permitting the resident to self-administer medication. The EMR also lacked documentation that the resident had been evaluated for self-administration of medications. Observation on 2/8/2025 at 9:23 am in R113's room revealed a pill on the resident's bedside table. The resident stated he was unsure of the purpose of the pill and would not take it until he confirmed its use. Interview on 2/8/2025 at 9:30 am with Licensed Practical Nurse (LPN) HH confirmed that R113 was not assessed for self-administration of medications. LPN HH observed the pill on the bedside table, retrieved gloves, and picked up the pill, noting that it appeared dirty. LPN HH identified the pill as [Name], a blood pressure medication and stated that R113 should have received it during the 6:00 am medication pass. LPN HH further explained that R113 was unable to self-medicate, and staff were required to remain with him until he takes his medication. During an interview on 2/9/2025 at 2:22 pm with the Director of Nursing (DON) and Assistant Director of Nursing (ADON), they confirmed the facility does not allow self-administration medication as a general rule. If someone has a request for self-administration, they will need permission, and an assessment will have to take place. DON further revealed if a resident has medication in their possession, it was typically a family member who brought in the medicines without their knowledge. The DON revealed, if there were concerns related to medications at the bedside, it should be removed, and education provided. 50374 3. R432 was admitted to the facility with a diagnosis that included but not limited to unspecified glaucoma (eye disease). Review of R432's Annual MDS dated [DATE] revealed for Section C (Cognitive Pattern), a BIMS score of 15 which indicated her cognition was intact. Review of the care plan dated 8/21/2024 documented R432 had impaired visual function related to glaucoma. There was no documented evidence of interventions for self-administration of medications. Further review of the care plans lacked a care plan for self-administration of medications. Review of R432's physicians orders revealed, [name] ophthalmic solution 0.5% (percent), Instill one drop in both eyes every 12 hours for glaucoma. Review of the Self Administration of Medication assessment dated [DATE] revealed, R432 was not capable for self-administration of medication. During an observation on 2/8/2025 at 8:44 am in R432's room revealed there was an eye drop medication ([name] ophthalmic solution) sitting on her bedside table position next to her. During an interview on 2/8/2025 at 12:17 pm with LPN DD confirmed the eyedrop medication on R432's bedside table. She stated R432 was a new admission and was not aware that her family had brought the eyedrops in from the hospital.

Based on staff interview, record review, and review of the facility's policy titled, Care Plan-Comprehensive, the facility failed to develop a comprehensive person-centered care plan for two out of 56 residents (R) (R35 and R6). Specifically, the facility failed to develop a comprehensive person-centered care plan for R35 related to Methicillin-resistant Staphylococcus aures (MRSA) and R6 related to oxygen therapy. Findings include: A review of the facility's policy titled Care Plan-Comprehensive, dated January 2023 under the section titled Policy Interpretation and Implementation revealed, 1. An interdisciplinary team, in coordination with the resident, his/her family or representative, would develop and maintain a Comprehensive Care Plan for each resident. 2. The Comprehensive Care Plan has been designed to: (a) Incorporate identified problem areas; (b) Incorporate risk factors associated with the identified problems .4. Care plans are revised as changes in the resident's condition dictate. Reviews are made at least quarterly. 1. A review of the Admission Record revealed R35 had a diagnosis of Methicillin-resistant Staphylococcus aures infection as the cause of diseases classified elsewhere dated 12/20/2024. A review of the Entry Tracking Record Minimum Data Set (MDS) assessment dated [DATE] for R35 revealed, Section A-Identification Information, documented R35 was readmitted to the facility on [DATE]. A review of the Quarterly MDS assessment dated [DATE] for R35 revealed, Section I-Active Diagnoses, documented R35 had a Multidrug-Resistant Organism (MDRO). A review of R35's progress notes dated 12/30/2024 revealed that R35 was readmitted to the facility with a diagnosis of (MRSA). A review of R35's comprehensive care plans revealed there was no care plan for MRSA. During an interview with Licensed Practical Nurse (LPN)/MDS Coordinator BB on 2/9/2025 at 10:50 am, she stated that when a resident was newly admitted or readmitted with a condition or diagnosis related to infection, the Infection Preventionist (IP) would add the care area to the resident's care plan. LPN/MDS Coordinator BB acknowledged R35 triggered in the MDS for MDRO after being diagnosed during a hospitalization , and the resident should have been care planned for the infection. She added it was an oversight. During an interview with the Director of Nursing (DON) on 2/9/2025 at 1:34 pm, she stated that if a resident had any infection, including a diagnosis of MRSA or any MDRO, she would expect the care plan to reflect that care area. 47947 2. Review of the clinical record revealed R6 was admitted to the facility with diagnoses including asthma, dependence of supplemental oxygen, and malignant neoplasm of unspecified part of unspecified bronchus or lung. Review of R6's medical records revealed a physician order for continuous oxygen (O2) at 2 LPM (liters per minute) via nasal cannula with a start date of 10/26/2024. Review of R6's Quarterly MDS dated [DATE] revealed, Section C-Cognitive Patterns, a Brief Interview for Mental Status (BIMS) of three, which indicated significant cognitive decline; Section O-Special Treatments and Programs, documented R6 received oxygen therapy while a resident. Review of R6's clinical records revealed a physician order for continuous oxygen (O2) at 2 (two) LPM (liters per minute) via nasal cannula with a start date of 10/26/2024. A review of R6's comprehensive care plans revealed that it did not include an oxygen therapy plan. Interview with LPN/MDS Coordinator BB on 2/10/2025 at 10:30 am confirmed that R6 did not have a care plan for oxygen therapy. During an interview with the DON on 2/10/2025 at 10:40 am, she stated if a resident was receiving oxygen continuously and depends on oxygen therapy, she would expect the care plan to reflect oxygen therapy. Cross Reference F695

Based on observations, staff and resident interviews, record review, and review of the facility's policy titled, Oxygen Safety, the facility failed to ensure one resident (R) (R6) was administered oxygen therapy in accordance with the physician order and to ensure that the oxygen concentrators' filters remained clean for three residents (R98, R64, and R105) out of 19 residents receiving respiratory treatments. This deficient practice had the potential to put residents at risk for increased respiratory infections, medical complications and potentially life-threatening complications. Findings include: Review of the facility's policy titled, Oxygen Safety, dated April 2022 under the section titled Oxygen Administration revealed, 1. Oxygen therapy is administered to the resident only upon the written order of a licensed physician. 1. Review of the clinical records revealed R6 admitted to the facility with diagnoses that included but not limited to asthma, dependence of supplemental oxygen, and malignant neoplasm of unspecified bronchus or lung. Review of R6's clinical records revealed a physician order for continuous oxygen (O2) at 2 (two) LPM (liters per minute) via nasal cannula with a start date of 10/26/2024. Observations on 2/8/2025 at 10:58 a.m. and 2/9/2025 at 8:45 a.m. revealed R6 receiving oxygen therapy via nasal cannula at 3 (three) LPM. Cross reference to F656 50374 2. Review of the clinical records revealed R98 was admitted to the facility with diagnoses that included but not limited to chronic obstructive pulmonary disease with acute exacerbation (COPD) (reduction of lung function). Review of R98's physician's order revealed, oxygen at 2 liters per minute (lpm) via nasal cannula to keep O2 saturation greater than 90 percent. Review of R98's physician's order revealed, change and date all respiratory supplies and tubing weekly. If oxygen concentrator is present, clean filter. During an observation on 2/8/2025 at 10:10 am revealed the filter on the oxygen concentrator contained a thick gray fuzzy substance. During an observation on 2/9/2025 at 7:59 am revealed the filter on the oxygen concentrator contained a thick gray fuzzy substance. 3. Review of the clinical records revealed R64 was admitted to the facility with a diagnosis that included but not limited to asthma. Review of R64's physician's order revealed, O2 at 2 liters (l) via nasal cannula prn to keep oxygen saturation above 90 percent. Review of R64's physician's order revealed, R64 has asthma, please monitor and report to nurse or physician if resident has shortness of breath with activities of daily living care or while lying flat. During an observation on 2/8/2025 at 9:03 am revealed the filter on the oxygen concentrator contains a thick layer of gray fuzzy substance. During an observation on 2/9/2025 at 7:57 am revealed the filer on the oxygen concentrator contains a thick layer of gray fuzzy substance. 47946 4. Review of the clinical records for R105 revealed she was admitted to the facility with diagnoses that included but not limited to other asthma and cough variant asthma. Observation on 2/8/2025 at 8:32 am revealed R105's oxygen concentrator's built-in filter was dirty with a thick dark brown substance. Observation on 2/9/2025 at 8:03 am revealed R105's oxygen concentrator's built-in filter was dirty with a thick dark brown substance. Interview on 2/9/2025 at 10:10 am with the Director of Nursing (DON) stated on every Sunday night shift, the nurse assigned to that resident's hall was responsible for the maintenance and cleaning of the oxygen machine filter, ensuring the nebulizer machine was stored properly when not in use and oxygen tubing was stored in a bag when not in use. She stated, it is my expectation for all my unit nursing manager staff to make rounds on Monday morning to make sure all the maintenance and cleaning of the oxygen equipment were properly done on that Sunday night. Observation and interview on 2/9/2025 at 10:18 am with DON and Licensed Practical Nurse (LPN) CC both confirmed that R6's oxygen concentrator's built-in filter was dirty with a thick dark brown substance and tank setting was on three liters. LPN CC checked R6's physician orders in the facility's electronic records and confirmed that physician order was two liters. Observation and interview on 2/9/2025 at 10:30 am with LPN DD confirmed the Sunday night shift nurses were responsible for the respiratory maintenance cleaning of equipment weekly which includes the oxygen concentrators' filters. She stated she does her round every Monday morning to ensure staff cleaned all the equipment. She confirmed R98 and R64 oxygen concentrators' spongy-foam filter was dirty with a thick fuzzy gray substance. She also confirmed that R105's oxygen concentrator's built-in filter was dirty with a thick dark brown substance.

