Every finding on record at Carriage House Manor

Based on observation, interview and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for 1 of 1 supply storage rooms reviewed for drugs and biologicals in that: The nurse storage room located on the hall identified as Cottage Street was left unlocked and unattended and the refrigerator storage in the storage room was unlocked and unattended. This failure could place residents at risk for loss of control of prescribed medications and essential resident care supplies. The findings included: During an observation round of the facility on 07/08/2026 at 10:05 a.m., the nurse's storage room located on the hall identified as College Street was not attended or secured. The surveyor turned the door handle to ensure the room was secured at which time, the door opened freely and revealed it was unlocked. The room was visible from the nurse's station with one nurse seated at the nurse's station. Additional staff and residents were observed in the immediate vicinity on the hall. There was a sign on the door with the words, Door must remain locked. The storage room contained nursing supply items to include 9 humidified water bottles, a container of oxygen tubing (bagged), 4 containers of sani-cloth wipes, 11 boxes (unopened) of alcohol pads, 5 bags (unopened) of 1cc insulin syringes 1mL (50 count), 3 boxes (unopened) of tuberculin syringes 0.5 needles 27 gauge (110 count), 1 box (unopened) of 1cc syringes hypodermic needles (the sharp, hollow attachment that pierces the skin to deliver or withdraw fluid) (100 count), 2 boxes (unopened) hypodermic needle 1.5 18 gauge, 2 boxes 1.5 25 gauge syringes, 18 nutren 2.0 supplement drinks, 20 containers of Glucerna 1.5 calorie supplement drink, 4 boxes of vinyl synthetic exam gloves, 3 sharp disposal containers and various packages of wound care dressing products (unopened). The refrigerator (unlocked) in the storage room contained resident specific insulin pens (unused and unopened) to include the following prescription numbers: Insulin Tresiba Rx503514466Insulin Tresiba Rx503524904 (2)Insulin Lispro Rx 503018124Insulin Lantus Rx503517659 (2)Insulin Novolog Rx503516469 (3)Insulin Mounjaro Rx50316452 (2)Insulin Humalog Rx503389231 (2)Insulin Lispro Rx 503060133Insulin Lispro 503496020 (2) During an interview on 07/08/2026 at 10:10 a.m., LVN A stated that the storage room was accessible by the nursing staff only with key entry. LVN A stated that she was not aware the door was unlocked and that she had not entered the room yet this morning. LVN A stated that the door does not automatically lock upon exit and the staff member needs to turn the lock to ensure it was locked and that she always checked it when she exited the room. LVN A stated that the risk for not locking the storage room was that residents would have access to insulin, needles and could injure themselves. During an interview on 07/08/2026 at 2:21 p.m., LVN B stated that she had been working at the facility for three days and believed she may have been the one to exit the nurse's storage room without ensuring the door was locked. LVN B stated that the medication room door will automatically lock upon exit, and she did not realize that the storage room did not automatically lock. LVN B stated that there was one key on the nurse's ring accessible for the floor nurses use only. LVN B stated that risks for not ensuring the door was secured upon exit was that a resident could have access to needles and insulin medication that could cause harm to them. During an interview on 07/08/2026 at 3:00 p.m., the DON stated that the nurse's storage room should be secure at all times and that failure was corrected as soon as it was brought to their attention. The DON stated that risk to residents was exposure to insulins and needles that could cause harm but noted that it would be unlikely that a resident could have entered the room without notice because the door was within line of sight of the nurse's station. The DON stated that the charge nurses were responsible for ensuring the door was secure. During an interview on 07/08/2026 at 3:30 p.m., the Administrator stated that she had been notified that the door was found unlocked by the surveyor and that she was not aware it did not automatically lock. The Administrator stated it was the nurse staff's responsibility to ensure the door was locked after each use to prevent access to potentially harmful supply stock such as needles by residents and visitors as well as to ensure inventory security. The Administrator stated that she and the DON would complete spot checks daily to ensure the door was secured or possibly change the type of lock to allow the door to lock automatically when closed. Review of the facility policy titled, medication Labeling and Storage, Revised February 2023, revealed Medication Storage, 4. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medication and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others; 6. Medications requiring refrigeration are stored in a refrigerator located in the medication room or other secured location.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 3 of 3 kitchens (Kitchen #1, Kitchen #2, and Kitchen #3) reviewed for dietary services.1. The dietary staff failed to label and date all food items in Kitchen #1.2. The dietary staff failed to effectively reseal, label and date frozen and refrigerated food items in Kitchen #1.3. The dietary staff failed to put separate dented cans from undented cans in Kitchen #1.4. The facility failed to ensure CNA B and CNA C wore their hairnets properly during the lunch meal in Kitchen #2 on 07/21/2025.5. The facility failed to ensure Honey Nut and Crisp [NAME] cereal were not left unsealed in Kitchen #3.6. The facility failed to ensure 2 containers of tea in Kitchen #3 were dated.7. The facility failed to ensure a medicine cup was not left in the sugar container in Kitchen #3.8. The facility failed to ensure proper storage and labeling of food in airtight containers after opening.9. The facility failed to ensure that kitchen staff appropriately restrained their hair with the hairnet.10. The facility failed to monitor the temperature of the household dishwasher in Kitchen #2 and Kitchen #3.11. The facility failed to monitor the temperature of the food heated in the microwave in kitchen #3.These failures could place residents at risk for food contamination and foodborne illness. Findings included: 1. During observations with the Dietary Manager on 07/23/25 beginning at 9:33 am, the following observations were made in the kitchen refrigerator (1 of 2) in Kitchen #1: -(1) 3-liter container of spaghetti sauce had a prep date of 7/18/25 and no expiration date. -(1) 3-liter container of jalapeno peppers had an open date of 5/5/25 and no expiration date -(1) 2-gallon size bag of lettuce had an open date 7/18/25 and no expiration date. -(1) 1-gallon of sweet tea had a preparation date of 7/21/25 and no expiration date -(1) 1-gallon of unsweet tea had a preparation date of 7/21/25 and no expiration date. During observations with the Dietary Manager on 07/23/25 beginning at 9:38 am, the following observations were made in the kitchen refrigerator (2 of 2) in Kitchen #1: -(3) cups of prune juice had a preparation date of 7/21/25 and no expiration date. -(1) cup of apple juice had a preparation date of 7/21/25 and no expiration date. -(1) gallon of orange juice was not labeled, had no expiration date, no preparation date. -(1) gallon of orange juice had a preparation date of 7/21/25 and no expiration date. -(1) gallon of apple juice had a preparation date of 7/20/25 and no expiration date. (1) gallon of cranberry juice had no expiration date and no preparation date. During observations with the Dietary Manager on 07/23/25 beginning at 9:41 am, the following observations were made in the kitchen freezer (1 of 3) of Kitchen #1: -(2) uncooked frozen cheese pizza had no label and no open date. During observations with the Dietary Manager on 07/23/25 beginning at 9:41 am, the following observations were made in the kitchen freezer (2 of 3): -(1) large zip top bag of pepperoni, unsealed, was not labeled, had no open date and no expiration date. -(1) bag of potato wedges had no label, no open date and no expiration date. During observations with the Dietary Manager on 07/23/25 beginning at 9:41 am, the following observations were made in the dry storage area of Kitchen #1: -(1) 6 ounces of can of diced potatoes (dented can) was located on a rack with the undented cans. Record review of the steam table temperatures with [NAME] H for the lunch meal items served on 7/22/25 included BBQ brisket was temped at 179 degrees Fahrenheit, the regular potato salad was temped at 35.8 degrees Fahrenheit, the pureed potato salad was temped at 56.3 degrees Fahrenheit, the regular fried okra was tempted at 141 degrees Fahrenheit, the sliced bread was not temped, and the vanilla [NAME] pie dessert was not temped. During an interview on 7/22/25 at 12:00 pm, [NAME] H stated she had been the [NAME] at the facility for 20 years. [NAME] H stated the facility had 3 residents on a puree diet. [NAME] H stated, the cooked cold foods should have a temperature of 55 degrees Fahrenheit or below prior to being served to the residents and the hot foods should have a temperature of 158 degrees Fahrenheit and above. [NAME] H stated she had not completed any in-services on food temperatures at the steam table. [NAME] H stated she did not understand the question when asked why it was important to the residents for the cold food to be served at 41 degrees and below and for the hot foods to be served at least 135 degrees and above at the steam table. [NAME] H stated the potato salad was a cold food item. During an interview on 7/23/25 at 9:40 am the Dietary Manager stated she had been the dietary manager since March of 2025. The Dietary Manager stated the Administrator oversaw her at the facility. The Dietary Manager stated she tasted the foods. The Dietary Manager stated she tasted the foods from the newer cooks more often than the older cooks. The Dietary Manager stated the last in-service on following recipes had not been completed on staff since she had been the dietary manager. The Dietary Manager stated she would in-service staff on following the recipe. The Dietary Manager stated the potato salad was to be served cold and at 41 degrees Fahrenheit and below. The Dietary Manager stated she had 3 residents on puree diets. The Dietary Manager stated it was important because it's their home and that's how staff are to serve the residents; the food is supposed to look neat and not sloppy; residents should get their food how we want our food. During an interview on 7/23/25 at 9:49am., the Dietary Manager stated she had been employed at the facility since March 2025. The Dietary Manager stated the Administrator oversaw her. The Dietary Manager stated she walked thru the kitchen every day. The Dietary Manager stated all food items were to be labeled, dated with the receive date, open date and expiration date. The Dietary Manager stated staff had completed in-services on labeling and dating all food items back on April 17th, 2025. The Dietary Manager stated she had not completed in-services with staff on resealing refrigerated and frozen food items. The Dietary Manager stated since she had been the Dietary Manager the Administrator did not conduct walk throughs in the kitchen. The Dietary Manager stated the owner of the facility conducted walk throughs in kitchen. The Dietary Manager stated, it was important to ensure staff were labeling, dating and resealing refrigerated and frozen food items so that staff knew what needed to be discarded and what staff can and can not use. During an interview on 7/23/25 at 10:24am, the Administrator stated she had been the Administrator at the facility for 7 years. The Administrator stated she oversaw the Dietary Manager. The Administrator stated she conducted regular walk throughs in the kitchen monthly. The Administrator stated all food items in the kitchen were to be labeled, dated with receive date, open date and expiration date. The Administrator stated the dietary staff had completed in-services on labeling and dating in the past. The Administrator stated in-services on resealing refrigerated and frozen food items was conducted by the Dietary Manager this week of 7/21/25. The Administrator stated it was important to ensure staff were labeling, dating and resealing refrigerated and frozen food items so that staff did not use something that was expired. 2. During an observation on 07/21/2025 at 11:35 AM, CNA B was plating the lunch meal and CNA C was standing right next to her while she plated the food in Kitchen #2. CNA B had a hair net on, but she had a piece of hair not contained in her hairnet. CNA B's strand of hair fell to her shoulder outside of the hairnet, while she was serving the lunch meal. CNA C was standing next to CNA B when CNA B was serving. CNA C was taking the uncovered plates to the dining table for the residents. CNA C's hairnet was not restricting the bottom half of CNA C's shoulder-length hair. During an interview on 07/22/2025 at 1: 56 PM, CNA B said when she was serving food her hairnet should restrict all her hair. CNA B said there should be no hair hanging out of the hairnet. CNA B said she did not realize her hair was hanging out of the hairnet. CNA B said it was important to wear the hairnets properly for it to be cleaner for the residents and so the hair did not get in the food. During an interview on 07/22/2025 at 2:00 PM, CNA C said the hairnet should restrict all of her hair not just the top half. CNA C said she was not wearing her hairnet properly because she was in a hurry. CNA C said hairnets should be worn properly to prevent hair from getting in the food. During an observation of the kitchen in Kitchen #3 with CNA G starting on 07/22/2025 at 2:27 PM, there were 35 oz bags of Honey Nut cereal and Crisp [NAME] cereal opened and not sealed. They were open to air. There were 2 pitchers of tea that were undated on the kitchen counter, and a container with sugar that had a plastic medicine cup inside of it. CNA G said the bags of cereal should be placed in a Ziploc bag and should not be left open to air. CNA G said they should be sealed so they did not get stale. CNA G said leaving it unsealed could result in contamination of the food and cause illness. CNA G said when tea was made it should be dated. CNA G said it should be dated to ensure they did not serve tea that was bad. CNA G said they were not supposed to leave medicine cups in the sugar. CNA G said the medicine cup should not be left in the sugar because different people used it, and it could result in contamination and infections. 3. During an observation on 07/21/2025 at 11:35 AM., in Kitchen #3: 1 1/2 full tub of cottage cheese with no open date. 1 bag of opened pancakes with no open date and no use by date. 2 bags of opened sliced ham with no open date and no use by date. 1 bag of sausage patties with no open date and no use by date. 2 1/4 quarts of tea without use by date. During an observation and interview on 07/21/2025 at 01:35 PM, CNA G was putting the dirty dishes in the residential/household dishwasher. CNA G said she used the sanitize cleaning mode with Cascade Platinum dishwasher soap. CNA G said she was unable to verify a temperature to ensure proper sanitation. During an observation and interview on 07/21//2025 at 04:35 PM. CNA G was in Kitchen #2 serving food without a hairnet. CNA G was plating all the food for the residents without a hairnet. CNA G was heating the lunch food in the microwave and failed to take the temperature of the food prior to serving. CNA G said she should have taken the temperature and/or allowed the food to cool off before serving to the residents. CNA G said the microwaved heated food could have been too hot and burned a resident. During an observation on 07/22/2025 at 11:35 AM., in Kitchen #2: 1 Ziploc bag of boiled shrimp not dated or labeled. 1 1/2 full tub of cottage cheese with no open date. a bag of opened pancakes with no open date and no use by date. crumbs and black crustlike substances in the microwave and oven. During an interview on 07/22/2025 at 02:35 PM., CNA G said staff should wear hairnets that covered hair appropriately while in the kitchen serving food. CNA G said all food once opened should be bagged, sealed and appropriately labeled with the date opened and expiration date. CNA G said it was important to follow appropriate food handling practices to keep the residents healthy and prevent cross contamination and food borne illness. CNA G said the appliances should be kept clean by wiping down after each use to prevent cross contamination. During an interview on 07/23/2025 at 3:58 PM, the Dietary Manager said she was not aware she was supposed to be checking Kitchen #2 and Kitchen #3. The Dietary Manager said she had just been focused on Kitchen #1. The Dietary Manager said when something was opened it should be dated. The Dietary Manager said cereal should be stored in a sealed bag once it was opened. The Dietary Manager said it was important to ensure it was stored sealed to keep the food fresh and to stop bacteria from getting into it. The Dietary Manager said the staff should not keep their personal items in the fridges. The Dietary Manager said the staff keeping their personal food with the resident's food could result in cross contamination. The Dietary Manager said the CNAs should be cleaning in Kitchen #2 and Kitchen #3 as they go. The Dietary Manager said she had not made them a cleaning schedule. The Dietary Manager said all the appliances in the kitchens should be cleaned daily. The Dietary Manager said she expected the CNAs to clean daily. The Dietary Manager said the dishwasher should not be used to wash the plates, forks, knives, cups, and trays because they could not check the temperature to ensure they were sanitized properly. The Dietary Manager said if the dishes were washed in the dishwasher it could result in a plate that was too hot or chemical left on the dishwasher, or the dishes could still be dirty. The Dietary Manager said containers of tea should be dated. The Dietary Manager said the microwave should not be used to reheat the food. The Dietary Manager said the microwave should not be used because they would not know the temperature of the food. The Dietary Manager said food should be reheated in a pot or pan or they should contact them to remake the food. The Dietary Manager said using the microwave to reheat food could result in the residents getting burned. The Dietary Manager said hairnets were supposed to be always worn properly in the kitchen area and all the hair should be tucked inside the hairnet. The Dietary Manager said the hairnet needed to be worn properly to ensure there was no hair in the resident's food. During an interview on 07/23/2025 at 4:02 PM., Administrator said that she expected the Dietary Manager to check behind the staff to ensure that the tasks to prevent infection and cross contamination and food borne illness were completed. The Administrator said the Dietary Manager was responsible for all the kitchens in each building to run in the same manner as the main kitchen. Record review of a undated policy titled Food Storage indicated, .in addition to labeling, dating items requires special attention. All foods that require time and temperature control (TCS) should be labeled with the following: Common name of the food, date the food was made and use by date. The TCS food can be kept for seven days if it is stored at 41 degrees or lower. If the TCS food is not used within seven days it must be discarded. Remember, Day 1 is the day 1 is the day the product was made. (Example: if a product was made on October 15, the use-by date would be October 21.was to ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to state, federal and US food codes. Dry storage rooms: d. to ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. Provide scoops for items stored in bins, such as sugar, flour, rice and other items. Store scoops covered in a protected area near the food containers. Was and sanitize the scoops weekly or as needed. Refrigerators: d. date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. Record review of an undated policy titled Preventing foodborne illness-Food Handling indicated . food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized.