Based on observations, staff interviews, record review, and review of the facility's policy titled Administering Medications, the facility failed to ensure the medication error rate was less than five percent. There were two errors with 26 opportunities for one of five residents R (R35) for a medication error rate of 7.69 percent. These failures had the potential to place R35 at risk of medical complications and decreased therapeutic effects of medications. Findings include: Review of the facility policy titled Administering Medications, revised April 2019, revealed the Policy Heading section stated, Medications are to be administered in a safe and timely manner, and as prescribed. The Policy Interpretation and Implementation section included . 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. Review of R35's Electronic Medical Record (EMR) under Admission Record revealed diagnoses including, but not limited to, type 2 diabetes and irritable bowel syndrome (IBS). Review of R35's EMR under Clinical Physician's Orders revealed an order dated 12/21/2024 for Linzess oral capsule 145 micrograms (mcg), two capsules one time a day for IBS. Further review revealed an order dated 12/26/2024 for NovoLog Flex Pen subcutaneous solution pen-injector 100 unit/milliliter (ml) (insulin aspart) [a medication used to treat diabetes] inject per sliding scale. The sliding scale order included administering four units of insulin if the resident's finger-stick blood sugar (FSBS) was 206 to 235. During medication pass observation on 2/8/2025 at 10:35 am, Licensed Practical Nurse (LPN) AA was observed administering medications to R35. The medications administered included Linzess oral capsule 290 mg two capsules. Further observation revealed she checked R35's FSBS and determined, based on the physician's order for sliding scale insulin, that R35 required four units of insulin. Observation revealed LPN AA to dial the dose of four units on the NovoLog Flex Pen and administer the insulin to R35. She was not observed to prime the insulin pen needle with two units of insulin before dialing the dose on the pen. In an interview on 2/8/2025 at 10:45 am, LPN AA verified the container of Linzess was labeled as 290 mg per capsule and confirmed she administered Linzess 290 mg two capsules to R35. She verified the physician's order was for Linzess 145 mg capsules, two capsules one time a day. She stated she was unaware the label on the Linzess stated it was 290 mg capsules. She further stated she should have looked at the dosage on the medication bottle before administering the medication and would notify the provider for further instruction. During a continued interview, LPN AA confirmed she did not prime the NovoLog insulin pen needle with two units of insulin before dialing the dosage on the pen to four units and administering it to R35. She stated she was unaware she should prime the needle before dialing the dose on the pen. In an interview on 2/9/2025 at 10:45 am, the Director of Nursing (DON) stated her expectations were for nurses to follow the five rights of medication administration and ensure medications were administered according to physician orders. She stated the nurse should ensure the correct medication and dosage was administered to the correct resident at the correct time and by the correct route. She further stated that administering an incorrect medication dosage could potentially cause adverse effects for the resident. During further interview, the DON stated she expected nurses to follow the manufacturer's guidelines for the administration of insulin via an insulin pen. She stated insulin pen needles should be primed with two units of insulin before dialing the ordered dosage on the pen to ensure the resident received the ordered insulin dose. She further stated that if the pen was not primed, the resident could receive a decreased insulin dose, potentially resulting in an adverse outcome. She stated the Nurse Practitioner had recently provided education on insulin administration and she planned further education on medication administration.

Based on observation, record review, interviews, and review of the policy titled Bed Hold Policy, the facility failed to provide written information about the facility's bed-hold policy to the resident or resident representative when the facility transfers a resident to the hospital for three of three residents (R) (R3, R14, R17) reviewed for Bed Hold. This failure had the potential to contribute to possible denial of re-admission following hospitalization for residents discharged emergently to the hospital. Findings included: A review of the Bed-Hold Policy revised January 2011 revealed it is necessary for the facility to explain the policies concerning reserving beds for residents that must be in the hospital for an undetermined number of days. 1. An approved Medicaid resident is allowed to receive seven days of bed hold and eight days for therapeutic leave per year (paid by the State) while confined to a hospital or on leave from this Healthcare facility. The patient's liability will continue to be paid to the Healthcare facility during this time. To continue holding the resident's bed at the facility beyond this defined period, the facility's Bed Hold Rate must be paid by the resident/legal representative. 2. All other payer types (Private Pay, Insurance, and HMO) must pay the 'Private Pay Bed Hold Rate' to hold the bed. This begins on the first day the Resident is admitted to the hospital and ends the day the Resident is admitted to the hospital and ends the day the Resident returns to the Healthcare facility. 1. A review of the clinical record revealed R3 was admitted to the facility on [DATE] with diagnoses including rectal adenocarcinoma and colostomy. R3 was transferred to the hospital on 12/9/2022 due to ear infection. The resident did not return to the facility. Phone interview on 7/3/2024 at 3:45 pm, the family of R3 received a phone call from the facility telling them to go to the facility to remove R3's belongings as she no longer had a bed at the facility. The Family was very upset as she had no warning of this happening. The family of R3 stated she did not receive any information regarding the Bed Hold for R3 at the time of transfer to the hospital on 12/9/2022. During further interview, she stated she thought there must be a mistake, but was informed that R3's bed hold was only for 7 days when out of the facility for hospitalization . The family member stated that R3 had been in that place since 2015. The family member stated, It was like they just threw us out. The social worker at the hospital helped to get R3 in another nursing home. 2. A review of the clinical record revealed R14 was admitted to the facility on [DATE] with diagnoses including diabetes, right shoulder pain, and Gastroesophageal reflux disease (GERD). Interview on 7/3/2024 at 2:30 pm, R14 stated she was transferred to the hospital on 6/17/2024 due to edema and pain. She stated she did not recall receiving anything in writing, or anyone with her receiving a document regarding the bed-hold policy. During further interview, R14 stated, Thank God I didn't have to stay that long and lose my bed here. 3. A review of the clinical record revealed R17 was admitted to the facility on [DATE] with diagnoses including diastolic congestive heart failure (CHF) and asthma. R17 was transferred to the hospital on 2/23/2024 due to respiratory distress. R17 returned to the facility on [DATE]. Interview on 7/1/2024 at 10:30 am, the family of R17 revealed that she was transferred to the hospital on 2/23/2024 at 3:50 pm due to respiratory distress and oxygen saturation level at 85%. The family member stated the facility did not give anybody a form or rules about a Bed-Hold. During further interview, R17's family member stated, I didn't realize I could have lost my bed. Interview on 7/8/2024 at 2:00 pm, the Minimum Data Set (MDS) Coordinator GG stated when residents are sent to the hospital, the facility should send a list of medications and e-Interact regarding the resident's condition. During a continued interview, MDS GG stated We don't give or send anything to a resident or the family regarding Bed Hold at that time. Interview on 7/9/2024 at 2:00 pm, the Director of Nursing (DON) confirmed the residents, nor their families are advised of the facility's Bed Hold on transfer to the hospital.

Based on record review, interviews, and review of the policy titled Antibiotic Stewardship, the facility failed to assess and determine clinical indications for use of antibiotics utilizing the McGreer Criteria, failed to implement systematic protocols to monitor, decrease use, and measure effectiveness of antibiotics and create an action plan to lower the use of antibiotics for two of three sampled residents (R) (R16 and R17). Findings included. Review of the policy titled Antibiotic Stewardship, dated April 2022, revealed the policy is the center will develop an Antibiotic Stewardship program to monitor antibiotics and determine true infections as part of the Infection Prevention and Control Program. Procedure: Program Overview: Number 1. The center will establish a multidisciplinary Antibiotic Stewardship Program that defines optimal antibiotic use and provides guidance for optimal antibiotics prescribed. Number 4. The members of the antibiotic stewardship committee should develop, endorse or adopt established guidelines for use by center staff for appropriate identification and observation of infections and treatment guidelines. Number 5. Essential data to be reviewed by the committee should include: a. Antibiotic orders b. Clinical documentation supporting resident condition and observation c. Supplemental information from: i. Infection surveillance logs ii. Microbiology testing iii. Other tests used to confirm infection, such as imaging iv. Trends in infections v. Trends by prescriber Number 8. Resident Assessment and Communication of Change in Condition. When the center staff suspects a resident has an infection, the nurse should complete an evaluation of the resident to determine if the resident's status meets minimum criteria for initiating antibiotics such as: the McGeer criteria. 1. Review of the clinical revealed R16 was admitted to the facility on [DATE] with diagnoses including diabetes, osteoarthritis, osteophyte of the right shoulder, and cellulitis. Review of the document provided by the facility titled Infection Control Log for reporting period December 2023, revealed line listing R16 was identified to have a positive urine culture for Escherichia coli and ESBL and was started on oral antibiotic from 12/14/2023 through 12/21/2023. There is no evidence of a McGreer criteria to determine clinical indications for antibiotic use. Review of the Lab Results Report dated 12/13/2023 revealed a urinalysis specimen was collected on 12/12/2023 for R16 and documented microscopic urinalysis results with white blood cells (WBC) too numerous to count and trace bacteria. A culture and sensitivity was performed and results reported on 12/15/2023 with >100,000 colony-forming unit per milliliter (cfmu/ml) escherichia coli. Review of the Progress Note dated 12/14/2023 revealed documentation of a Physician Order for Macrobid 100 mg every 12 hours for UTI for seven days. Review of the Infection Control Resident Tracking Note dated 12/14/2023 documented R16 had a healthcare acquired UTI. 2. Review of the clinical record revealed R17 was admitted to the facility on [DATE] with diagnoses including diastolic congestive heart failure (CHF) and asthma. Review of the document provided by the facility titled Infection Control Log for reporting period May 2024, revealed line listing R17 was identified to have a positive urine culture for Escherichia coli and ESBL and was started on oral antibiotic from 5/9/2024 through 5/14/2024. There is no evidence of a McGreer criteria to determine clinical indications for antibiotic use. Review of the Physician Visit Note dated 5/6/2024 indicated R17 had symptoms of urinary tract infection (UTI) including burning, difficulty urinating, and frequency. Review of the Lab Results Report dated 5/7/2024 revealed a urinalysis specimen was collected on 5/6/2024 for R17 and documented microscopic urinalysis results without abnormalities; however, culture results reported on 5/9/2024 revealed >100,000 colony-forming unit per milliliter (cfmu/ml) escherichia coli and proteus mirabilis. Review of the Progress Note dated 5/9/2024 revealed documentation of a Physician Order for Nitrofurantoin Capsules 100 milligrams (mg) one capsule every 12 hours for UTI for five days. Review of the Infection Control Resident Tracking Note dated 5/9/2024 documented R17 was confused, had burning upon urination, and retention. Review of R17's May 2024 Medication Administration Record (MAR) revealed an order date of 5/9/2024 for Nitrofurantoin Macrocrystal 100 milligrams (mg) capsule every 12 hours for UTI for five days. Interview on 7/9/2024 at 11:05 am, the Infection Control Preventionist (ICP) was asked for documentation for signs and symptoms and the McGreer criteria worksheet R16 and R17. She provided a line listing that documented the name of the resident, what antibiotic they were on and dates. There was no documentation of the signs/symptoms the residents were having when prescribed antibiotics. The ICP stated, I don't know anything about that. The ICP further stated, If there was a problem, then the nurses are supposed to document it and call the doctor to get an antibiotic. I am not doing any infection surveillance as I didn't get any training. The ICP was asked how long she had worked at the facility. She stated, One and half years.

Based on record review, interviews, and review of the policy titled Infection Control -Infection Preventionist, the facility failed to ensure that the person in the role of the Infection Control Preventionist (ICP) adequately assessed, developed, implemented, monitored, and managed the Infection Control and Prevention (IPCP) program, to prevent and control the spread of infections. This failure created the potential for an ineffective infection control program that placed residents at risk for the potential transmission of infections and communicable diseases. The facility census was 136. Findings included. Review of the undated policy titled Infection Control-Infection Preventionist, indicated it is the policy of the facility to employ an appropriate qualified professional to establish and maintain an infection control and prevention program designed to prevent the development and transmission of communicable diseases and infections. Procedure: Number 1. The facility will designate a qualified individual as the Infection Preventionist whose primary role is to coordinate and be actively accountable for the facility's infection prevention and control and antibiotic stewardship programs. Number 4. Responsibilities of the Infection Preventionist include but are not limited to: a. Implementing a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based on the facility assessment. b. Ensuring written standards, policies, and procedures for the program, which must include, but not limited to. i. A system of surveillance designed to identify possible communicable diseases or infection before they can spread to other persons in the facility. iii. Standard and transmission-based precautions to be followed to prevent spread of infections. f. Ensuring the implementation of an antibiotic stewardship program consistent with the requirements. Review of the CDC (Center for Disease Control) Nursing Home Infection Preventionist Training Course revealed the facility's ICP completed the course on 11/7/2022. The training course included, but not limited to, the following modules: ~ Infection Prevention and Control Program. ~ Infection Surveillance. ~ Principles of Transmission-Based Precautions. ~ Outbreaks. ~ Infection Prevention and Antibiotic Stewardship Considerations During Care Transitions. Review of the facility's Antibiotic Stewardship Program (ASP) documents, Immunization documents, and Infection Control program documents, revealed the ICP was not adequately assessing, implementing, monitoring, or managing the Infection Control and Prevention (IPCP) program, to prevent and control the spread of infections. Interview on 7/1/2024 at 2:55 pm, the ICP revealed she had not obtained any updated infection control trainings or education since 11/2022. Interview on 7/1/2024 at 3:36 pm, the Administrator stated I knew we had some issues but didn't know the extent. Cross Refer F880, F881, F883, F887

Based on observations, interviews, and review of the policy titled Maintenance Service, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and visitors. Specifically, the facility failed to address and remove bulking wallpaper and water-stained ceiling tiles from room C14. In addition, the facility failed to maintain the aesthetic appeal of the exterior of the facility and a clean and safe porch area at the entrance of the facility. The census was 136. Findings included: Review of the policy titled Maintenance Service dated April 2022 documented Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation: Number 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Number 2. The following functions are performed by maintenance, but not limited to: a. Maintaining the building in compliance with current federal, state, and local laws, regulations and guidelines. b. Maintaining the building in good repair and free from hazards h. Maintaining the grounds, sidewalks, parking lots, etc. in good order i. Providing routinely scheduled maintenance service to all areas. Observation and interview on 7/1/2024 at 10:30 am, R16 revealed that she and her sister used to sit out on the porch area, but there's cat hair all over the place and a strong odor that smells like pee. Interview on 7/1/2024 at 10:45 am, R17 stated I don't go outside anymore. I would like to but there's so many cats. I don't like cats. Observation on 7/1/2024 at 4:08 pm, revealed the front entrance to the facility, obvious cat hair on the cushions of the outdoor furniture under the porch area. There was also a strong odor of car urine. Observation and interview on 7/1/2024 at 4:10 pm, with Activity Assistant AA, revealed two cats jumped out from behind the bushes near the front entrance and scurried away. The Activity Assistant AA was informed that cats are a common allergy to many people, especially when the hair sheds often and freely. She stated that one particular resident enjoys feeding the cats, but there are other residents that don't sit outside because of the cat hair and the urine odor. During further interview, she revealed she would have the resident feed the cats at a less used entrance, and would ask for staff to pressure wash or find some other way to reduce the cat hair and urine odor from the outdoor sitting area. Observation and interview on7/3/2024 at 2:30 pm, with R14 stated, I would love to go outside, but now it's too hot and the stench is horrible. There are cats all over there and people just throw their trash down anywhere. Observation on 7/3/2024 at 3:30 pm, in room C14, revealed on the outer wall of the bathroom, an area of wallpaper peeling away from the wall, with dark detaching edging on the bottom of the wallpaper. There are large brown, water spots in various places on the ceiling tiles in the resident's room. Observation on 7/5/2024 at 7:30 am, upon arrival at facility, there was garbage and debris including tissues, paper, disposable cups, and a disposable face mask in the parking lot, on the sidewalk, and inside the covered porch at the front entrance of the facility, despite there being a trash bin near the front door. These observations were in common areas that are frequented by the residents, staff and visitors. Interview on 7/5/2024 at 8:30 am with the Administrator, confirmed the environmental concerns identified during the survey. The Administrator stated the new Maintenance employee usually picks up all the outdoor trash in the morning. Observation and interview at 8:40 am, with the Environmental Director (ED) of the front outside areas of the facility were confirmed, and he stated the area and trash is unsightly to the facility and stated that's why a staff member comes around in the early morning hours to remove the trash. During further interview, the ED stated that the most frequented time of day by visitors is early in the morning, and after people get off work in the afternoons. He agreed that the trash needed to be cleaned from the exterior.