Based on observations, interviews, and record review, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 1 of 3 meals (7/22/2025 Lunch) and for 5 of 5 residents reviewed for palatability, attractiveness, and appetizing (Resident #'s 63, 33, 10, 54, and 88). The dietary staff failed to provide food that was palatable and appetizing temperature for 1 of 3 meals observed on 7/22/25 (lunch) meal in Kitchen #1.The facility failed to ensure Resident #s 63, 33, 10, 54 and 88 food was not served bland and lacking flavor. These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: Record review of the menu indicated the lunch meal items on 7/22/25 included BBQ brisket, potato salad, fried okra, sliced bread and vanilla [NAME] pie dessert. During an interview on 07/21/2025 at 09:55 AM Resident #63 stated the food was bland. During an interview on 07/21/2025 at 10:53 AM Resident #33 stated the food was bland. During an interview on 07/21/2025 at 2:34 PM, Resident #10 said, They do not know how to cook; it doesn't look or taste good. During an interview on 07/21/2025 at 2:20 PM, Resident #54 said the food did not taste good. During an interview on 07/23/2025 at 12:49 PM Resident #88 said the food was often cold because it was brought in from the main building and by the time the residents got the food it was cold which made the food taste bad. During observation and tasting of the lunch meal on 7/22/25 at 12:09 p.m., the Dietary Manager and [NAME] H stated the BBQ was warm, the fried okra was not warm, the potato salad tasted like potato salad and the vanilla [NAME] dessert pie crust was hard. During observation and tasting of lunch meal on 7/22/25 at 12:09 p.m., the surveyors stated the BBQ was not warm and was salty, the fried okra was not warm, the potato salad tasted like potato salad and the vanilla [NAME] dessert pie crust was hard. During an interview on 7/22/25 at 12:00 pm, [NAME] H stated she had been the [NAME] at the facility for 20 years. [NAME] H stated the facility had 3 residents on a puree diet. [NAME] H stated she did not understand the question when asked why it was important to the residents for the cold food to be served at 41 degrees Fahrenheit and below for cold foods and for the hot foods to be served at least 135 degrees Fahrenheit and above at the steam table. [NAME] H stated the potato salad was to be served as a cold food item. During an interview on 7/23/25 at 9:40 am the Dietary Manager stated she had been the dietary manager since March of 2025. The Dietary Manager stated the Administrator oversaw her at the facility. The Dietary Manager stated she tasted the foods. The Dietary Manager stated she tasted the foods from the newer cooks more often than the older cooks. The Dietary Manager stated the last in-service on following recipes had not been completed on staff since she had been the dietary manager. The Dietary Manager stated she would in-service staff on following the recipe. The Dietary Manager stated she had 3 residents on puree diets. The Dietary Manager stated it was important because it's their home and that's how staff are to serve the residents; the food is supposed to look neat and not sloppy; residents should get their food how we want our food. During an interview on 7/23/25 at 10:14am the Administrator stated she had been the administrator for 7 years. The Administrator stated she oversaw the Dietary Manager. The Administrator stated she would eat at the facility. The Administrator stated her last test tray was completed about 3 months ago at the facility. The Administrator stated the food complaints were tricky because a lot of times the residents had issues with food preferences. The Administrator stated the residents had not complained about cold food to her recently. The Administrator stated she handled food complaints by letting the Dietary Manager know about the food complaint and having the Dietary Manger talk to the resident to address all food complaints issues. The Administrator stated she did not know if the staff had completed in-services on following the recipes recently. The Administrator stated it was important to ensure the food was palatable, attractive and appetizing to the residents because, the food was the one of the main things the resident had looked forward everyday. Record review of the food preparation and service policy dated October 2017 indicated, (1) the danger zone for food temperature is between 41 degrees and 135 degrees. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. (3) The longer food remain in the danger zone the greater the risk for growth of harmful pathogens. Therefore, PHF must be maintained below 41 degrees or above 135 degrees. Potentially hazardous food held in the danger zone for more than 4 hour (if being prepared from ingredients at room temperature) Or 6 hours (if cooked and then cooled) may cause foodborne illness.

Based on observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 1 of 21 residents (Resident #24) and 2 of 8 medication carts (Building #2 and Building #3 nurse medication carts) reviewed for drugs and biologicals. 1. The facility failed to ensure Resident #24's formoterol fumerate (inhaled medication to improve breathing) was properly stored and secured. 2. The facility failed to ensure LVN A did not leave Resident #24's budesonide and formoterol fumerate (inhaled medications) in the chamber of his nebulizer (chamber on the breathing machine that holds the liquid medication to be converted to a mist for inhalation) . 3. The facility failed to ensure a lock box inside the nurse medication cart for Building #2 with diazepam (anti-anxiety medication), hydrocodone/acetaminophen tablets (controlled pain medication), and tramadol (controlled pain medication) was permanently affixed. 4. The facility failed to ensure a lock box inside the nurse medication cart for Building #3 with alprazolam (anti-anxiety medication) acetaminophen/codeine tablets (controlled pain medication), and hydrocodone/acetaminophen tablets (controlled pain medication) was permanently affixed. 5. The facility failed to ensure LVN F secured the nurse medication cart keys for Building #3, when it was not in use on 07/22/2025. These failures could place residents at risk of not receiving drugs and biologicals as needed, medication errors, medication misuse, and drug diversion.Findings included: 1. Record review of Resident #24's face sheet dated 7/23/2025 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs) and vascular dementia (condition caused by the lack of blood that carries oxygen and nutrients to a part of the brain and causes problems with reasoning, planning, judgment, and memory). Record review of Resident #24's Quarterly MDS assessment dated [DATE] indicated he was understood by others and was able to understand others. The MDS assessment indicated Resident #24 had a BIMS score of 9, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #24 required partial/moderate assistance with dressing, personal hygiene, and showering/bathing. The MDS assessment indicated Resident #24 had shortness of breath or trouble breathing with exertion and when lying flat. Record review of Resident #24's Order Summary Report dated 07/23/2025 indicated he had an order for: Budesonide Suspension 0.25 mg/2 ml inhale orally two times a day with a start date of 05/20/2025. Perforomist Inhalation Nebulization Solution 20 mcg/2 ml (Formoterol Fumarate) 20 mcg inhale orally via nebulizer every morning and at bedtime with a start date of 05/29/2025. Record review of Resident #24's care plan revised 06/17/2024 indicated he had impaired cognitive function and dementia, or impaired thought processes related to difficulty making decisions. Resident #24's care plan indicated he used his own nebulizer machine (machine used to turn liquid medication into a fine mist for inhalation into the lungs) per his choice to administer aerosol (liquid suspension used in an inhaler) or bronchodilators (medication that opens the airways to help breathe better) as ordered and monitor/document any side effects and effectiveness. Record review of Resident #24's July 2025 MAR indicated his budesonide suspension 0.25mg/2ml and Perforomist Inhalation Nebulization Solution 20 mcg/2 ml were marked as administered by LVN A for the morning doses on 07/21/2025. During an observation and interview on 07/21/2025 at 2:23 PM, Resident #24 was in his room, he had 2 ampules of formoterol fumerate 20 mcg/ml nebulizer on his overbed table. Resident #24 said he brought them from home. There was clear liquid, approximately halfway full, in the chamber of Resident #24's nebulizer. Resident #24 said it was his breathing treatment, but he did not specify who left it there or how long it had been there. During an interview on 07/21/2025 3:19 PM, LVN A said she was Resident #24's nurse. LVN A said she had left Resident #24's breathing treatments (budesonide and formoterol fumerate) in his nebulizer that morning (morning of 07/21/2025). LVN A said she tried to tell Resident #24 to do his breathing treatments. LVN A said left the breathing treatments for him to do later in the day. LVN A said Resident #24 said he would do it later. LVN A said she should not have left Resident #24's breathing treatment in his nebulizer. LVN A said she should have stayed with Resident #24 until he completed his breathing treatment. LVN A said she did not know Resident #24 had 2 ampules of formoterol fumerate on his overbed table. LVN A said she had not given them to Resident #24. LVN A said he was not supposed to have them in his room because they had confused residents, and someone else could go in his room and get them. LVN A said she did not know of risks associated with leaving Resident #24's budesonide and perforomist in the nebulizer chamber. During an interview on 07/23/2025 at 3:36 PM, the ADON said they did not use self-administration for the residents. The ADON said they had several demented residents that could go in the rooms, and they did not have any residents who would qualify to self-administer medications. The ADON said Resident #24 should not have had ampules of formoterol fumerate on his overbed table. The ADON said the charge nurse, management, and the CNAs should report medications in the residents' rooms if they saw them. The ADON said Resident #24 had memory lapses and he was not able to administer medications to himself. The ADON said other residents could go in Resident #24's room and consume the medications, and they could have negative reactions. The ADON said Resident #24 could potentially get double dosed. The ADON said when a nurse administered a breathing treatment they should stay with the resident and make sure the residents were taking the medication. The ADON said if the resident did not want to complete the breathing treatment the nurse should document the medication as refused, but they should not leave it in the nebulizer chamber. The ADON said leaving the medication in the nebulizer chamber could result in Resident #24 not getting the full medication. The ADON said the residents could have respiratory issues if they did not get the full effect of the treatment and have a negative outcome. During an interview on 07/23/2025 at 3:45 PM, the DON said the residents should not have medications in their rooms. The DON said Resident #24 should not have formoterol fumerate in his room. The DON said the department heads should be making rounds weekly to check for medications in the residents' rooms. The DON said medications in the residents' rooms could cause medication errors. The DON said the nurses should not leave the breathing treatments in the nebulizer chamber. The DON said the nurses were supposed to stay with the residents during their breathing treatment and rinse the chamber after the treatment. The DON said leaving the medication in the chamber could result in the residents getting too much or too little. During an interview on 07/23/2025 at 4:33 PM, the Administrator said the residents should not keep medications at the bedside. The Administrator said nursing was responsible for ensuring this did not happen. The Administrator said it was important for the residents not to keep medications in their rooms because they had not been approved to give themselves medications. The Administrator said if the nurse left medication in the chamber of the nebulizer, they should be following up with the resident to ensure the breathing treatment was completed. The Administrator said if medication was left in the nebulizer chamber, it placed residents at risk to self-administer medications or they could drink it. 2. During an observation and interview on 07/22/2025 01:55 PM, LVN F entered the building and opened the unlocked desk drawer at the nurse station and took out the keys to Building 3's medication cart. LVN F proceeded to unlock the Building 3's medication cart and removed the locked box of narcotics and sat it on top of the medication cart. LVN F said she normally counted down the medication cart with the other nurse on duty and gave the medication keys to her before exiting the building. LVN F said the medication cart keys had not been placed in a locked secured place and could place the resident's medications at risk of misappropriation or a drug diversion. LVN F said she was not aware of the need for an affixed locked narcotic box on the medication cart. LVN F said the box not permanently affixed could result in the entire box being stolen and could put the residents at risk of not having medications. During an observation and interview on 07/23/2025 at 09:14 AM, LVN N opened Building #2's medication cart and removed the locked narcotic box of narcotics and sat it on the top of the medication cart. LVN N said she was not aware the medication cart locked narcotic box was supposed to be permanently affixed to the medication cart. LVN N said a drug diversion would occur if the locked narcotic box was taken. During an interview on 07/23/2025 at 09:40 AM, the ADON said he was not aware that it was necessary to have permanently affixed locked narcotic box on the medication carts. The ADON said he expected the staff to ensure the medication cart keys stayed always secured to prevent any drug diversions. During an interview on 07/23/2025 at 12:30 PM, the DON said she was not aware that it was necessary to have a permanently affixed locked narcotic box on the medication carts. The DON said she expected all staff to ensure the medication cart keys stayed secured by whoever was assigned to the cart to prevent misappropriation and/or a drug diversion. The DON said it was important to ensure the residents had their medication readily available for their needs. The DON said she and the ADON conducted random rounds daily to check to ensure the medication carts were secured. The DON said the nurses were responsible for ensuring the medication carts were locked. During an interview on 07/23/2025 at 1:30 PM, the Administrator said there was a system in place to check the medication carts. This system included the clinic staff and the pharmacy consult checking the medication carts to ensure everything was secured and dated. The Administrator said it was important to ensure the resident's medications were secured to prevent any misappropriation and eliminate the potential of any drug diversions. The Administrator said a drug diversion could place the residents at risk of not having needed medications readily available. Record review of the facility's policy, titled, Medication Labeling and Storage, revised February 2023, indicated, The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys.7.controlled substances are separately locked in permanently affixed compartments, except when using single dose drug distribution systems. Record review of the facility's policy, titled Controlled Substances, revised November 2022, indicated, 3. The charge nurse on duty maintains the keys to controlled substance containers.