Based on record review, interview, and review of the policy titled Care Plan-Goals and Objectives, the facility failed to develop a comprehensive person-centered plan of care which included a focus, goal, and interventions related to communication for four of four residents (R) (R4, R18, R26, and R27) reviewed for communication needs. Specifically, the facility failed to develop a care plan related to hearing loss for R4 and failed to develop a care plan for R18, R26, and R17 related to language barrier for non-English speaking residents. Findings included. Review of the policy titled Care Plan-Goals and Objectives dated January 2024, documented the policy is care plans shall incorporate resident-centered/trauma informed goals and objectives that lead to the resident's goals for admission and desired outcomes. Policy Interpretation and Implementation: Number 1. Goals and objectives are defined as the desired outcome for a specific resident problem. Number 2. Goals and objectives are: a. Resident-centered and individualized c. Measurable e. Be culturally competent and trauma informed 1. Review of the clinical record revealed R4 was admitted to the facility on [DATE] and had a Cochlear Implant (an electric device that is implanted in the inner ear that allow severely deaf people to hear sounds.) R4 was discharged on [DATE]. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/20/2022 revealed that R4 had moderate difficulty hearing, and did not wear hearing aids. Review of the comprehensive care plan dated 7/14/2022 revealed there was no evidence of a focus problem, goal, or interventions related to R4's hearing loss or cochlear implant. 2. Review of the clinical record revealed R18 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease and dementia. Review of the annual MDS with an ARD of 4/2/2024 revealed R18 had a Brief Interview of Mental Status (BIMS) score of zero out of 15 which indicated R18 was severely impaired in cognition. R18's preferred language is Korean. She would like an interpreter to communicate with staff. Review of the comprehensive care plan dated 1/21/2024 revealed there was no evidence of a focus problem, goal, or interventions related to R18's inability to speak English. Interview on 7/1/2024 at 8:20 am, Certified Nurse Aide (CNA) NN stated that she tends to R18 and confirmed that she did not speak or understand English. She stated that staff use hand gestures to communicate with the resident. 3. Review of the clinical record revealed R26 was admitted to the facility on [DATE] with diagnoses including muscle atrophy, hypertension (HTN), and fracture right hip. Review of the admission MDS with an ARD of 5/31/2024 revealed R26 had a BIMS score of nine out of 15 which indicated moderate cognitive impairment. R26's preferred language is Spanish. Review of the comprehensive care plan dated 5/31/2024 revealed no focus, goal, or interventions related to his inability to speak English. Interview on 7/2/2024 at 10:15 am, during a group resident council meeting, R26 was accompanied by a staff interpreter. The interpreter asked R26 how he is able to make his needs known to the staff. R26 replied I point and use gestures. The staff interpreter, who is the Activity Assistant (AA) AA, was asked if there were communication boards available for the residents, who did not speak English? The Activity Assistant AA stated No, I don't know anything about that. 4. Review of the clinical record revealed R27 was admitted to the facility on [DATE] with diagnoses including gastro-esophageal reflux disease (GERD), HTN, and Alzheimer's disease. Review of the admission MDS with an ARD of 2/14/2024 revealed R27 had a BIMS score of 13 out of 15 which indicated no cognitive impairment. R27's preferred language is Vietnamese. She would like an interpreter to communicate with staff. Review of the 5/16/2024 comprehensive care plan revealed no focus, goal, or interventions related to his inability to speak English. Interview on 7/2/2024 at 10:15 am, during a group resident council meeting, R27 revealed she was able to speak and understand very little English. During further interview, she indicated that she was not able to consistently communicate and understand the English language, in order to have her needs met. She stated she didn't understand the staff's English as they come from other countries. Interview on 7/9/2024 at 11:08 am, MDS Coordinator (MDSC) was asked about communication focus on resident care plans, and she confirmed that the comprehensive care plans were not person-centered to reflect the residents communication needs. The MDSC stated, I don't see them, but they definitely should have been developed.

Based on observations, interviews, and a review of the policy titled Certification Medication Aide Program, the facility failed to ensure that services provided by Certified Medication Technicians (CMTs) met professional standards of quality. Specifically, the facility failed to provide evidence that three of five CMTs (CMT MM, CMT LL, and CMT FF) were competent with skills and knowledge to provide insulin administration, before being allowed to administer insulin to residents. This failure had the potential to result in adverse outcomes for residents related to medication administration. Findings included: A review of the policy titled Certification Medication Aide Program, dated May 1, 2022, documented the policy is the intent of this facility to utilize individuals certified as medication aide who are listed on the Georgia Medication Aide Registry in the role of administering technical aspects with certain medications to nursing home residents. Procedure: Step 2. The nursing home shall conduct a comprehensive clinical skills competency review of each certified medication aide employed by the facility upon hire and annually by a licensed pharmacist or Registered Profession Nurse. Step 3. A Certified Medication Aide who meets the criteria established by the Georgia Code Section 31-7-12.2 shall be permitted to perform the following tasks in a nursing home in accordance with written instructions of a physician. b) Administer insulin .pursuant to the physician's direction and protocol and will validate medication dose with a licensed nurse prior to administration. Further review of the policy indicated that a signed copy of the policy and procedure will be maintained in the employee record. 1. A review of the employee file for CMT MM revealed a hire date of 3/8/2024. During an interview on 7/3/2024 at 1:15 pm, CMT MM was asked if she was able to perform accu-checks and insulin administration for diabetic residents. She replied, Yes. She was asked if she had skills competencies completed to ensure she could safely and correctly perform this task. CMT MM replied, No, not here, but in my last job I did. There was not a Medication Administration - Subcutaneous Injection checklist for CMT MM completed. 2. A review of the employee file for CMT LL revealed a hire date of 8/22/2022. During an interview on 7/9/2024 at 11:08 am, CMT LL was asked what the process is when obtaining an FBS (fasting blood sugar) sample that resulted in the need for a resident to be administered insulin. She stated that she would administer the insulin that was prescribed by the doctor. She was asked about whether or not she needed to have the insulin dosage verified by a licensed nurse, and she replied, Not here I don't. During further interview, she stated that at her previous job, she had to get a nurse to verify the dosage of insulin before administering it, but not at this job. CMT LL was shown the Georgia State Certification Medication Aide policy and procedure and shown the paragraph which states that insulin was to be verified by a licensed nurse. CMT LL stated, Oh, I was not aware of needing to have insulin verified. Review of the Medication Administration - Subcutaneous Injection checklist for CMT LL, dated 4/8/2024 was not signed by CMT LL. 3. A review of the employee file for CMT FF revealed a hire date of 11/11/2020. During an interview on 7/9/2024 at 11:33 am, CMT FF was asked if she had yearly competencies related to obtaining FBS and administering insulin. CMT FF stated, I think so, but I am not sure. A review of the Medication Administration - Subcutaneous Injection checklist for CMT FF, dated 3/7/2024 was not signed by CMT FF. Interview on 7/9/2024 at 12:27 pm, the Staff Development Coordinator (SDC) was asked to provide competency documentation for the CMTs regarding obtaining FBSs and administration of insulin to the residents. The SDC stated there are five CMTs employed by the facility, and replied No, I don't have anything. The SDC provided documentation that the five CMT's could administer subcutaneous injections only, not specific to insulin administration. Cross Refer F760

Based on record review, interviews, and review of the policy titled Pharmacy Services, the facility failed to ensure medications were administered as ordered for two of three residents (R) (R17 and R25) reviewed for medication administration. Specifically, R17 missed 20 doses of her inhaler (Xopenex) and Atorvastatin 13 times, as ordered; and R25 missed seven doses of Pregabalin (Lyrica-can be used for nerve pain). The deficient practice had the potential for adverse consequences and events due to not receiving ordered and scheduled medications timely. Findings included: A review of the undated policy titled Pharmacy Services, revealed the facility will provide Pharmacy Services in accordance with state and federal regulations. Procedure: Number 5. The facility will provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administration of all drugs and biological to meet the needs of each resident. Review of the policy titled Medication Delivery Expectations dated April 2022, revealed the policy is to ensure all residents will receive their medications as ordered and to ensure if medications are not received, center immediately intervenes, and medications received within 4 hours. Protocol: A. Notify the pharmacy of medication that has not been received. Pharmacy has someone on call 24 hours a day, so it is never acceptable to document that a medication is 'not available.' It is the center's responsibility to ensure medications are administered. D. If medication is not available, call the pharmacy and request medication to be delivered STAT [as soon as possible] either from your facility pharmacy or community back-up pharmacy. H. Notify the physician if medication will be given late or obtain an order for different start times, if appropriate. 1. A review of the clinical record revealed R17 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), diastolic congestive heart failure (CHF) and asthma. A review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/10/2024, revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated she was cognitively intact. A review of the June 2024 Medication Administration Record (MAR) revealed the following medication orders: 1. Xopenex Inhaler two puffs every six hours related to COPD ordered 5/11/2024. According to the June 2024 MAR, the inhaler was not administered (as indicated by the code 13) eight times, and on two occasions, at 6:00 pm, the documentation was left blank. 2. Atorvastatin 40 milligrams (mg) one tablet at bedtime for elevated cholesterol ordered 3/1/2024. According to the June 2024 MAR, the Atorvastatin was coded as 13 which indicated not administered eight times. A review of the May 2024 MAR revealed: 1. Xopenex Inhaler - was not administered (as indicated by the code 13) 10 times. 2. Atorvastatin - was not administered five times. During a group resident council meeting on 7/2/2024 at 10:15 am, the residents were asked if they received their medications on time. R17 stated, They run out of my medications. They don't care if they are missing pills. 2. A review of the clinical record revealed R25 was admitted to the facility on [DATE] with diagnoses including diabetes and neuralgia (intense, intermittent pain in the nerves.) A review of the quarterly MDS assessment with an ARD of 4/18/2024 revealed R25 had a BIMS score of 12 out of 15, which indicated she was moderately impaired in cognition. A review of the June 2024 MAR revealed the following medication order: 1. Pregabalin (Lyrica-used for nerve pain) 50 mg one capsule every 12 hours ordered 4/24/2024. According to the June 2024 MAR, the Lyrica was coded as 13-not administered seven times; however, on 6/5/2024, the documentation showed that the medication was not administered due to surgery. During a group resident council meeting on 7/2/2024 at 10:15 am, R25 stated, The nurse brings me my pills and I don't even know what they are for. It takes two to three days to get medications when they reorder. Interview on 7/8/2024 at 1:13 pm, the Nurse Practitioner (NP) was asked whether of not she knew if medications were not being administered on time to residents. The NP stated, Yes, I am sorry to say it is true. Interview on 7/8/2024 at 3:30 pm, the Director of Nursing (DON) stated the insurance companies are asking for prior authorizations for some medications, and we keep signing them 100 times over. It's been a struggle. Interview on 7/9/2024 at 1:56 pm, the Pharmacy Consultant stated, The nurses should be able to call the pharmacy and get the medication they need. They can go onto the website and order medication there also. The Pharmacy Consultant was asked if he was aware of medications not being available due to prior authorizations by insurance companies or Medicare. The Pharmacy Consultant stated, No, I have not.

Based on record review, interviews, and review of the policy titled, Diabetes Care-Insulin Administration and Administration of Drugs, the facility failed to ensure staff administered insulin as ordered for three of five residents (R) (R15, R11, R5) reviewed for insulin administration. Specifically, there were multiple discrepancies in the blood sugar (BS) documentation and insulin sliding scale orders, as well as multiple days and times with no documentation that insulin was administered. This failure placed the residents at risk of hypoglycemia, hyperglycemia, and a diminished quality of life. Findings included. Review of the policy titled Diabetes Care-Insulin Administration, dated April 2022, revealed the policy is that special precautions should be followed in the administration of insulin. Policy Interpretation and Implementation: Number 2. Insulin dosage should be drawn only by personnel licensed to administer such drug and must be administered by the person drawing the injection. Number 3. The type of insulin, dosage requirements, strength, and method of administration should be verified to assure that it corresponds with the order on the medication sheet and the physician's order. Number 4. Any discrepancies should be reported to the Charge Nurse or designee. Number 5. The resident's physician should be notified of any discrepancies or adverse drug reactions. Review of the policy titled, Administration of Drugs, dated April 2022 revealed Policy Interpretation and Implementation: Number 2. Drugs must be administered in accordance with the written orders of the attending physician. Number 9. The nurse administering the drug must record such information on the resident's eMAR (electronic medication administration record) immediately after administration. Number 12. Should a drug be withheld, refused, or given other than at the scheduled time, the nurse should give the appropriate chart code inside the eMAR that states the reason for not administering that drug. Number 13. The nurse should enter an explanatory note in the progress notes for eMAR when drugs are withheld, refused, or given other than at scheduled times. The physician should be notified of drugs that are withheld and/or repeated refusal of drugs. 1. Review of the clinical record revealed R15 was admitted to the facility on [DATE] with a diagnosis of diabetes. Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/10/2024 revealed R15 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated he was cognitively intact. Section N documented resident was administered insulin seven of seven days of the look back period. Review of R15's care plan revised on 6/27/2024 revealed resident has a diagnosis of diabetes. Interventions to care include administer diabetes medication as ordered and monitor/document for side effects and effectiveness. Review of the June 2024 Medication Administration Record (MAR) revealed an order for Novolog (short-acting) insulin via sliding scale, .Inject as per sliding scaled .0-160 = 1 unit; 161-200 = 2 units; 201-240 = 3 units; 241-280 = 4 units; 281-300 = 5 units; 301-340 = 6 units before meals and at bedtime . The order was dated 6/4/2023. Review of the June 2024 MAR revealed that the blood sugar (BS) was documented between 0-160 and the insulin was not administered per the sliding scale a total of 16 times. According to the sliding scale orders, the resident should have been administered one unit of insulin for blood sugar level of 0-160; it was documented as not administered/BS within parameters. Further review revealed blood sugar (BS) was greater than 160 on three occasions, but no insulin was administered - documented as not administered/BS within parameters. On 6/14/2024 at 11:30 am, BS was recorded as 363, but no insulin was given - documented as not administered/BS within parameters. On 6/26/2024 at 9:00 pm, the BS was documented as 347 however, there was no documentation that insulin was administered, per the sliding scale. Review of the July 2024 MAR from 7/1/2024 to 7/3/2024 revealed, the BS indicated insulin should have been administered four times (7/1/2024 at 11:30 am and 4:30 pm, 7/2/2024 at 6:30 am and 11:30 am) but was not documented as administered. 2. Review of the clinical record revealed R11 was admitted to the facility on [DATE] and discharged on [DATE]. R11 had a diagnosis of diabetes. Review of the admission MDS with an ARD of 10/11/2023 revealed R11 had a BIMS score of nine out of 15 which indicated she was moderately impaired in cognition. Section N documented resident was administered insulin four of seven days of the look back period. Review of the November 2023 MAR revealed the following orders: 1. Accu check AC [before meals] QID [four times daily] before meals and at bedtime with order date of 10/11/2023. 2. Novolog (Insulin Aspart) inject per sliding scale: 0-250 = 0 units; 251-280 = 4 units; 281-320 = 5 units; 321-360 = 6 units; 361-400 = 7 units; [PHONE NUMBER] = 0 units. less than 60 = 0 units give glucose gel, greater than 400 call MD, NP [nurse practitioner] for further orders. Order date was 10/6/2023 and discontinued on 11/17/2023. 3. Humalog (Insulin Lispro) inject per sliding scale: 0-200 = 0 units; 201-240 = 3 units; 241-280 = 4 units; 281-320 = 5 units; 321-360 = 6 units; 361- 400 = 7 units; [PHONE NUMBER] = 0 units and notify MD for further orders. Order date was 11/17/2023. Review of the November 2023 MAR revealed the following discrepancies in the BS amount from the accu check number documented and the sliding scale on 11/1/2023 - accu check recorded as 232, sliding scale BS documented as 234; NA [not applicable] was used on the sliding scale 28 times but documented on the accu check section; the accu check documentation identified that insulin needed to be administered but was not documented as administered on the sliding scale for 11/3/2023 at 9:00 pm BS was 319, should have received five units and 11/17/2023 at 9:00 pm BS was 243, should have received four units; the BS on 11/25/2023 at 11:30 am, showed a BS of 261, however, on the sliding scale, the BS was documented as 231 and three units of insulin was administered. There was no documentation that the BS was obtained or insulin administered on 11/21/2023 at 6:30 am or 11/30/2023 at 4:30 pm. Review of the December 2023 MAR revealed the following orders: 1. Accu check AC [before meals] QID [four times daily] before meals and at bedtime with order date of 10/11/2023. 2. Humalog (Insulin Lispro) inject per sliding scale: 0-200 = 0 units; 201-240 = 3 units; 241-280 = 4 units; 281-320 = 5 units; 321-360 = 6 units; 361- 400 = 7 units; [PHONE NUMBER] = 0 units and notify MD for further orders. Order date was 11/17/2023. Review of the December 2023 MAR revealed the following discrepancies: The BS documentation differed between the accu check and the sliding scale five times (12/2/2023 at 9:00 pm, 12/9/2023 at 9:00 pm, 12/13/2023 at 6:30 am, 12/18/2023 at 4:30 pm, 12/26/2023 at 4:30 pm); there was no documentation that the BS was obtained or insulin administered, five times (12/13/2023 at 4:30 pm, 12/15/2023 at 4:30 pm, 12/19/2023 at 11:30 am and 4:30 pm, 12/29/2023 at 4:30 pm); the accu check documentation showed one number and the sliding scale showed another number and insulin was administered per the sliding scale, two times (12/16/2023 accu check at 9:00 pm BS was documented as 210, sliding scale revealed BS documented as 341 and six units insulin administered; 12/26/2023 accu check BS at 4:30 pm was documented as 220, sliding scale revealed BS documented as 307 and five units insulin administered); accu check showed one number and the sliding scale showed another number and no insulin was administered one time (12/2/2023); the accu check documentation and the sliding scale documentation showed that insulin should have been administered, but was not, one time (12/25/2024 at 4:30 pm). 3. Review of the clinical record revealed R5 was originally admitted to the facility on [DATE] and discharged on [DATE] and had a diagnosis of diabetes. Review of the admission MDS with an ARD of 7/5/2023 revealed R5 had a BIMS score of 15, which indicated he was cognitively intact. Section N documented resident was administered insulin seven of seven days of the look back period. Review of R5's care plan revised on 6/21/2023 revealed resident has a diagnosis of diabetes. Interventions to care include administer diabetes medication as ordered and monitor/document for side effects and effectiveness; Fasting Serum Blood Sugar/accu checks as ordered by the doctor; monitor/document/report to doctor signs/symptoms of hypoglycemia such as sweating, tremors, increased heart rate, slurred speech, lack of coordination and staggering gait. Review of the January 2023 MAR revealed the following orders: 1. Novolog insulin, inject per sliding scale: 0-250 = 0 units; 251-280 = 4 units; 281-320 = 5 units; 321-360 = 6 units; 361-400 = 7 units; [PHONE NUMBER] = 0 units call MD, NP for further orders. Order date 11/16/2022 and discontinued on 8/2/2023. Review of the January 2023 MAR revealed the following discrepancies: The BS documentation on 1/4/2023 at 11:30 am was 253, there is no evidence insulin was administered according to the sliding scale orders; on 1/28/2023 the BS was documented as 397 and there was no documentation of insulin having been administered-documented as not administered/BS within parameters. Review of the February 2023 MAR revealed the following discrepancies: There was no documentation of an accu check documented or insulin administered three times (2/12/2023 at 6:30 am, 2/13/2024 at 6:30 am, 2/26/2023 at 6:30 am). On 2/9/2023 at 9:00 pm, the BS was documented as 40 however, there was no documentation in the medical record to indicate the physician was notified or the condition of the resident. Interview on 7/8/2024 at 1:18 pm, the Nurse Practitioner (NP) revealed she has taken care these residents and stated, it's been a struggle for me also. My expectation would be that insulin is given for the amount needed based on the blood sugar reading on the machine, and they are to call me if it's over 400, and document correctly. Interview on 7/8/2024 at 3:30 pm, the Director of Nursing (DON) stated, I was not aware of the extent of the insulin administration problems. This information has surprised me. The DON further stated, My expectation is that insulin is documented and administered according to the physician orders.