Based on interview and record review, the facility failed to make a comprehensive assessment of each residents' needs, strengths, goals, life history, and preferences within 14 calendar days after admission for 1 of 21 residents (Resident #43) reviewed for accuracy of assessments. The facility failed to complete Resident #43's admission MDS assessment, with an ARD of 06/03/2025, within 14 days of admission. This failure could place residents at risk of not having their needs met.Findings included: Record review of a face sheet dated 07/23/2025 indicated Resident #43 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease (progressive disease that destroys memory and other important mental functions) and dementia in in other diseases classified elsewhere, severe, with other behavioral disturbance (deterioration of memory, language, and other thinking abilities with behaviors). Record review of Resident #43's Comprehensive MDS assessment with an ARD of 06/03/2025 indicated in Section A0310 it was an admission assessment (required by day 14). The MDS assessment for Resident #43 indicated in Section A1600 an entry date of 05/22/2025. The MDS assessment in Section Z0500B was signed completed on 06/13/2025, which indicated the MDS assessment for Resident #43 was completed 9 days late. During an interview on 07/23/2025 at 3:15 PM, MDS Coordinator D said she was responsible for completing Resident #43's admission MDS assessment. MDS Coordinator D said the admission MDS assessment should be completed within 14 days of admission. MDS Coordinator D said she tried her best to complete them within the 14 days. MDS Coordinator D said she kept a calendar to keep track of the MDS assessments that needed to be completed. MDS Coordinator D said she completed Resident #43's admission MDS assessment late because she was working on the floor. MDS Coordinator D said not completing the admission MDS assessment by the required timeframes could affect the way they got paid. During an interview on 07/23/2025 at 4:29 PM, the Administrator said the MDS Coordinators should be completing the MDS assessments per the requirements. The Administrator said she did not know how it could affect the residents, but it could affect the way they got paid. Record review of the facility's policy revised July 2017, titled, MDS Completion and Submission Timeframes, indicated, Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes.Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11 updated October 2023 indicated, For the admission assessment, the MDS Completion Date (Z0500B) must be no later than 13 days after the Entry Date (A1600).

Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 1 of 3 residents reviewed for respiratory care. (Resident #33) The facility failed to administer Resident #33's oxygen as ordered on 07/22/25. This failure could place residents who receive respiratory care at risk for developing respiratory complications.Findings included: Record review of Resident #33's face sheet dated 07/22/25, indicated a [AGE] year-old male who readmitted to the facility on [DATE] with diagnoses which included heart failure (chronic condition in which the heart doesn't pump blood as well as it should) and acute respiratory failure with hypercapnia (condition where the lungs cannot adequately remove carbon dioxide from the blood, leading to dangerously high levels of carbon dioxide). Record review of Resident #33's quarterly MDS assessment dated [DATE], indicated he was able to be understood and understood others. Resident #33 had a BIMS score of 9 which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #33 received oxygen therapy. Record review of Resident #33's comprehensive care plan revised on 09/10/24, indicated Resident #33 had oxygen therapy related to ineffective gas exchange. The care plan indicated Resident #33 received oxygen via nasal cannula at 2 liters per minute for shortness of breath and oxygen saturation 90%. Record review of Resident #33's order summary report dated 07/22/25, indicated he had an order for oxygen 2 liters as needed to maintain oxygen saturation greater than 90% with an order start date of 05/29/25. The order indicated to obtain oxygen saturation every shift and mark Y if oxygen was applied with the amount and to mark N if oxygen was not applied. Record review of Resident #33's medication administration record dated 07/01/25-07/31/25, indicated on 07/22/25 in the AM Resident #33 was administered oxygen at 2 liters by LVN M. During an observation on 07/22/25 at 09:07 AM Resident #33 was in his bed. He received oxygen at 3.5 liters per minute via nasal cannula. During an observation and interview on 07/22/25 at 1:47 PM, Resident #33 was in his bed and received oxygen at 3.5 liters per minute via nasal cannula. He said he started using the oxygen about a week ago and was unsure of what the oxygen was supposed to be set at. He said the nurse handled the oxygen setting. During an observation and interview on 07/22/25 at 4:29 PM, the MDS Coordinator went to Resident #33's room and observed his oxygen setting. She said Resident #33's oxygen was set at 4 liters per minute. She went to review his orders and said Resident #33 had an order for oxygen at 2 liters per minute. She said the oxygen task had been marked completed by LVN M that morning. She said the nurse making the morning rounds was responsible for ensuring the oxygen was set at the ordered rate. She said failure to check the oxygen rate could place the resident at risk for receiving too much oxygen or not enough which could cause them to have trouble breathing. The MDS Coordinator went and checked Resident #33's oxygen saturation and it read 90% which she said could have been the reason the oxygen was titrated up. She said the nurse should have made a note or notified the doctor when the oxygen was increased. During an interview on 07/23/25 at 2:17 PM, the DON said she strongly believed oxygen was a nursing intervention. She expected the orders and care plan to reflect the amount of oxygen the resident received. She said every resident in the facility should have had an order for oxygen at 2-4 liters per minute and the nurse who placed Resident #33's order should have never written it for 2. She said the nurse should have known to write the oxygen orders for 2-4 liters per minute. She said there were no risks for Resident #33 not receiving his oxygen at the ordered rate. During an interview on 07/23/25 at 2:40 PM, the Administrator said administration of oxygen was a nursing function and to be used as an intervention. She said she expected orders to be obtained and the residents orders to be updated accordingly. She said she expected the nurse to check the oxygen rate during their morning rounds. She said she was unsure of the risks for setting the oxygen at the wrong rate. During an interview on 07/23/25 at 4:22 PM, LVN M said when she marked the oxygen order on Resident #33 MAR, his oxygen was set at 2 liters per minute. She said the nurse was responsible for ensuring the oxygen was set at the ordered rate. She said there were no risks to the resident as he was set at the correct rate when she had worked that morning. Record review of the facility's policy Oxygen Administration revised October 2010, indicated . The purpose of this procedure is to provide guidelines for safe oxygen administration.1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 7 residents (Resident #35 and Resident #88) and 2 of 2 staff (CNA K and CNA G) reviewed for infection control. 1. The facility failed to ensure CNA K changed her gloves and performed hand hygiene when she provided incontinent care to Resident #35 on 07/22/2025. 2. The facility failed to ensure CNA G followed enhanced barrier precautions related to a wound while assisting Resident #88 with the use of a urinal on 07/23/2025. These failures could place residents and staff at risk for cross-contamination and the spread of infection. Findings included: 1. Record review of Resident #35's face sheet dated 07/22/25, indicated a [AGE] year-old female who admitted to the readmitted to the facility on [DATE] with diagnoses which included dysphagia (difficult swallowing) and protein-calorie malnutrition (inadequate intake of protein and calories in diet). Record review of Resident #35's quarterly MDS assessment dated [DATE], indicated she was able to make herself understood and understood others. Resident #35's BIMS score was a 12, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #35 was totally dependent on facility staff with toileting, showering, dressing and personal hygiene. Resident #35 was always incontinent of bowel and bladder. Record review of Resident #35's comprehensive care plan revised on 12/09/24, indicated she had bowel and bladder incontinence. The care plan interventions included to clean peri-area with each incontinent episode. During an observation on 07/21/25 at 10:09 AM, revealed CNA K and CNA L entered Resident #35's room to transfer the resident to the shower chair. CNA K and CNA L observed Resident #35 to have an incontinent episode of bowel. CNA K proceeded to provide incontinent care to Resident #35. CNA K unfastened Resident #35's brief and tucked it underneath her. CNA K then removed clean linen from the trash bag and placed them on the bed while wearing the same dirty gloves. CNA K failed to change her gloves and perform hand hygiene. CNA K then completed providing incontinent care to Resident #35. CNA K removed the dirty brief and placed it in a plastic bag. CNA K removed her gloves and applied the mechanical lift pad underneath Resident #35. CNA K failed to perform hand hygiene after removing her gloves. CNA K and CNA L transferred Resident #35 to the shower chair using the mechanical lift. CNA K and CNA L performed hand hygiene after completion of transfer. During an interview on 07/21/25 at 12:11 PM, CNA K said she should have changed her gloves after she touched Resident #35's dirty brief and before touching the clean linen. She said she did not do that. She said she should have also performed hand hygiene when she removed her gloves. She said failure to change dirty gloves and perform hand hygiene placed residents at risk for infection. She said she was responsible for maintaining infection control protocols when providing incontinent care. During an interview on 07/23/25 at 2:17 PM, the DON said she expected staff to change their gloves when going from dirty to clean and when they removed their gloves. She said failure to do so placed the residents at risk for infection. She said the CNA providing the incontinent care was responsible for ensuring infection control was maintained during incontinent care. During an interview on 07/23/25 2:40 PM, the Administrator said she expected gloves to be changed when going from dirty to clean and when removing gloves. She said failure to change gloves or perform hand hygiene placed the residents at risk for infection. She said the CNA providing the incontinent care was responsible for ensuring infection control was maintained during incontinent care. 2. Record review of a face sheet dated 07/23/2025 indicated Resident #88 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing (care provided after a hip fracture). Record review of Resident #88's electronic medical record on 07/23/2025 indicated his admission MDS assessment was in progress and had not been completed. Record review of Resident #88's Order Summary Report dated 07/23/2025 indicated he had an order for enhanced barrier precautions related to a surgical incision and wounds to monitor staff for PPE use and make sure the room was stocked with a start date of 07/18/2025. Record review of Resident #88's care plan revised 07/21/2025 indicated he required enhanced barrier precautions related to his surgical incision and wounds. Resident #88's care plan indicated staff would wear gloves and gowns for the following high contact care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting. During an observation on 07/22/2025 starting at 11:08 AM, on the doorway entrance, next to Resident #88's name were the letters EBP on bright pink paper. Resident #88 was in his bed and requested to use the urinal. CNA G put on gloves and did not put on a gown. CNA G went to Resident #88 while he was in the bed, leaned her body against the bed, and helped him by uncovering him and lowering his pants and brief. CNA G helped Resident #88 with holding the urinal in place while he attempted to use it. During an interview on 07/22/2025 at 11:23 AM, CNA G said she was not aware Resident #88 required enhanced barrier precautions. CNA G said usually when residents required special precautions, they had a cart outside their door with the PPE required, and they had a sign on the door. CNA G said PPE should be worn when necessary to prevent germs from getting on the resident and prevent them getting germs from the resident. During an interview on 07/22/2025 at 11:28 AM, LVN F said Resident #88 required enhanced barrier precautions because he had a wound. LVN F said the staff should be wearing PPE when providing care to him such as with transfers and incontinent care. LVN F said when assisting Resident #88 with the urinal the staff should wear gown and gloves. LVN F said the charge nurses were responsible for ensuring the CNAs knew the residents who required enhanced barrier precautions. LVN F said it was important for enhanced barrier precautions to be followed to prevent the transfer of germs. During an interview on 07/23/2025 at 3:31 PM, the ADON said Resident #88 required enhanced barrier precautions due to his wound. The ADON said ensuring the CNAs knew to use enhanced barrier precautions was a group effort between MDS Coordinator E, the charge nurses, and himself. The ADON said the charge nurses should be enforcing the use of enhanced barrier precautions. The ADON said when the CNA assisted a resident on enhanced barrier precautions with the use of a urinal, they should wear a gown and gloves. The ADON said he randomly conducted rounds to ensure the staff were wearing the appropriate PPE, and he had not noticed any issues with this. The ADON said it was important for enhanced barrier precautions to be followed to prevent the spread of infection. During an interview on 07/23/2025 at 3:49 PM, the DON said Resident #88 required the use of enhanced barrier precautions. The DON said all the department heads should be ensuring the staff were wearing the appropriate PPE. The DON said if CNA G was assisting Resident #88 with the use of a urinal, she should have worn a gown and gloves. The DON said it was important for enhance barrier precautions to be followed for infection control. During an interview on 07/23/2025 at 4:35 PM, the Administrator said she expected the staff to follow the enhanced barrier precautions. The Administrator said the charge nurse was responsible for monitoring the CNAs to ensure they were wearing the proper PPE and nurse management provided oversight. The Administrator said it was important to follow the enhanced barrier precautions to prevent multi-drug-resistant organisms. Record review of the facility's policy titled, Enhanced Barrier Precautions, dated August 2022, indicated, Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents.Gloves and gown are applied prior to performing the high contact resident care activity.examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing. d. providing hygiene. f. changing briefs or assisting with toileting. Record review of the facility's policy Perineal Care revised February 2018, indicated . The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. 8. b. wash perineal area, wiping from front to back. 10. Remove gloves and discard into designated container. 11. Wash and dry your hands thoroughly. 12. Reposition bed covers. Record review of the facility's policy Handwashing/Hand Hygiene revised August 2019, indicated . This facility considers hand hygiene the primary means to prevent the spread of infections. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations. m. after removing gloves.