Based on observations, record review, interviews, and review of the policy titled Enhanced Barrier Precautions, the facility failed to ensure enhanced barrier precautions (EBP) and transmission-based precautions (TBP) were implemented for two residents (R) (R19 and R20) of four residents reviewed for infection control. Specifically, the facility failed to have personal protective equipment (PPE) supplies readily available and accessible for use by staff when providing high-contact care. This failure had the potential to expose residents to infections due to cross-contamination. Findings include: Review of the policy titled Enhanced Barrier Precautions revised March 30, 2024, documented Enhanced Barrier Precautions (EBP) are infection control interventions designed to reduce transmission of resistant organisms. Procedure: Number 1. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of (Multi Drug Resistant Organisms (MDRO) to staff hands and clothing. Number 4. For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: a. Dressing b. Bathing/showering c. Transferring d. Providing hygiene e. Changing linens f. Changing briefs or assisting with toileting g. Device care or use: central line, urinary catheter, feeding tube, tracheostomy h. Wound care: any skin opening requiring a dressing 1. Review of the clinical record revealed R19 was readmitted to the facility on [DATE] with diagnoses including cerebral vascular accident (CVA) with right-sided paralysis, seizures, and vascular dementia. Review of the significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/14/2024 documented R19 had a Brief Interview of Mental Status (BIMS) score of 14, which indicated he was cognitively intact for daily decision-making. Section M documented that R19 had one unstageable pressure ulcer (a pressure ulcer that had full or partial thickness of dead tissue). Review of the Wound Evaluation and Management Summary dated 5/2/2024 revealed R19 had three pressure sores: left lower extremity, right lower extremity, and right sacrum. R19 is being followed by wound physician weekly. Observation on 7/1/2024 at 8:15 am, Licensed Practical Nurse (LPN) CC was observed providing wound care to R19. LPN CC was not observed to be wearing a gown. The signage for EBP was located on the floor, behind the door and was not readily visible for staff/visitors. In addition, there was no trash receptacle near the door to place the soiled gowns and gloves in before leaving the room. Interview on 7/1/2024 at 8:25 am, LPN CC stated I saw the enhanced barrier precaution sign on the floor, but did not know the precautions were for R19 or his roommate. She further stated that she did not know R19 required EBP when providing wound care. 2. Review of the clinical record revealed R20 was admitted to the facility on [DATE] with diagnoses including pneumonia, open wounds, and multiple rib fractures. Observation on 7/1/2024 at 10:30 am, Certified Nurse Aide (CNA) FF was placing PPE and a TBP sign for contact precautions, on the door for R20. CNA FF was asked why R20 needed to have TBP. She stated, I think he has MRSA (Methicillin-Resistant Staph Aureus-a bacteria that is resistant to most antibiotics and can spread by touching people with unclean hands or unclean surfaces). Interview on 7/1/2024 at 4:03 pm, Unit Manager (UM) was questioned about CNA FF placing the PPE/door signage for R20 seven days after he was admitted to the facility. The UM stated resident was admitted from the hospital with a PICC (Peripherally inserted central catheter-used to give intravenous medications) line. During further interview, the UM revealed resident was not placed on EBP precautions at the time of admission and should have been, due to his wounds and PICC line access. She stated she was not aware that R20 had MRSA until she reviewed his discharge paperwork. She replied, I was not told this by the hospital, when he transferred. Interview on 7/2/2024 at 7:47 am, R20 revealed the staff started wearing gowns and gloves yesterday. He stated when he was admitted to the facility last Monday, they were not wearing using any protective equipment. Interview on 7/2/2024 at 10:35 am, the Infection Control Preventionist (ICP) was asked regarding there not being EBP signage on the residents' doors, to alert staff of the requirements when caring for them. The ICP stated, I was told to put the signage inside the room, by the sharps container. The ICP was informed about the observation of the signage for R19 having been on the floor and behind the door, and LPN CC revealing she did not know if the requirements were for R19 or his roommate. The ICP stated, I was out last week. During further interview, she revealed that the UM was responsible for ensuring EBP and TBP signage is readily visible and PPE was accessible for the staff/visitors.

Based on observation, clinical record review, EMS Call Sheet Detail Form review, hospital history and physical examination [REDACTED]#8), and failed to administer pressure sore treatment as ordered by the physician as specified by the Care Plan of one (1) resident (#3). The abbreviated survey sample was nine (9) residents. Resident #8 sustained harm, as the resident was found with a laceration around the left temple area requiring hospital transfer and stapling, and was diagnosed with [REDACTED]. Findings include: 1. Resident #8's Annual Minimum Data Set (MDS) assessment of 03/24/2015 documented diagnoses, in Section I - Active Diagnoses, including, but not limited to, Arthritis and [MEDICAL CONDITION]. Section G - Functional Status documented Functional Limitation in Range of Motion (ROM) and that the resident required two (2)-plus persons for transfer. The Care Plan of Resident #8 identified as a Focus area that the resident had an Activities of Daily Living self-care performance deficit related to reasons which included, but were not limited to, limited ROM and limited mobility. This Care Plan identified as an Intervention to address Resident #8's self-care performance deficit that the resident required mechanical lift transfers with the assistance of two (2)-plus staff. A 04/13/2015, 3:34 p.m. Progress Notes entry documented that at 9:45 a.m., Certified Nursing Assistant (CNA) CC and Licensed Practical Nurse (LPN) AA transferred the resident to bed by Hoyer lift and observed blood in the resident's hair and an approximate 3 centimeter (cm) laceration to the left side of the head. Emergency Medical Services (EMS) was called, per physician's orders [REDACTED]. During a 04/22/2015, 1:25 p.m. interview, LPN AA stated that Resident #8 had been in the dining room on 04/13/2015 at 6:30 a.m., and that after breakfast, LPN AA and CNA CC transferred the resident via Hoyer Lift to bed, at which time the CNA notified him/her of blood on the back of Resident #8's head. During a 04/22/2015, 2:00 p.m. interview, the Assistant Director of Nursing (ADON) stated that LPN AA had notified him/her of Resident #8's head injury resulting in the resident's hospital transfer. A 04/13/2015 EMS Call Sheet Detail form for Resident #8's hospital transfer documented, in the Narrative section, that EMS responded to the facility to transport Resident #8 for a laceration to the left side of the head, with the Special Comments section documenting the resident's involvement in a Hoyer Lift accident. A hospital History and Physical (H&P) Examination form documented Resident #8's 04/13/15 hospital transfer secondary to head injury. This H&P documented a laceration around the Resident #8's left temple and that a Computed Tomography head scan revealed bilateral subarachnoid hemorrhages, with the presumed etiology of trauma. A hospital Consultation Report documented that Resident #8 had sustained bilateral subarachnoid hemorrhages from a fall and was admitted to the hospital. A facility investigation Follow-Up report dated 04/17/15 documented that on 04/13/15 at around 10:18 a.m., CNA CC and LPN AA transferred Resident #8 to bed via Hoyer Lift, and CNA CC then asked LPN AA to examine the left side of Resident #8's head after seeing a laceration approximately 3 to 4 cms long. A ring of dried blood of about 3 inches was noted in the hair around the wound. This Follow-up report documented that Resident #8 was gotten up by CNA HH at approximately 5:30 a.m. or 6:00 a.m. on 04/13/2015. When contacted by telephone by the DON, CNA HH denied bumping Resident #8's head during the bed-to-Geri chair transfer, but acknowledged he/she had transferred the resident by himself/herself. This report also documented that CNA HH was suspended for not obtaining assistance during Resident #8's Hoyer Lift transfer. During a 04/22/2015, 3:00 p.m. interview, the DON acknowledged that on 04/13/2015, CNA HH admitted to transferring Resident #8 using a mechanical lift without assistance, and that Resident #8 required two-persons for transfer. Cross refer to F323 for more information regarding Resident #8. 2. Resident #3's Annual MDS assessment of 04/21/2015 documented diagnoses, in Section I-Active Diagnoses, including, but not limited to, Heart Failure, Hypertension, and Arthritis, and Section M - Skin Conditions documented existing pressure sores. Review of the Care Plan of Resident #3 revealed the Care Plan to identify the resident's potential for pressure ulcer development, and also referenced the presence of pressure sores of the right great toe; left outer ankle; right inner ankle; and right outer ankle. Care Plan Interventions to address the pressure sores of Resident #3 included, but were not limited to, the administration of treatments as ordered. A current physician's orders [REDACTED]. However, even though the Care Plan of Resident #3 referenced above specified that pressure sore treatment be administered as ordered, during an observation conducted on 04/22/2015 at 11:40 a.m., Resident #3 was observed to have no dressing on the left ankle pressure sore, as specified by the physician's orders [REDACTED].>During a 04/22/2015, 11:40 a.m. interview, LPN HH acknowledged that the dressing ordered for the left ankle pressure sore of Resident #3 was absent. Cross refer to F314 for more information regarding Resident #3.