Based on interview and record review, the facility failed to ensure an encoded, accurate, and complete MDS discharge assessment was electronically completed and transmitted to the CMS System within 14 days after completion for 1 of 1 resident (Resident #86) reviewed for discharge MDS assessments. The facility failed to ensure Resident #86's discharge MDS assessment was completed within 14 days of discharge. This failure could place residents at risk of not having records completed and submitted in a timely manner as required.Findings include: Record review of a face sheet dated 07/23/2025 indicated Resident #86 was an [AGE] year-old female admitted to the facility on [DATE] and discharged on 04/26/2025. Resident #86 was admitted with diagnoses which included acute respiratory failure with hypoxia (condition where there is not enough oxygen in the blood) and fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing (fracture of the thigh long bone). Record review of Resident #86's Nursing Home Discharge Item Set with an ARD of 04/26/2025 indicated Resident #86 discharged home/community on 04/26/2025. The Nursing Home Discharge Item Set was signed completed on 05/15/2025 by MDS Coordinator E., which indicated it was completed 5 days late. During an interview on 07/23/2025 at 3:07 PM, MDS Coordinator E said she was responsible for completing Resident #86's discharge assessment. MDS Coordinator E said they had the discharge day plus 14 days to complete the discharge assessments, and Resident #86's discharge assessment was completed a couple days late. MDS Coordinator E said it was hard to complete the discharge assessments in a timely manner because they were swamped with other MDS assessments, and the discharge assessments were not a priority. MDS Coordinator E said MDS Coordinator D helped her to complete the discharge assessments to try to keep them up to date. MDS Coordinator E said it was important to complete the discharge assessments timely for CMS to be aware the residents had been discharged from the facility. During an interview on 07/23/2025 at 3:15 PM, MDS Coordinator D said Resident #86's discharge assessment was probably not completed in a timely manner. MDS Coordinator D said their priority was the admission MDS assessments and the skilled MDS assessments. MDS Coordinator D said she did not know the required timeframes for completion of the discharge assessments. MDS Coordinator D said it was important to complete the discharge MDS assessments because that was how they got paid. During an interview on 07/23/2025 at 4:32 PM, the Administrator said the MDS Coordinators were responsible for completing the discharge assessments. The Administrator said she expected for them to be completed per the requirements. The Administrator said not completed the discharge assessments per the requirements could affect their reports. Record review of the MDS Final Validation Report, submission date 05/15/2025, indicated, Resident #86's Nursing Home Item Discharge Set was completed more than 14 days after the ARD. Record review of the facility's policy titled, MDS Completion and Submission Timeframes, revised July 2017 indicated, Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.18.11 dated October 2023, indicated, Discharge Assessment-Return Not Anticipated must be completed discharge date plus 14 calendar days.

Based on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that: The facility did not label, or date food stored in the kitchen's refrigerator. These deficient practices could place residents who received meals from the kitchen at risk for food borne illness. The findings were: During an observation on [DATE] at 8:55 a.m., it was observed that a whole pie, a slice of pie, French fries, tater tots, 1 gallon of partially eaten ice cream, and 2 bags of hard-boiled eggs did not have a date or label. During an interview on [DATE] at 8:53 a.m., the Dietary Manager said he expected that his staff to follow the dietary policy by dating and labeling all foods stored in their kitchen. He stated that residents can be placed at risk of foodborne illness by eating contaminated food. During an interview on [DATE] at 11:40 a.m., the DON said she expects that all facility staff including the kitchen staff follow facility policy. She said that residents could be placed at risk of foodborne illness if they ate expired food. During an interview on [DATE] at 11:52 a.m., with the ADM she said she expected that all facility policies are followed. She said she expected that food is labeled, dated and stored properly. She said that residents could be placed at risk of foodborne illness if they ate contaminated food. Review of the facility document revised on [DATE], titled Storage of Frozen and Refrigerated foods provided by the Administrator revealed: Refrigerate foods in shallow containers to speed the cooling process. Label to date placed in the refrigerator, time, expiration or use by date. Once a product has been opened the date opened shall be written on the product and use by date is 7 days from date opened. Food prepared in the building and properly cooled will be dated as to the date prepared and use by date which will be 7 days from the date Prepared.

Based on observation , interview, and record review the facility failed to ensure assessments accurately reflected the resident status for 4 of 22 residents (Resident #14, Resident 73, Resident #53, and Resident #186) reviewed for MDS assessment accuracy. 1. The facility failed to accurately document Resident #53's chair alarm use. 2.The facility failed to accurately reflect Resident #14 was PASRR positive (identified as having a serious mental illness) on her annual MDS assessment. 3. The facility failed to accurately reflect Resident #73 was receiving hospice services on her significant change MDS assessment. 4. The facility failed to accurately reflect Resident #186 had bed and chair alarms on his quarterly MDS assessment. These failures could place residents at risk for not receiving care and services to meet their needs. Findings included: 1. Record review of an undated face sheet revealed Resident #53 was an 86- year-old-female admitted to the facility on [DATE] with the diagnoses of Respiratory Failure with Hypoxia (happens when you don't have enough oxygen in your blood), Encephalopathy (a group of conditions that cause brain dysfunction), Acute Kidney Failure (Acute kidney failure occurs when your kidneys suddenly become unable) Record review of an Annual MDS dated [DATE] for Resident #53 revealed a BIMS of 05, which indicated severe cognitive impairment. The MDS also revealed Resident #53 was not marked for use of a chair alarm. Record review of resident #53's care plan revealed a problem initiated on 9/8/2023, I am at risk of falls and history of falls with multiple fractures and poor safety awareness. Fall alarm to wheelchair and bed. Record review of Resident #53's consolidated physician's orders dated 4/16/23 revealed Resident #53 had an order for, Alarm pad to chair and bed until further notice - make sure this is in place. During an observation on 06/24/24 at 10:40 a.m., Resident # 53 was observed with a chair alarm on her wheelchair. A chair alarm device that had a wire with a clip was attached to Resident #53's clothing. During an interview and observation on 06/25/24 at 08:49 a.m., revealed Resident #53 had a chair alarm attached to her clothing. Resident #53 said she did not know what it was. Resident #53 said it did not bother her. Resident #53 said she was not scared of the noise that was made by the wheelchair alarm. During an interview on 6/26/24 at 11:40 a.m., the DON said she expected accurate and timely MDSs as per facility policy. She said incorrect MDSs could affect the information transmitted to the state. She said it was the MDS nurse's responsibility to correctly code the MDS for residents. During an interview on 6/26/24 at 11:52 a.m. the ADM said it was the MDS nurse who was responsible for correctly coding the MDS. She said she expected accurate and timely MDSs. She said incorrect MDSs affected the information transmitted to State. 2. Record review of Resident #14's face sheet dated 6/25/24 revealed she was [AGE] years old and admitted to the facility on [DATE] and readmitted on [DATE]. Resident #14 had diagnoses of Primary Lateral Sclerosis (rare, slowly progressive neuromuscular (nerve and muscle) disease that leads to lose of muscle control and movement problems) and schizoaffective disorder, bipolar type (mental illness that combines symptoms of schizophrenia, such as hallucinations (seeing, hearing, smelling, tasting something that is not there), delusions (belief or altered reality that was persistently held despite evidence or agreement to the contrary), and psychosis (mental disorder characterized by a disconnection from reality), with a mood disorder such as mania (excessive enthusiasm or desire, or obsession) and depression (persistent sadness)). Record review of Resident #14's annual MDS assessment dated [DATE] indicated she marked as not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. The MDS did not indicate Resident #14 had serious mental illness. The MDS indicated a BIMS score of 12 which indicated Resident #14 had moderate cognitive impairment. The MDS indicated Resident #14 had a diagnosis of Schizophrenia (for example schizoaffective and schizophreniform disorders). Record review of Resident #14's PASRR Comprehensive Service Form dated 4/10/24 indicated Resident #14 was PASRR positive for mental illness only. Record review of Resident #14's care plan printed 6/26/24 revealed she was PASRR positive for mental illness with a diagnosis of Schizoaffective disorder Bipolar Type. Resident #14 refused PASRR services but was receiving counseling services. 3. Record review of Resident #73's face sheet dated 6/25/24 revealed she was [AGE] years old and admitted to the facility on [DATE]. Resident #73 had diagnoses of dementia (progressive or persistent loss of intellectual functioning, memory, related to disease of the brain), Alzheimer's (progressive disease that destroys memory and other important mental functions), and anxiety disorder. Record review of Resident #73's significant change MDS dated [DATE] revealed she had a BIMS of 99, which indicated she had severe cognitive impairment and was unable to complete the interview. The MDS did not indicate she was receiving hospice services. Record review of Resident #73's Physician Orders dated June 2024 revealed an order to admit to hospice for diagnosis of dementia with a start date of 5/03/24. Record review of Resident #73's care plan printed 6/24/24 revealed she was receiving hospice care. 4. Record review of Resident #186's face sheet dated 6/25/24 revealed he was [AGE] years old and admitted to the facility initially on 8/09/19 and readmitted on [DATE]. Resident #186 had diagnoses of dementia, Parkinson's (disease of the brain that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), and delusional disorder (belief or altered reality that was persistently held despite evidence or agreement to the contrary). Record review of Resident #186's quarterly MDS assessment dated [DATE] revealed he had a BIMS of 7, which indicated he had severe cognitive impairment. The MDS did not indicate he had bed or chair alarms. Record review of Resident #186's Physician Orders dated June 2024 revealed there was no orders for bed or chair alarms. Record review of Resident #186's care plan dated 6/26/24 revealed he was at risk for falls with history of multiple falls and had an intervention to place alarms as appropriate. During an interview and observation on 6/24/24 at 11:00 AM, Resident #186 was self-propelling himself in his wheelchair in the hallway with a chair alarm attached to the back of his wheelchair that attached to a pad under him. Resident #186 said he was doing just fine, and he did not know what the chair alarm was for. During an observation on 6/25/24 at 3:52 PM, Resident #186 was lying in bed asleep with a bed alarm attached to a pad under Resident #186. During an interview on 6/26/24 beginning at 2:24 PM with both MDS Coordinators, MDS B said she was responsible for the MDS assessments of residents with Medicare and MDS C said she was responsible for the MDS assessments of residents with Medicaid and private pay. MDS C said she completed Resident #73's significant change MDS assessment due to Resident #73 was admitted to hospice services. MDS C said she was responsible for ensuring the MDS assessments were accurate. MDS C said the MDS assessment calculated the RUG (Resource Utilization Group) score, and it reflected what the resident's care needs were. MDS C said if the MDS assessment was not accurate then the resident's care plan may not be accurate due to the care areas marked on the MDS assessment helped build the care plan for the resident. MDS C said hospice should have been checked on the Resident #73's significant change MDS assessment. MDS C reviewed Resident #73's 5/03/24 significant change assessment and said hospice was not checked. MDS C said she was responsible for Resident #186's MDS assessments. MDS C said Resident #186 had bed and chair alarms in place for a long time because he was a fall risk. MDS B reviewed Resident #186's MDS assessment and said Resident #186 did not have bed or chair alarms checked on his MDS assessment. MDS B said bed and chair alarms should have been included on Resident #186's MDS assessment. MDS C said she was responsible for Resident #14's MDS assessments. MDS C and MDS B said Resident #14 was PASRR positive and it should have been marked on her annual MDS assessment. MDS B reviewed Resident #14's annual MDS assessment and said PASRR was not marked on her MDS assessment. MDS B and MDS C said the PASRR section usually prepopulated, and they did not know why it did not prepopulate on Resident #14's MDS assessment, but it should have been marked. During an interview on 6/26/24 at 2:45 PM, the ADM said the MDS nurses were responsible for ensuring the MDS assessments were accurate. She said the MDS assessment should paint an accurate picture to the state on what level of care they were providing to the residents. The ADM said she would expect the MDS assessments to be accurate and paint a picture of the resident. Requested a policy on Accuracy of Assessments on 6/26/24 at 1:30 PM from the ADM and was provided policies on Electronic Transmission of MDS, MDS Completion and Submission Timeframes, and MDS Error Correction. These policies did not address accuracy of assessments. Record review of the Resident Assessment Instrument 3.0 User's Manual (RAI) last revised October 2023, revealed . the RAI process was the basis for the accurate assessment of each resident . Code yes if PASRR Level II screening determined that the resident had a serious mental illness . code serious mental illness, if resident had been diagnosed with a serious mental illness . code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions . identify all alarms that were used at any time during the 7-day look back period . bed alarm . chair alarm . code 2 if used daily . 45643