Based on observation, clinical record review, facility Mechanical Lift Policy review, EMS Call Sheet Detail Form review, hospital Patient Information Form review, hospital history and physical examination [REDACTED]#8). The total abbreviated survey sample was nine (9) residents. Resident #8 sustained harm, as the resident was found to have a laceration around the left temple area requiring hospital transfer and stapling, and was diagnosed with [REDACTED]. Findings include: Review of the facility's Mechanical Lift Policy revealed the Policy to specify that for resident safety, two (2) or more personnel must be in attendance when a mechanical lift was used. Record review for Resident #8 revealed an Annual Minimum Data Set (MDS) assessment having an Assessment Reference Date of 03/24/2015 which documented diagnoses, in Section I - Active Diagnoses, which included, but were not limited to, Arthritis and Alzheimer's disease. Section C - Cognitive Patterns of this MDS documented that Resident #8 had a Brief Interview for Mental Status (BIMS) Summary Score of 99, thus indicating the resident to be unable to complete the BIMS interview. Section G - Functional Status documented that Resident #8 had a Functional Limitation in Range of Motion, with impairment on both sides in the upper and lower extremities, and that the resident required the extensive assistance of two (2)-plus persons for transfer. A Progress Notes entry of 04/13/2015, timed at 3:34 p.m. and titled as a Nurse's Note, for Resident #8 documented the following: At 9:45 a.m., Certified Nursing Assistant (CNA) CC was preparing to use a Hoyer lift to place Resident #8 back to bed after breakfast and asked Licensed Practical Nurse (LPN) AA to assist with the transfer. Resident #8 was already in the dining room when LPN AA and CNA CC arrived earlier that morning. Resident #8 was guided into the proper position after the Hoyer lift was in the proper place over the bed, the resident was lowered down, and the lift was removed. CNA CC turned Resident #8 on his/her right side to provide personal care, and it was at that time that LPN AA and CNA CC observed Resident #8 to have blood in his/her hair. These staff members observed an approximate three (3) centimeter (cm) laceration to the left side of the back of the Resident #8's head, and therefore notified the Assistant Director of Nursing (ADON). A physician's orders [REDACTED].#8 to the hospital emergency room (ER), Emergency Medical Services (EMS) was called, and the resident was transported at 10:50 a.m. The EMS Call Sheet Detail form dated 4/13/2015 documented that EMS had arrived at the nursing facility at 10:44 a.m. to transport Resident #8 to the hospital, and had then arrived at the hospital ER at 11:09 a.m. The Narrative section of this EMS Call Sheet Detail form documented that EMS staff had responded to the nursing facility to transport Resident #8 to the hospital for a laceration to the left side of the head. This EMS Call Sheet Detail form further documented that EMS staff were informed by facility staff that they had not been aware of Resident #8's wound until breakfast, when they had seen blood, and that during the previous shift, the resident might possibly have been mistakenly hit in the head. EMS staff noted Resident #8 to be lying in bed, unable to speak and having no motor function, and the resident was transported to the hospital. The Special Comments section of this EMS Call Sheet Detail form included the Comment that Resident #8 had been involved in a Hoyer Lift accident. A hospital Patient Information Form for Resident #8 documented the resident's transfer to the hospital and hospital admission date of [DATE], with a Primary [DIAGNOSES REDACTED].#8 had received a head laceration at the nursing facility, and that the nursing facility did not know how the resident received the injury. A hospital History and Physical (H&P) Examination form for Resident #8 also documented the resident's 04/13/2015 admission to the hospital. This H&P form documented, in the History of Present Illness section, that Resident #8 had presented to the hospital from the nursing facility secondary to a head injury, with nursing facility staff stating the facility was unsure of the details related to the resident's trauma. The Physical Examination portion of this H&P documented that Resident #8 had a laceration around the left temple area which was not actively bleeding at that time, and that the area was stapled and bandaged. The Laboratory and Diagnostic Data section of this H&P documented that a Computed Tomography (CT) head scan for Resident #8 revealed bilateral subarachnoid hemorrhages in the posterior frontal and parietal sulci, with the documented presumed etiology being trauma. A hospital Consultation Report for Resident #8, as related to the resident's 04/13/2015 hospital admission, also identified, in the History of Present Illness section, that the resident had been admitted to the hospital after a fall in the nursing facility, and that Resident #8 had been diagnosed via CT scan with a bilateral subarachnoid hemorrhage which was consistent with the contusions. The Assessment and Plan section of this Consultation Report specifically documented that Resident #8 had sustained bilateral subarachnoid hemorrhages from a fall, and that he/she would need hospice care. A facility investigation Follow-Up report dated 04/17/2015 outlined the facility's investigation into the 04/13/2015 incident involving the discovery of Resident #8 to have a head laceration. This Follow-Up report, which was signed by the facility's Director of Nursing (DON), documented the following: On 04/13/2015 at approximately 10:18 a.m., CNA CC and LPN AA put Resident #8 back to bed by the use of a Hoyer Lift, which was always used with transfers for this resident. After placing Resident #8 in the bed, the Hoyer Lift was removed by these two staff members. CNA CC called LPN AA to look at the left side of Resident #8's head after turning the resident to the right side and noting a laceration, approximately 3 to 4 cms in length, to the left side of the head. A ring of dried blood, approximately 3 inches in circumference was noted in the hair around the wound, and a small amount of non-dried blood was noted in the laceration. Both CNA CC and LPN AA stated there was no incident when transferring Resident #8 from the Geri-chair to the bed via Hoyer Lift, and both staff denied hitting the resident's head at any time during the transfer. During an interview with LPN AA conducted on 04/22/2015 at 1:25 p.m., LPN AA stated that Resident #8 was up in the dining room on 04/13/2015 at 6:30 a.m., having been gotten up and transported to the dining room earlier by a CNA from the 11:00 p.m.-7:00 a.m. shift. LPN AA stated that CNA BB assisted Resident #8 with breakfast. LPN AA stated that later, he/she and CNA CC lifted Resident #8 by Hoyer Lift, placed the resident and turned him/her turned to the side. LPN AA stated that the CNA then notified him/her that the back of Resident #8's head was covered with blood and that this LPN had received no prior report of an injury regarding Resident #8 earlier that day. LPN AA stated that the Assistant Director of Nursing (ADON) then called the EMS to transport the resident to the hospital. During an interview with CNA CC conducted on 04/22/2015 at 1:38 p.m., CNA CC stated that Resident #8 had been in the hallway in front of his/her room after breakfast (on 04/13/2015), and that he/she had returned Resident #8 to the room. CNA CC acknowledged that he/she and LPN AA then transferred Resident #8 to the bed using the Hoyer Lift, and that when the resident was turned on his/her side, the CNA observed blood coming from the (L) side of the resident's head above the ear. CNA CC stated that LPN AA then notified the DON and ADON. During an interview with the ADON conducted on 04/22/2015 at 2:00 p.m., the ADON acknowledged that LPN AA summoned him/her to the room of Resident #8 to assess an injury to the resident's head. The ADON stated that he/she visualized the injury to Resident #8's head, observing an injury on the left side of the head, slightly behind the ear near the back of the head. The ADON stated that a small amount of blood was observed on Resident #8's pillow and that the physician, when notified, ordered to transport the resident to the ER. The ADON stated the investigation of Resident #8's head injury included assessing the sheet covering the Geri chair, which had no evidence of blood on it; however, blood was observed on the pillow which had been under Resident #8's head while in the Geri-chair. The ADON further stated that Resident #8 had been transferred earlier on 04/13/2015 by 11:00 p.m.-7:00 a.m. shift staff. Continued review of the facility's 04/17/2015 investigation Follow-Up report referenced above, completed by the DON, revealed the report to document that Resident #8 had been first gotten up by CNA HH at approximately 5:30 a.m. or 6:00 a.m. on the morning of 04/13/2015. The DON contacted CNA HH by telephone and asked CNA HH if he/she had bumped Resident #8's head at any time during the transfer from bed to the Geri-chair, to which CNA HH stated this had not happened. When the DON asked CNA HH if he/she had transferred the resident to the Geri-chair by himself/herself, the CNA stated that he/she had transferred the resident without assistance. The DON informed CNA HH that transferring the resident without assistance was against facility policy and asked CNA HH if she was aware of that fact, to which CNA HH responded in the affirmative. CNA HH further stated that she/she had combed Resident #8's hair and did not see a laceration or blood and, after placing the resident in the Geri-chair, had taken him/her to the dining room for breakfast. Resident #8 had been assisted during breakfast by CNA BB, who stated he/she had not seen any blood on the resident's head. Additionally, the DON documented in this Follow-Up report that all staff who worked the morning of the discovery of Resident #8's head wound were questioned, as were 11:00 p.m.-7:00 a.m. shift LPN EE and CNA GG, but no staff reported observing blood on the resident's head. The DON further documented that the facility's investigation did not reveal the source of Resident #8's head injury which had resulted in the resident's hospital admission due to a subdural hematoma; however, CNA HH was suspended for the failure to obtain assistance when transferring Resident #8 via the Hoyer Lift. During an interview with the DON conducted on 04/22/2015 at 3:00 p.m., the DON stated that on 04/13/2015 at 10:30 a.m., LPN AA notified him/her of Resident #8's head laceration. The DON stated the laceration was about one (1) inch behind the (L) ear on the back of Resident #8's head. The DON stated that dried blood was noted on Resident #8's pillow where the resident's head was lying; however, there was no evidence of blood on the Hoyer Lift which was used to transfer Resident #8, nor was there evidence of blood in the resident's room (except on the pillow upon which Resident #8 had been positioned, as referenced above). The DON acknowledged that 11:00 p.m.-7:00 a.m. shift staff had prepared Resident #8 for breakfast, including the resident's transfer out of bed into the Geri-chair, further stating that staff who had assisted Resident #8 in the dining room with breakfast denied observing any evidence of blood from the resident. The DON stated that, upon the discovery of Resident #8's head injury, an investigation was begun immediately, and that interviews were conducted with every resident who was capable of interview on the hall where Resident #8 resided. The DON stated that all interviewed residents denied hearing any unusual noise, with the exception of one (1) resident (Resident A). The DON stated that Resident A stated he/she had heard a loud bang and assumed that someone had dropped something. Record review for Resident A revealed an Annual MDS for April of 2015 which documented in Section C-Cognitive Patterns that Resident A had a BIMS Summary Score of 10, thus indicating only moderate cognitive impairment. During an interview with Resident A conducted on 04/22/2015 at 3:40 p.m., Resident A acknowledged he/she had heard a loud noise on the morning of the discovery of Resident #8's head laceration, further stating that the noise sounded like someone being hit. Resident A stated he/she did not get up to see what had caused the noise, but stated that the noise was very loud. Resident A stated he/she did not remember the exact time he/she overheard the noise but that it was early in the morning. Observation conducted at the time of this interview revealed Resident A to reside on the same hall on which Resident #8 had resided, three (3) rooms down and on the same side of the hall from Resident #8's former room. Review of the medical record of Resident I (the roommate of Resident #8 at the time of discovery of Resident #8's head wound) revealed a Quarterly MDS assessment having an Assessment Reference Date of 02/09/2015 which documented, in Section C - Cognitive Patterns, a BIMS Summary Score of 99, thus indicating Resident I was not able to complete the BIMS interview, and could not be interviewed regarding Resident #8's injury. During the 04/22/2015, 3:00 p.m. interview referenced above, the DON acknowledged that on 04/13/2015, CNA HH had admitted to transferring Resident #8 using a mechanical lift, but without the assistance of a second staff member (as also documented in the facility's investigative Follow-Up report referenced above). The DON acknowledged that Resident #8 required two-person transfers. The DON stated that CNA HH had been terminated due to the failure to follow facility Policy, and stated that the transfer of Resident #8 without the assistance of a second staff member was the latest of multiple non-resident-care-related infractions by this CNA. The DON stated that the facility's investigation had been unable to determine the exact cause of the head laceration of Resident #8 discovered on 04/13/2015. An Employee Counseling Form dated 04/20/2015 referenced CNA HH and documented the CNA used a Hoyer Lift for the resident by himself/herself, further documenting that Hoyer Lift transfers must always have two (2) personnel to assist. A facility Separation Notice dated 04/21/2015 for CNA HH documented the resident's separation from employment on 04/20/2015, and documented that the circumstances of CNA HH's separation involved the failure to follow facility Policies and Procedures.