Based on observation, interview, and record review, the facility failed to ensure that a resident received appropriate treatment and services to prevent urinary tract infections (UTI) for 1 of 7 residents who were reviewed for quality of care. (Resident #77) 1. The facility failed to ensure Resident #77 had orders for the size and amount of fluid in the bulb of her indwelling urinary catheter (tube inserted into the bladder to drain urine). 2. The facility failed to ensure Resident# 77 had proper catheter care with an indwelling urinary catheter. The failures could place residents at risk for indwelling urinary catheter pain, urinary tract infections, and not receiving needed care. Findings included: 1. Record review of Resident #77's face sheet dated 6/24/24 indicated Resident #77 was a [AGE] year old female and admitted to the facility initially on 4/17/24 and readmitted on [DATE] with diagnoses including Unspecified dementia (progressive or persistent loss of intellectual functioning with impairment or memory and thinking and often with personality changes), UTI (urinary tract infection) site not specified, other acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood), and urine retention. Record review of Resident #77's quarterly MDS assessment dated [DATE] indicated Resident #77 was usually understood and understood others. The MDS indicated Resident #77 had a BIMS score of 13 which indicated her cognition was intact. Resident #77 was maximal assistance on staff for toileting hygiene. The MDS indicated Resident #77 had an indwelling catheter (urinary catheter) and was always continent of bowel. Record review of Resident #77's care plan dated 4/18/2024 indicated she had a diagnosis of retention of urine and a failed removal of urinary catheter on 5/28/24. She had a current UTI. She was on enhanced barrier precautions with interventions of gloves and gown should be donned (put on) if any of the following activities occurred: linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bathing, or other high contact activity. Record review of Resident #77's Order Summary Report dated 5/09/24 revealed an order to check the Foley catheter two times daily for correct placement, leaking and anchored to the skin. Staff should ensure her catheter bag is placed in a dignity bag when out of room. Resident #77's orders revealed there was no order noted related to Resident #77's urinary Foley catheter size and amount of fluid in the bulb. During an interview on 6/25/24 at 10:15 AM, the DON was notified Resident #77's urinary catheter size and bulb orders were not noted in her chart. The DON said she would find the orders. During an interview on 6/25/24 at 2:30 PM the DON stated Resident #77's urinary catheter size and bulb orders were not in the resident's chart. During an observation and interview on 6/26/24 at 8:02 AM, revealed CNA D performed and CNA E assisted with incontinent/catheter care for Resident #77. CNA D washed her hands and applied gloves before she started incontinent care. CNA D cleaned Resident #77's crease between her right leg and groin area, then CNA D changed towels and proceed to clean her left leg and groin area. CNA D changed the towel and proceeded to clean the catheter tubing away from her but did not clean her meatus (a passage or opening leading to the interior of the body). CNA D did not clean Resident #77's mons pubis (the rounded mass of fatty tissue lying over the joint of the pubic bones). CNA D then provided perineal care to Resident #77's buttocks. CNA D was wearing the same gloves and removed a dirty incontinent pad and applied a clean incontinent pad. CNA D did not change her gloves and put the covers over Resident #77,then removed her gloves and washed her hands. During an interview on 6/26/24 at 8:32 AM, CNA E said she was 95% sure that CNA D missed a step while performing catheter care. CNA E said after washing the front peri area of the body CNA D was supposed to sanitize her hands then apply new gloves, then perform incontinent care to the backside of resident. CNA E said she would have cleaned the middle of the vagina and catheter first then clean the sides of the groin areas. CNA E said CNA D did not clean Resident #77's meatus. CNA E said the importance of catheter care was to keep the peri area clean and keep the catheter in place. CNA E said bad catheter care could cause infections. CNA E said when going from dirty to clean staff were supposed to change their gloves to prevent cross contamination. During an interview on 6/26/24 at 8:42 AM, CNA D said she felt like she did horrible with Resident #77's catheter care. CNA D said she felt like her clean hand got in the way. CNA D said she should have changed her gloves after peri care and catheter care. CNA D said the importance of catheter care was cleanliness and to keep the catheter intact. CNA D said bad catheter care could cause infections and not changing gloves during catheter care can cause cross contamination. During an interview on 6/26/24 at 10:23 AM, LVN F said CNAs should be going from the inside area to the outside areas with soap and water, unless the outer areas were soiled. LVN F said during catheter care cleaning they should be removing dirty gloves, sanitizing hands and changing gloves when they went from one part of the body to the other, to prevent cross contamination. LVN F said bad catheter care can cause a urinary tract infection with the elderly. During an interview and record on 6/26/24 at 11:11 AM, CNA G provided CNA D's skills check offs. CNA G said when she trained the CNAs she trained them on a dummy first. CNA G said CNAs should start catheter care with the top of the catheter and clean down. She said after she cleaned the tubing, removed dirty gloves, hands should be washed and clean gloves should be applied, then proceed to clean the peri area. She said after the peri area was cleaned, then clean across the top of the pubic area, then pat dry. She said after the front side was cleaned, then turn the resident over to proceed to clean the back area. She said to always have someone to help assist with catheter care . She said after she was done with catheter care she would roll her dirty pad, then change her gloves and sanitize my her hands, then apply clean gloves. She said she would have applied a clean incontinent pad under the resident, then the other person assisting with catheter care should remove the dirty pad. She said after the dirty pad was removed she would pull out the other side of the pad from underneath the resident. CNA G said improper catheter care could cause an UTI (urinary tract infection) or other infections. Record review of CNA D's skills check off dated 2/28/24 revealed CNA D passed and was very nervous, but she would be rechecked on her skills later. CNA D skills recheck off dated 4/1/24 revealed CNA D did very good, but she second guessed herself. During an interview on 6/26/24 at 2:12 PM, LVN F said before applying a catheter or replacing a catheter there should always be a physician or a nurse practitioner order reviewed. LVN F said the orders were typically on the MAR. LVN F said the charge nurses put in phone orders and the nurse that did the resident's admission usually put in their orders. LVN F said the way the nurses knew when orders were due was the orders came up on the MAR to inform them. LVN F said she typically read the orders of the resident and verified the orders before she changed a catheter. During an interview on 6/26/24 at 2:19 PM, the ADON said there should be orders for a catheter and catheter care on the resident's chart. The ADON said the orders should list the size and the amount of fluid should be placed in the bulb and the frequency the catheter should be changed. The ADON said the admitting nurses should put in the resident's orders, but any nurse can put in orders. The DON and ADON check the orders after the nurses. The ADON said he except the CNA to perform catheter care and go from clean to dirty. He said the CNAs should be washing their hands and changing their gloves in between steps. The ADON said the risk of not performing hand hygiene during catheter care could result in an infection. During an interview on 6/26/24 at 2:29 PM, the DON said there should be an order for an indwelling catheter. She said the order should had the size of the catheter, the amount of fluid in the bulb and when to change the catheter. The DON said the treatment nurse or the admitting nurse usually put the resident's orders in. The DON said the order fell through, because Resident #77's orders were discontinued when she was discharged to the hospital and the admitting nurse forgot to put the orders back in. The DON said during catheter care the CNAs were supposed to go from clean to dirty and change their gloves periodically. The DON said proper catheter care prevented infections. During an interview on 6/26/24 at 2:37 PM, the ADM said there should be an order for an indwelling catheter. The ADM said when applying a catheter, the nurse should be following the doctors' orders. The ADM said she expected the CNAs to use the correct PPE and follow the standard precautions guidelines, with incontinent care and catheter care. The ADM said staff members should be trying to prevent cross contamination and infections throughout the facility. Review of a Catheter Care, Urinary Policy dated revised August 2022 revealed .the purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. Follow aseptic technique when inserting a urinary catheter. Use aseptic technique when handling or manipulating the drainage system. Routine perineal hygiene: With non-dominant hand separate the labia of the female resident. Maintain the position of this hand throughout the procedure. Assess the urethral meatus. For a female resident: Use a washcloth with warm water and soap (or clean bathing wipe) to cleanse the labia. Use one area of the washcloth (or wipe) for each downward, cleansing stroke. Change the position of the washcloth (or wipe) and cleanse around the urethral meatus. Do not allow the washcloth/wipe to drag on the resident's skin or linen. With a clean washcloth (or wipe), rinse using the above technique. Discard disposable items into designated containers. Remove gloves and discard into designated container. Wash and dry your hand thoroughly. Reposition the bed covers. Make the resident comfortable. Review of Physician Services Policy dated revised February 2021 revealed .The medical care of each resident is supervised by a licensed physician. Once a resident is admitted , orders for the resident's immediate care and needs can be provided by a physician, physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS).

Based on observation, interview, and record review the facility failed to develop, and implement a comprehensive care plan to meet the medical, nursing, mental and psychosocial needs for 1 of 22 residents (Resident #1) reviewed for care plans. The facility failed to implement a comprehensive person-centered care plan for Resident #1's diagnosis of Chronic combined systolic and diastolic congestive Heart Failure (heart does not pump blood adequately causing cough, shortness of breath, difficulty breathing, swelling, chest pain, weight gain, tiredness, and weakness). This failure could place residents in the facility at an increased risk of a decline in physical or functional well-being, of not receiving necessary care or services, and having personalized plans developed to address their needs. Findings included: 1. Record review of Resident #1's face sheet dated 6/25/24 revealed she was [AGE] years old and admitted to the facility initially on 4/25/16 and readmitted on [DATE]. Resident #1 had diagnoses of hypokalemia (low potassium), hypertension (high blood pressure), chronic combined systolic and diastolic heart failure. Record review of Resident #1's annual MDS assessment dated [DATE] revealed she had a BIMS of 10, which indicated she had moderate cognitive. The MDS indicated Resident #1 required total to maximum assistance for most ADLs. The MDS indicated Resident #1 had diagnoses of heart failure and hypertension. The MDS indicated Resident #1 had shortness of breath when lying flat. The MDS did not indicate Resident #1 was receiving a diuretic medication (used to pull extra fluid from body with increased urination). Record review of Resident #1's Physician Orders dated June 2024 revealed the following orders: * Torsemide 20 mg by mouth daily as needed, hold for blood pressure less than 100/60 or heart rate less than 60 for chronic combined systolic and diastolic heart failure with a start date of 3/1/24 *Torsemide 20 mg by mouth daily, hold for blood pressure less than 100/60 or heart rate less than 60 for chronic combined systolic and diastolic heart failure with a start date of 3/1/24. Record review of Resident #1's care plan dated 6/26/24 revealed she had hypertension and took a diuretic, but the care plan did not indicate Resident #1 had heart failure. Record review of Resident #1's Departmental Notes dated 6/11/24 indicated resident had a chest x-ray and new orders were to add torsemide 20 mg at 3:00 PM times five days in addition to the 20 mg every morning she was already taking. On 6/20/24, Resident #1 continued to have loose congestion and new orders received to increase Torsemide to twice daily for three days. During an observation and interview on 6/24/24 at 11:07 AM, Resident #1 was lying in bed. Resident #1 said the staff took good care of her and she did not have any concerns with her care. Resident#1 had a wet sounding rattle while breathing. During an interview on 6/26/24 at 2:07 PM, the ADON said he was responsible for ensuring the care plans were accurate and included everything needed after the assessments were complete and updated the care plans as needed. The ADON said the purpose of the care plan was to guide the resident's care. The ADON said things such as wounds, risks dehydration, code status, hospice, weight loss, things that could affect disease processes, and congestive heart failure to monitor for edema (swelling) should be included in the resident's care plan. The ADON said if he caught that congestive heart failure was not on care plan during his review, he would add it. The ADON said congestive heart failure was not on Resident #1's care plan and it should have been included. The ADON said if the resident did not have a care plan for congestive heart failure, the resident could go into fluid overload, have respiratory issues, and could lead to death. The ADON said by not having a care plan for an active disease process, it could lead to an exacerbation of the disease process and be detrimental to the resident. During an interview on 6/26/24 at 2:16 PM, the DON she said the interdisciplinary team consisting of the Social Worker, DON, ADON, Activities Directory, Dietary Manager, and MDS Coordinators were all part of the care planning process. The DON said mostly the ADON was responsible for ensuring the care plans included all pertinent information. The DON said the purpose of the care plan was so staff would know how to take care of the resident and to individualize the resident's care. The DON said congestive heart failure was a diagnosis that should be included in the care plan if the resident was taking a medication for it. The DON said if the care plan did not have all pertinent information, then staff that did not know the resident, would not know how to take care of them. During an interview on 6/26/24 at 2:45 PM, the ADM said the purpose of the care plan was to give a clear picture of the resident and how the staff was to best care for the resident. The ADM said the staff may not know how to address the resident's care if there was not a care plan. The ADM said she would expect the care plans to include pertinent resident information such as CHF. Record review of the facility's policy dated revised March of 2022 and titled Care Plans, Comprehensive Person-Centered, revealed . a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs were developed and implemented for each resident . comprehensive, person-centered care plan would . describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . reflected currently recognized standards of practice for problem area and conditions . care plan interventions were chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making . assessments of residents were ongoing and care plans were revised as information about the residents and the resident's conditions change .

Based on interview and record review, the facility failed to ensure PRN orders for psychotropic drugs are limited to 14 days unless the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order for 2 of 7 residents (Resident #58 and Resident #73) reviewed for unnecessary medications. The facility failed to ensure Resident #58 and Resident #73 had a stop date or duration for PRN Lorazepam (a medication used to treat anxiety). These failures could put residents at risk of possible psychotropic medication side effects, adverse consequences, decreased quality of life, and dependence on unnecessary medications. Findings included: 1. Record review of Resident #58's face sheet, dated 06/26/24, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included Acute on chronic combined systolic and diastolic heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), cardiomyopathy (an acquired or hereditary disease of heart muscle), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), chronic viral hepatitis C (an infection caused by a virus that attacks the liver and leads to inflammation), depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and Parkinson's disease (a disorder of the central nervous system that affects movement). Record review of Resident #58's quarterly MDS assessment, dated 05/09/24, indicated she was usually able to make herself understood and she usually understood others. She had a BIMS score of 7, which indicated severe cognitive impairment. The assessment further indicated Resident #58 did not receive any antipsychotics during her 7-day assessment window. Record review of Resident #58's Physician's orders, printed on 06/26/24, indicated the following orders: *Lorazepam intensol 0.5mg by mouth every four hours as needed for anxiety. The start date was 02/09/24. There was no stop date. There was no duration given for the order. *Lorazepam 1ml by mouth every four hours as needed for anxiety. The start date was 02/09/24. There was no stop date. There was no duration given for the order. Record review of Resident #58's MAR for the month of February 2024 indicated she did not receive the PRN Lorazepam from 02/09/24 through 02/29/24. Record review of Resident #58's MAR for the month of March 2024 indicated she did not receive the PRN Lorazepam during the month of March. Record review of Resident #58's MAR for the month of April 2024 indicated she did not receive the PRN Lorazepam during the month of April. Record review of Resident #58's MAR for the month of May 2024 indicated she did not receive the PRN Lorazepam during the month of May. Record review of Resident #58's MAR for the month of June 2024 indicated she did not receive the PRN Lorazepam during the month of June as of 06/26/24. Record review of Resident #58's consultant pharmacist physician communication, dated 03/11/24, indicated the consultant pharmacist communicated to the physician that the PRN lorazepam required a 14 day stop date. The note further indicated the provider could document a rationale for the extended time period and indicate a specific duration. The physician/prescriber response reflected: She's on hospice. There was no indicated duration or stop date for the PRN lorazepam. Record review of Resident #58's consultant pharmacist physician communication, dated 04/04/24, indicated the consultant pharmacist communicated to the physician that the PRN lorazepam required a 14 day stop date. The note further indicated the provider could document a rationale for the extended time period and indicate a specific duration. The physician/prescriber response reflected: She is on hospice. Extend Rx. There was no indicated duration or stop date for the PRN lorazepam. Record review of Resident #58's consultant pharmacist physician communication, dated 05/05/24, indicated the consultant pharmacist communicated to the physician that the PRN lorazepam required a 14 day stop date. The note further indicated the provider could document a rationale for the extended time period and indicate a specific duration. The physician/prescriber response reflected: Hospice [patient]. There was no indicated duration or stop date for the PRN lorazepam. Record review of Resident #58's consultant pharmacist physician communication, dated 06/04/24, indicated the consultant pharmacist communicated to the physician that the PRN lorazepam required a 14 day stop date. The note further indicated the provider could document a rationale for the extended time period and indicate a specific duration. The physician/prescriber response reflected: [patient] on hospice. There was no indicated duration or stop date for the PRN lorazepam. During an interview on 06/26/24 at 10:10 AM, RN A said she was taking care of Resident #58 on that day. She said Resident #58 had 2 orders for PRN Lorazepam and neither have a stop date. She said the orders should have a stop date at 14 days so the provider could re-evaluate the medications. She said there was a potential for the resident to receive too much medication if it was not stopped after 14 days. 2. Record review of Resident #73's face sheet dated 6/25/24 revealed she was [AGE] years old and admitted to the facility on [DATE]. Resident #73 had diagnoses of dementia (progressive or persistent loss of intellectual functioning, memory, related to disease of the brain), Alzheimer's (progressive disease that destroys memory and other important mental functions), and anxiety disorder. Record review of Resident #73's significant change MDS dated [DATE] revealed she had a BIMS of 99, which indicated she had severe cognitive impairment and was unable to complete the interview. The MDS did not indicate Resident #73 had an anxiety disorder. The MDS indicated Resident #73 received an antianxiety medication (used to treat anxiety). Record review of Resident #73's care plan dated 6/24/24 revealed she had a potential for drug toxicity due to psychotropic medication regimen. Resident #73 took lorazepam, and the facility was to monitor her for side effects of lorazepam. Record review of Resident #73's Physician Orders dated June 2024 revealed an order for lorazepam 0.5 mg by mouth every four hours as needed for anxiety/agitation with a start date of 05/03/24. There was no end date. There was no documentation in the order for the duration of the order. Record review of Resident #73's care plan dated 6/24/24 revealed she had a potential for drug toxicity due to psychotropic medication regimen. Resident #73 took lorazepam, and the facility was to monitor her for side effects of lorazepam. Record review of Resident #73's MAR dated May 2024 revealed she had an order for lorazepam 0.5 mg by mouth every four hours PRN for anxiety/agitation with a start date of 5/03/24. There was no stop date. There was documentation of Resident #73 only receiving PRN lorazepam 0.5 mg once on 5/03/24 and twice on 5/04/24 . Record review of Resident #73's MAR dated June 2024 revealed she had an order for lorazepam 0.5 mg by mouth every four hours PRN for anxiety/agitation with a start date of 5/03/24. There was no stop date. There was no documentation of Resident #73 receiving PRN lorazepam 0.5 mg during the month of June. Record review of the facility's Consultant Pharmacist/Physician Communication note dated 6/03/24 for Resident #73 revealed the consulting pharmacist had sent a note to the physician indicating . the resident was receiving the following psychotropic medication on a PRN basis: lorazepam 0.5 mg every four hours PRN . Per regulatory guidelines, the duration of treatment with such medications or a PRN basis should be limited to 14 days, however, a new order may be written to extend the duration beyond 14 days if the prescriber believed it was appropriate . Please evaluate the continued need for this medication . If it was to be extended, please document the rationale for the extended time period in the medical record and indicate a specific duration . The physician's response was to continue the medication due to the resident was on hospice and there was no specific duration documented for the medication. During an interview on 06/26/24 at 11:38 AM, the ADON said there should be a 14 day stop date on PRN psychotropics. He said personally he thought hospice was an appropriate rationale for continuing the lorazepam. He said the ADON was responsible for ensuring that PRN psychotropics had an end date. He said the medication not having a stop date could become an unnecessary medication. The nurses should also ensure that psychotropics that are PRN have an end date. During an interview on 06/26/24 at 11:43 AM, the DON said she felt that the rationale of being on hospice was an appropriate rationale for continuing the PRN lorazepam orders indefinitely. She said the regulation said that all psychotropics that were PRN should have a 14 day stop date. She said she did not think there was a negative effect to the resident for not having a stop date. She said the bedside nurse was responsible for ensuring that all prn psychotropics had stop dates. She said the ADON, DON, and medical records personnel were also responsible for ensuring that PRN psychotropics have a stop date. During an interview on 06/26/24 at 11:55AM, the Administrator said she was unsure if there should have been a stop date for PRN psychotropics. She said she was unsure of any negative effect to the residents as a result of the medication continuing to be on the orders. She said she was not a medical provider, so she did not know. She said nursing and pharmacy were responsible for ensuring that the PRN psychotropics have a stop date. Record review of the facility's policy, Psychotropic Medication Use, dated July 2022, stated: .A psychotropic medication is any [medication] that affects brain activity associated with mental processes and behavior . .12. Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnoses specific condition that is documented in the clinical record. a. PRN orders for psychotropic medications are limited to 14 days. (1) For psychotropic medications that are NOT antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order . 46062