Based on clinical record review, facility Mechanical Lift Policy review, EMS Call Sheet Detail Form review, hospital history and physical examination [REDACTED]#8), who required mechanical lift transfer. The abbreviated survey sample was nine (9) residents. Resident #8 sustained harm, as the resident was found to have a laceration around the left temple area requiring hospital transfer and stapling, and was diagnosed with [REDACTED]. Findings include: Record review for Resident #8 revealed the Annual Minimum Data Set (MDS) assessment of 03/24/2015 documented, in Section I - Active Diagnoses, the resident to have [DIAGNOSES REDACTED]. Section G - Functional Status documented that Resident #8 had Functional Limitation in Range of Motion and impairment on both sides in the upper/lower extremities required extensive assistance of two (2) - plus persons for transfer. A Progress Notes entry of 04/13/2015 at 3:34 p.m. for Resident #8 documented that at 9:45 a.m., Certified Nursing Assistant (CNA) CC requested that Licensed Practical Nurse (LPN) AA assist in a Hoyer lift transfer of Resident #8 to bed. Resident #8 was lifted to the bed via Hoyer lift and lowered to bed. LPN AA and CNA CC then observed Resident #8 to have blood in the hair, and to have an approximate three (3) centimeter (cm) laceration to the left side of the back of the head. The Assistant Director of Nursing (ADON) was notified, the physician was contacted and ordered Resident #8's hospital transfer, and Emergency Medical Services (EMS) was called. The EMS Call Sheet Detail form of 4/13/2015 documented that EMS staff responded to the facility to transport Resident #8 who had a laceration to the left side of the head. EMS staff were informed by facility staff that they observed blood on Resident #8 around breakfast, and that the resident might have been mistakenly hit in the head the previous shift. The Special Comments section of this EMS Call Sheet Detail form included that Resident #8 was involved in a Hoyer Lift accident. A hospital History and Physical (H&P) Examination form documented, in the History of Present Illness section, that Resident #8 was transferred secondary to a head injury. The H&P Physical Examination documented stapling of a laceration around Resident #8's left temple area, and the H&P Laboratory and Diagnostic Data section documented a Computed Tomography (CT) head scan revealed bilateral subarachnoid hemorrhages. A hospital Consultation Report for Resident #8 documented, in the History of Present Illness section, that the resident had been admitted to the hospital on [DATE] after a fall, and documented [DIAGNOSES REDACTED]. This Consultation Report also documented that Resident #8 sustained bilateral subarachnoid hemorrhages from a fall. During an interview with LPN AA on 04/22/2015 at 1:25 p.m., LPN AA stated that Resident #8 had been in the dining room on 04/13/2015 at 6:30 a.m. and had been taken to the dining room by a CNA from the 11:00 p.m.-7:00 a.m. shift. LPN AA stated that he/she and CNA CC transferred Resident #8 back to bed via Hoyer Lift, and that CNA CC then noticed the back of Resident #8's head was covered with blood. LPN AA stated he/she had received no earlier report of an injury involving Resident #8. During an interview conducted on 04/22/2015 at 2:00 p.m., the Assistant Director of Nursing (ADON) acknowledged that Resident #8 had been transferred by 11:00 p.m.-7:00 a.m. shift staff. The ADON stated that, after LPN AA notified him/her of Resident #8's head injury, he/she observed the resident to have an injury on the left side of the head, slightly behind the ear near the back of the head. The ADON stated blood was observed on the pillow which had been under Resident #8's head while in the Geri-chair. A 04/17/2015 facility investigation Follow-Up report related to Resident #8's [MEDICAL CONDITION] documented that on 04/13/2015 at approximately 10:18 a.m., CNA CC and LPN AA put Resident #8 back to bed using a Hoyer Lift. After Resident #8's transfer to bed, CNA CC asked LPN AA to look at the left side of the resident's head due to a laceration of approximately 3 to 4 cms in length. A ring of dried blood, approximately 3 inches in size, was observed in Resident #8's hair around the wound. CNA CC and LPN AA denied any incident, or hitting the resident's head, during Resident #8's Hoyer Lift transfer from the Geri-chair to bed after breakfast. The investigation Follow-Up report documented that Resident #8 had been gotten up by CNA HH (prior to breakfast) on 04/13/2015 at approximately 5:30 or 6:00 a.m. CNA HH had been contacted via telephone by the Director of Nursing (DON), and CNA HH denied bumping Resident #8's head during the transfer from bed to the Geri-chair on the morning of 04/13/2015. CNA HH did acknowledge, however, that he/she had transferred Resident #8 to the Geri-chair by himself/herself, without the assistance of a second staff person. This report further documented CNA HH had acknowledged to the DON that he/she was aware that transferring a resident without assistance was against facility policy. (The facility's Mechanical Lift Policy was reviewed and found to specify that two or more personnel must be in attendance during mechanical lift use.) Review of an Education Attendance Record dated 01/3/2015 (approximately four months prior to the 04/13/2015 incident during which CNA HH transferred Resident #8 from the bed to the Geri-chair via Hoyer Lift but without assistance) revealed that CNA HH had attended an in-service entitled Lifts and Lift Management. The Policy entitled Lift Management Program Policy included the following guidelines: -Transfers for residents without using mechanical lifting devices are limited to ambulatory residents and residents that may assist themselves. -All co-workers required to use the lifting devices will be oriented and trained on proper use including firsthand experience on what the lift feels like from a resident perspective. During a 04/22/2015, 3:00 p.m. interview, the DON acknowledged that on 04/13/2015, CNA HH acknowledged he/she had transferred Resident #8 on 04/13/2015 using a mechanical lift without assistance. The DON stated that Resident #8 required two-person transfers, and that CNA HH was terminated due to the failure to follow facility Policy. Cross refer to F323 for more information regarding Resident #8.