Based on observation, interview, and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 5 residents (Resident #1) reviewed for pharmacy services. The facility failed to ensure LVN A followed the facility's Administering Medications policy which resulted in Resident #1 receiving Resident #2's hydrocodone/APAP 7.5 mg/325 mg tablet (opioid analgesic medication used to treat pain) that was not prescribed to her. This failure could place residents at risk of receiving incorrect medications, dosages of medications , and significant adverse effects from medication errors. Findings included: 1. Record review of Resident #1's face sheet dated [DATE] revealed she was [AGE] years old and admitted to the facility on [DATE]. Resident #1 had diagnoses including dementia (forgetfulness that interferes with daily functioning), cognitive communication deficit, muscle weakness, repeated falls, and chronic pain. Record review of Resident #1's annual MDS assessment dated [DATE] revealed she was usually understood and usually understood others. Resident #1 had a BIMS score of 5, which indicated she had severe cognitive impairment. Resident #1 was independent with most ADLs. Resident #1 received as needed pain medications for frequent pain that rarely affected her day-to-day activities. Record review of Resident #1's care plan with a start date of [DATE] revealed she rarely had pain and had interventions including to administer medications as ordered and monitor her for side effects and effectiveness of her medications and contact her physician as needed. Resident #1 was at risk for falls. Record review of Resident #1's Physician Orders dated [DATE] revealed an order for Tramadol 50 mg (opioid analgesic medication used to treat pain) by mouth every four hours as needed for pain with a start date of [DATE]. Record review of Resident #1's Med Aide EMAR dated [DATE] revealed there was no documentation indicating Tramadol 50 mg by mouth had been administered [DATE]-[DATE]. Record review of Resident #1's Departmental Notes dated [DATE]-[DATE] revealed there was no documentation of Resident #1 complaining of pain or being administered a medication for pain on the 6 PM to 6 AM shift on [DATE]-[DATE]. Record review of Resident #1's Individual Patient's Antibiotic/Narcotic Record for Tramadol 50 mg tablets revealed the tablets expired on [DATE] and there was no documentation of medications given after that time. During an observation and interview on [DATE] at 2:30 PM, Resident #1 was clean and well groomed. She said she did not have any pain at the time. Attempted to notify Resident #1's RP on [DATE] at 3:02 and [DATE] at 12:44 PM, there was no answer, and a voicemail was left. Resident #1's RP did not return call prior to exiting the facility. 2. Record review of Resident #2's face sheet dated [DATE] revealed he was [AGE] years old and admitted to the facility initially on [DATE] and readmitted on [DATE]. Resident #2 had diagnoses including fistula of stomach and duodenum (abnormal opening in the stomach or intestines that allows contents to leak into another part of the body), cognitive communication deficit, and chronic pain. Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed he was usually understood and understood others. Resident #2 had a BIMS of 11, which indicated he had moderate cognitive impairment. Resident #2 used a wheelchair for mobility and was dependent on staff assistance with most ADLs. Resident #2 received scheduled pain medications for occasional pain that occasionally affected his sleep and rarely affected his day-to-day activities. Record review of Resident #2's care plan with a start date of [DATE] revealed he had contractures to his right upper extremity and both lower extremities with interventions including pain medications as ordered and pain assessment per orders. Resident #2 was at risk of falls. Record review of Resident #2's Physician Orders dated [DATE] revealed an order for Hydrocodone 7XXX,d+[DATE] mg by mouth every six hours for pain with a start date of [DATE]. Record review of Resident #2's Med Aide EMAR dated [DATE] revealed he received hydrocodone/APAP 7.5 mg/325 mg by mouth every six hours (4:00 AM, 10:00 AM, 4:00 PM, and 10:00 PM) for pain with a start date of [DATE] and it was discontinued [DATE]. Record review of Resident #2's Individual Patient's Antibiotic/Narcotic Record for Hydrocodone 7.5 mg/325 mg revealed LVN A had administered 1 tablet to Resident #2 on [DATE] at 10:00 PM and 1 tablet on [DATE] at 5:00 AM. Resident #2's hydrocodone tablet count should have been 46, but there was a count of 45 circled by LVN A, indicating the count was wrong. During an observation and interview on [DATE] at 2:45 PM, Resident #2 was lying in bed and was clean and well groomed. He said he received routine pain medication, and his pain was managed. During an interview on [DATE] at 12:10 PM, LVN B said she was the oncoming nurse on [DATE] AM shift and counted narcotics with LVN A, who was the outgoing nurse from the night shift. LVN B said the count was wrong and it was her first day back on duty. LVN B said the count was wrong and she did not accept the cart keys, and she notified management the narcotic count was off by one hydrocodone for Resident #2. LVN B said she was instructed to start drug testing staff with access to that cart. LVN B said they tested LVN A and all staff that had been in that medication cart for the three days prior. LVN B said all staff were negative. LVN B said she did not know the outcome of the investigation. LVN B said the oncoming nurse counts the narcotic medications with the outgoing nurse each shift change, and then they sign the sheet together indicating the count was correct. LVN B said if the narcotic count was wrong, then the oncoming nurse should not accept the medication cart keys and then notify management. LVN B said if a resident voiced, they wanted something for pain, the nurse should have the resident rate their pain level. LVN B said she did not trust the computer and she always checked what the computer said the last medication dose was against what the narcotic log said the last dose was. LVN B said she would ask the resident their name if they were alert and oriented or use the picture in the chart to identify the resident. LVN B said staff should check the MAR, dose, route, and check the medication card for correct resident and correct medication/dose prior to administering a medication to a resident. LVN B said there should be name alert sticker (big orange sticker) on the medication cards to give staff a clue there were multiple residents with the same last name. During an observation and interview on [DATE] at 1:00 PM, MA C unlocked her cart for Hall 5 and the narcotic box, viewed Resident #2's medication card for hydrocodone, followed by Resident #2's medication card for Zolpidem, and then followed by Resident #1's medication card for Tramadol. There were no name alert stickers on the cards. MA C said the nurses count the narcotics when the nurses come in during the 6 AM or 6 PM shift changes. MA C said then she counts again with the nurse when she comes in at 8 AM before accepting the cart keys. MA C said she would count again with the nurse before going off duty. MA C said she ensured the correct medication was given to the correct resident by following the five rights of medication administration by verifying the right patient, medication, dose, frequency, and route. MA C said if a resident was given a medication that was not prescribed, it could lead to adverse reactions or side effects for the resident, or they could be allergic to the medication. During an interview on [DATE] at 1:56 PM, the DON said Resident #2's hydrocodone count was wrong at the end of the night shift. LVN A was coming off the night shift and she could not place where Resident #2's hydrocodone had gone, so it was reported. The DON said video surveillance showed LVN A took the hydrocodone to the wrong room to Resident #1. The DON said everything was signed out as if the hydrocodone was for Resident #2, however, LVN A took it to Resident #1 and administered the hydrocodone to Resident #1. The DON said they had name alerts with stickers for their paper charts and then a name alert was in the electronic chart also. The DON said they did not place name alert stickers on the medication cards. The DON said the risk of receiving a medication that was not ordered for the resident, could result in adverse drug reactions, allergies, and possible death. During an interview on [DATE] at 2:30 PM, the ADM said they watched LVN A on the video surveillance sign the medication out and walk it to Resident #1's room and not Resident #2, which left his hydrocodone count short one pill. The ADM said the effect of receiving a medication that was not prescribed to a resident would depend on the medication, but it could affect the resident and counter react with other medications. During an interview on [DATE] at 2:49 PM, LVN A said Resident #1 had requested something for pain. LVN A said she mistakenly pulled Resident #2's card of hydrocodone and administered one tablet to Resident #1. LVN A said she was honestly just not paying attention and pulled the wrong card. LVN A said both residents have the same last name. LVN A said she had never given Resident #1 anything for pain and did not even realize she had anything for pain. LVN A said she should pay more attention when administering medications. LVN A said she usually signed the medications out and she checked the orders to make sure the resident had something for pain. LVN A said she was aware of the five rights of medication administration, which included verifying the right resident, right medication, right dose, right time, and right route. LVN A said Resident #1 was administered a medication that was not prescribed to her, and the medication placed the resident at risk of having an allergic reaction to the medication, the medication could have been too strong, and it could have suppressed her breathing. LVN A said she did not realize she had done it until she and LVN B were doing the narcotic count at shift change and Resident #2's hydrocodone was short one tablet. LVN A said she called the DON to report the hydrocodone count was short for Resident #2. LVN A said she did a drug test and then continued to try to figure out what happened. LVN A said she realized later what she did, and she called the DON and then the DON and the ADM watched the video surveillance cameras and confirmed what happened. LVN A said she had taken a hydrocodone from Resident #2's medication card and administered it to Resident #1. LVN A said they continued to monitor Resident #1 for two days to monitor for any adverse reactions. LVN A said Resident #1 did not have any reactions to the hydrocodone. Record review of the facility's Medication Error Report dated [DATE] revealed Resident #1 was given Norco (hydrocodone) 7XXX,d+[DATE] mg from a resident's medication with the same last name across the hall, who did have an order for it. The report indicated Resident #1 did not have any adverse reactions from the Norco. The Assessment and Summary of the Error indicated the type of error was wrong resident and the reason for the error was failure to identify resident. Record review of the facility's policy titled Administering Medications, dated revised on [DATE] stated . medications were administered in a safe and timely manner, and as prescribed . medications were administered in accordance with the prescribers orders . the individual administering medications verifies the resident's identity before giving the resident his/her medications . methods of identifying the resident include . checking identification band . checking photograph attached to the medical record . and if necessary, verifying resident identification with other facility personnel . the individual administering medication checks the label THREE times to verify the right resident, right medication, right dosage, right time, and right method/route of administration before giving the medication . as required or indicated for a medication, the individual administering the medication records in the resident's medical record . the date and time the medication was administered, the dosage, route of administration . any complaints or symptoms for which the drug was administered . any results achieved and when those results were observed . and signature and title of person administering the drug . medications ordered for a particular resident may not be administered to another resident, unless permitted by state law and facility policy, and approved by the director of nursing services .

Based on observation, interview, and record review, the facility has failed to ensure that the resident environment remains as free of accident hazards as possible and provide supervision to prevent avoidable accidents for 1 of 4 residents reviewed for accidents. (Residents #3) The facility failed to ensure Resident #3 had on a Wanderguard (bracelets that residents wear, sensors that monitor doors and a technology platform that sends safety alerts in real time) leading him to be able to elope out of the door at the end of the 400 Hall. This failure could place residents at risk of injury from accident and hazards. Findings included: 1. Record review of the face sheet dated 06/12/24 revealed Resident #3 was [AGE] years old and admitted on [DATE] with diagnoses including stroke, dementia, and anxiety disorder. The face sheet revealed Resident #3 was discharged on [DATE]. Record review of the quarterly MDS dated [DATE] revealed Resident #3 was discharged to the hospital on 05/07/24. The MDS revealed Resident #3 had a BIMS score of 00 which indicated severe cognitive impairment. The MDS indicated Resident #3 was independent with ADLs. The MDS revealed the resident required substantial/maximal assistance with chair/bed-to-chair transfers and the resident used a wheelchair. Record review of the care plan last revised on 04/22/24 did not indicated Resident #3 was an elopement risk or required a Wanderguard. Record review of an Elopement Risk Alert dated 09/30/20 indicated Resident #3 had dementia with behaviors. The areas/places to focus search indicated, .will try to get home .angry with family for moving him to SNF . Record review of an Elopement Risk assessment dated [DATE] indicated Resident #3 had an elopement risk score of 10. The assessment indicated a resident with a score of 10 or greater was an elopement risk. Record review of an Elopement Risk assessment dated [DATE] indicated Resident #3 had an elopement risk score of 12. The assessment indicated a resident with a score of 10 or greater was an elopement risk. No other Elopement Risk Assessments for Resident #3 were provided by the facility prior to exit. Record review of a Wanderguard, Personal Alarms, and Door Alarm Log for 05/2023 and 06/2023 indicated there was no documentation of Resident #3's Wander Guard being checked on 05/10/23, 05/12/23, 05/15/23, 05/17/23, 05/19/23, 05/22/23, 05/24/23, 05/26/23, 05/29/23, 05/31/23, 06/02/23, 06/05/23, 06/07/23, 06/09/23, 06/12/23, 06/14/23, 06/16/23, 06/19/23, 06/24/23, 06/23/23, 06/26/23, and 06/28/23. Record review of a Provider Investigation Report dated 06/30/23 indicated Resident #3 eloped from the facility on 06/29/23 at 10:30 p.m. The report indicated Resident #3 had dementia with behaviors and exit-seeking was a new behavior. The report indicated Resident #3 exited a hallway door at 10:30 PM without staff noticing. He was outside until 10:45 when staff heard him at the front door . A Wander Guard alert tag was immediately placed on the resident so that hallway exits will delay egress and sound an alarm if the resident seeks exit. The Investigation Summary indicated, Surveillance video was reviewed. The resident experienced no injury or adverse events. He let himself out of the building . Record review on an Intake Investigation Worksheet with a received date of 06/30/23 concerning Resident #3 indicated, .The resident had no injuries upon assessment .the resident eloped through the laundry room exit at 10:38 PM, and staff did not discover it until he was heard at the front door at 10:53 PM .The resident has not tried to elope in a few years and did not have a Wander Guard device on at the time . The intake was a facility reported incident reported by the Administrator. During an interview on 6/12/24 at 1:03 p.m., LVN E said on the evening of 06/29/23 they had put Resident #3 to bed, but he had gotten back up. She said he always wandered. She said she was charting. She said she looked up and he was gone. She said an alarm never went off. She said she could not remember but he may not have had a wander guard on. She said she did not know why he did not have one on. She said staff began looking for him because they did not see him. She said they found him outside the exit door at the end of the 500 Hall. She said he was still in his wheelchair. She said he had no injuries. She said, He was perfectly fine. She said no staff witnessed him outside. She said, as far she knew, he never left the property. She said he was not sweaty or hurting. She said after that, they increased supervision for Resident #3. She said someone told her he had been to the hospital and his Wanderguard had been cut off . She said she knew he would refuse to have his Wanderguard checked at times. During an interview on 6/12/24 at 2:05 p.m., the DON said she was notified by staff that Resident #3 had eloped when staff discovered he was missing. She said the Administrator had completed the investigation. She said there were cameras outside, and he never left the property. She said he had no injuries. She said he had a Wanderguard after he was admitted . She said the nurse said he had been to the hospital and the hospital cut it off. She said the nurse said the Wanderguard had not been replaced before he eloped. She said there was no documentation during the month of June 2023 that he had been out to the hospital, and he did have his Wanderguard on. During an interview on 06/12/24 at 2:54 p.m., CNA E said on the evening of 06/29/23, Resident #3 could not sleep and wanted to get up. She said he was moving around at the nurse's station. She said he was in a good mood. She said it had not been less than 5 minutes and suddenly she did not see him. She said she did not hear an alarm. She said they began looking down each hall for him. She said it did not take long at all. She said they could hear him making sounds outside. She said they followed his voice. She said he had gone out the door on the 400 Hall. She said he never left the property. She said he had no injuries. She said he was not hot. She said he was found very quickly. She said he was not upset and did not realize what was going on. She said she did not know anything about the Wanderguard. During an interview on 6/13/24 at 11:36 p.m., the Maintenance Supervisor said if a resident had a Wanderguard on, the door at the end of the 400 Hall would still open but would alarm. He said he was unaware of any doors malfunctioning over the last year. He the nursing staff checked to make sure the Wanderguards were working. He said it had never been reported to him that a Wanderguard was malfunctioning. He said to his knowledge the door had no issues in the last year. During an interview on 6/13/24 at 12:16 p.m., CNA F said on the evening of 06/29/23, Resident #3 was talking to her. She said she went to make her rounds and when she came back he was gone. She said the door never alarmed. She said she started looking for him. She said she started her rounds at ten. She said it was at least 30 minutes before she realized he was missing. She said he was found out beside the building near the 500 Hall. She said he looked fine. She said there was nothing wrong with him. She said he was in no distress. She said he never left the property. She said she was amazed he got as far as he did. She said he normally stayed around the nurse's station. During an interview on 6/13/24 at 12:38 p.m., Restorative Aide G said it was her responsibility to make sure all Wanderguards were working. She said she was told that Resident #3 did not have on a Wanderguard on 06/29/23. She said it had been a long time and she could not remember. She said she did not know why he would not have had on his Wanderguard. She said she checked all residents with Wanderguards on Mondays, Wednesdays, and Fridays. She said she wheeled each resident to each door to make sure they were working. She said a Wanderguard did not cause the door on the end of the 400 Hall to lock, but it would alarm if someone with a Wanderguard went out. During an interview on 06/13/24 at 1:26 p.m., the DON said only the front door and the dining hall door locked with Wanderguards and all doors alarm after hours when anyone goes out . She said she thought the time began at 6 p.m. She said only the glass door going to the laundry room did not alarm during the day. She said she did not know why Resident #3 did not have his Wanderguard on. She said she would assume he had been out to the hospital, and it would have been cut off. She said she had found no hospital records for the month of June 2023 that would indicate he had been out. She said right after the incident, staff told her they did not know if he had it on. She said she did have staff verify he had it on, but she did not know the date. She said the only elopement risk assessments was the one from October 2020 and the one done March 2024. She said a resident that eloped, obviously they could die, heat exposure, cold exposure, and vehicles. She said there had been no other elopements since 6/29/2023. During an interview on 06/13/24 at 2:17 p.m., the Administrator said Resident #3 went out the door at the end of the 400 Hall on the night shift. She said he went out in his wheelchair and no alarms sounded. She said she watched him leave on a video and she was able see he went around the side of the building. She said he never left the property. She said staff told her he did not have a Wanderguard on when he went out. She said a resident that eloped could have been injured or gotten lost. During an observation on 6/13/24 at 2:20 p.m., the CNA Supervisor, in presence of the DON, wheeled a resident with a wander guard in a wheelchair just out the 400 Hall outside door and the alarm sounded and they had to put a code in to silence the alarm. Review of a Wandering and Elopements facility policy last revised in March 2019 indicated, .The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents . if identified at risk for wandering, elopement, or other safety issues, the resident's care plan would include strategies and interventions to maintain the resident's safety .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure: 1. Food items were dated and labeled. 2. Hair restraints were worn appropriately by dietary staff. These failures could place residents at risk for foodborne illness. Findings include: 1. During an observation and interview with the Dietary Manager of the refrigerator and freezer on 04/24/2023 starting at 9:52 a.m., revealed 2 plastic bags that was identified by the Dietary Manager as cheese pizza unlabeled and undated; 1 plastic bag that was identified by the Dietary Manager as corn dogs unlabeled; 1 plastic bag that was identified by the Dietary Manager as hamburger patties unlabeled; 2 bags that was identified by the Dietary Manager as tater tots unlabeled; 3 bags that that was identified by the Dietary Manager as French fries unlabeled; a tray with 10 (16oz) of margarine undated; 1 bag that was identified by the Dietary Manager as tomatoes unlabeled and undated; and 1 bag that was identified by the Dietary Manager as cucumbers unlabeled and undated. 2. During an observation on 04/24/2023 at 10:13 a.m., Cook C was not wearing a hair restraint appropriately while preparing the lunch meal. Cook C's hair was visible outside of the hairnet at the ears and necks. During an interview on 04/26/2023 at 12:25 p.m., Dietary Aide D stated the morning cook and aide were responsible for labeling and dating. Dietary Aide D stated that way staff would know what food and how old it was. Dietary Aide D stated these failures could potentially cause food borne illness/contamination. During an interview on 04/26/2023 at 12:34 p.m., Cook C stated whoever worked the morning that the truck comes in was responsible for labeling and dating. Cook C stated the hair restrained should cover her whole head. Cook C was unable to say why her hair was not covering her whole head. Cook C stated these failures could potentially cause food borne illness/contamination. During an interview on 04/26/2023 at 1:11 p.m., the Dietary Manager stated she was responsible for making sure the kitchen was cleaned appropriately. The Dietary Manager said all food should be labeled with date received and the date it was opened. The Dietary Manager stated when the food truck comes and delivers, whoever touched the item should label and date the item. The Dietary Manager stated when the food was opened it should be labeled and dated. The Dietary Manager stated all hair must be covered while in the kitchen area. The Dietary Manager stated she did daily spot checks during the day and address any issues. The Dietary Manager stated she was under the impression if you can see through the bag, it did not have to be labeled. The Dietary Manager stated these failures could potentially cause a food borne illness or cross contamination. Record review of the Food Receiving and Storage policy, last revised on 07/2014, indicated food shall be received and stored in a manner that complies with safe food handing practices . 8. All foods stored in the refrigerator or freezer will be covered, labeled, and dated . 12. Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens .

Based on observations, interviews, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 4 of 12 resident rooms reviewed on Hall 5 (Room #'s 502, 204, 507, and 510) for resident rights and privacy. The facility failed to ensure Laundry Aide O, HA P, CNA Q and MA R knocked on Room #'s 502, 504, 507, and 510. These failures could place residents at an increased risk of embarrassment, isolation, and diminished quality of life. The findings included: Record review of an in-service, dated 04/21/2023, addressed knocking prior to entering a resident's room revealed Laundry Aide O, HA P, and MA R had signed the in-service. During an observation and interview on 04/24/2023 at 9:15 AM, MA R knocked on open doorframe and immediately entered room [ROOM NUMBER], interrupting conversation with state surveyor. MA R stood at medication cart in front of room [ROOM NUMBER]'s open door and proceeded to prepare the medication. Resident #50 stated he was used to the staff not knocking. During an observation and interview on 04/23/2023 at 9:21 AM, CNA Q entered room [ROOM NUMBER] without knocking, interrupting conversation with state surveyor. CNA Q walked over to the B bed, spoke with Resident #18, and then exited room. Resident #22 (A bed) stated the staff hardly knocked before coming in the room. Resident #22 stated it happened more often with the agency staff. During an observation and interview on 04/23/2023 at 9:34 AM, HA P knocked and immediately entered room [ROOM NUMBER], interrupting conversation with surveyor. Resident #63 immediately stopped talking while HA P took her water pitcher, filled it up, and brought it back. Resident #63 stated she was used to the staff just walking in. During an observation and interview on 04/23/2023 at 9:48 AM, Laundry Aide O opened and entered room [ROOM NUMBER] without knocking, interrupting conversation with surveyor. Resident #54 immediately stopped talking, while Laundry Aide O opened her closet door. Resident #54 stated staff walked in without knocking frequently. During a confidential telephone interview on 04/25/2023 at 9:23 AM, the family member stated respect and dignity for the residents was her only issue. The family member stated on numerous occasions the staff had left the door open while providing care. The family member also said staff hardly knocked when entering the residents' rooms. The family member stated it was sad to watch the facility staff provide no respect or dignity for the residents at the facility. During an interview on 04/26/2023 at 2:46 PM, a telephone interview was attempted with HA P to gather more information. HA P did not answer the phone and voice message was unable to have been left related to a full mailbox. During an interview on 04/26/2023 at 2:48 PM, a telephone interview was attempted with MA R to gather more information. MA R did not answer the phone and voice message was unable to have been left. During an interview on 04/26/2023 at 2:50 PM, CNA Q stated she remembered entering room [ROOM NUMBER] without knocking. CNA Q stated she should have knocked but the door was opened, and she did not realize the state surveyor was in the room. CNA Q stated it was important to knock and wait for a response to respect the resident and their privacy. During an interview on 04/26/2023 at 2:53 PM, Laundry Aide O stated she remembered entering room [ROOM NUMBER] without knocking. Laundry Aide O stated she should have knocked but another resident had asked for a shirt, and she was trying to find it. Laundry Aide O stated she was busier than normal and was in a hurry and did not remember to knock. Laundry Aide O stated it was important to knock and wait for a response to respect the resident and their privacy. During an interview on 04/26/2023 at 3:03 PM, CNA S stated facility staff should knock and wait for a response prior to entering a resident's room. CNA S stated it was important to knock to maintain the resident's dignity and privacy. During an interview on 04/26/203 at 4:03 PM, the DON stated she expected the facility staff to knock and wait for a response prior to entering a resident's room. The DON stated this was monitored by observations and education was provided to the staff member responsible. The DON stated it was important to knock to maintain resident's dignity and privacy. During an interview on 04/26/2023 at 5:24 PM, the Administrator stated she expected facility staff to knock and wait for a response prior to entering a resident's room. The Administrator stated this was monitored by in-servicing staff and random checks. The Administrator stated it was important to knock prior to entering a resident's room out of respect for privacy and dignity. Record review of the Dignity policy, revised February 2021, revealed 7. Staff are expected to knock and request permission before entering residents' rooms.

Based on interview, and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for RN coverage. The facility failed to provide RN coverage for 8 consecutive hours daily on 10/22/2022, 11/1/2022, 11/5/2022, 11/6/2022, 11/19/2022, 11/20/2022, 12/3/2022, 12/4/2022, 12/8/2022, 12/17/2022, 12/18/2022, 12/26/2022, and 12/31/2022. The deficient practice had the potential to affect residents in the facility by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as an emergency care and disasters. Findings include: Record review of a nursing staff information sheet dated 10/22/2022, 11/1/2022, 11/5/2022, 11/6/2022, 11/19/2022, 11/20/2022, 12/3/2022, 12/4/2022, 12/8/2022, 12/17/2022, 12/18/2022, 12/26/2022, and 12/31/2022 indicated that the facility did not have an RN in the facility. During an interview on 04/26/2023 at 9:15 a.m., the DON stated she was aware that there was a regulation to have 8 hours of RN coverage a day. The DON stated she was aware that there were days RNs were not scheduled due to no RN available. The DON stated she did have an ad running for a registered nurse. When asked how often days with no RN onsite, the DON stated currently about 4 days a month. The DON stated she was always available by phone if no RN was on schedule to work, and she lived 7 minutes from the facility. When asked how the facility provided care to residents that required a RN if one was not available to work, the DON stated she would come in to take care of the need. The DON stated she was unaware of a resident who needed care or services only performed by a RN and did not receive it. When asked possible negative outcomes to residents if no RN was on duty, she stated she did not think there would be one since she was on call and available and could be at the building quickly. During an interview on 04/26/2023 at 4:49 p.m., the Administrator stated the DON was responsible for ensuring a registered nurse was in the building 8 hours every day. When asked possible negative outcomes to residents if no RN was on duty, she stated she did not think there was one since the DON was always available by phone. The Administrator stated there was not a policy and procedure regarding RN staffing.

47006 Based on observation, interview, and record review the facility failed to ensure residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for 2 of 5 residents reviewed for unnecessary psychotropic medications. (Resident's #9 and #31) The facility failed to ensure a clinical rationale for declination of a GDR was documented by the physician for Resident #9 and #31. This failure could place residents at risk for possible psychotropic medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications. The findings included: 1. Record review of Resident #9's face sheet, dated 04/26/2023, revealed Resident #9 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of Parkinson's disease (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), depression (mood disorder that causes a persistent feeling of sadness and loss of interest), and generalized anxiety disorder (condition with exaggerated tension, worrying, and nervousness about daily life events). Record review of the physician orders, dated April 2023, revealed Resident #9 had an order, which started on 11/22/2022, for clonazepam (anti-anxiety) 1mg by mouth three times daily. Record review of the MAR, dated April 2023, revealed Resident #9 received clonazepam 1 mg. Record review of the MDS assessment, dated 03/16/2023, revealed Resident #9 had clear speech and was understood by staff. The MDS revealed Resident #9 was able to understand others. The MDS revealed Resident #9 had a BIMS score of 10, which indicated moderately impaired cognition. The MDS revealed Resident #9 had a PHQ-9 score of 04, which indicated normal or minimal depression. The MDS revealed Resident #9 had no behaviors or rejection of care. The MDS revealed Resident #9 received an anti-anxiety and anti-depressant medication 7 out of 7 days during the look-back period. Record review of the comprehensive care plan, dated 02/12/2023, revealed Resident #9 no longer exhibited physical combative behavior but did have verbally abuse behaviors. The interventions included: Administer behavior medication as ordered by physician. The care plan further revealed Resident #9 had potential for drug toxicity due to her medication regimen. Record review of the pharmacy recommendation, dated 01/09/2023, revealed Resident #9 was receiving clonazepam 1mg three times a day and it was due for review. The pharmacy recommendation further revealed a trial dosage reduction was recommended to decrease clonazepam to 0.5mg three times daily. No indication or rationale was provided for continued use. During an observation and interview on 04/24/2023 at 9:33 AM, Resident #9 was sitting up in her wheelchair. Resident #9 was wringing and constantly moving her hands. Resident #9 stated she was upset about some medications that were removed from her room. Resident #9 stated her medication regimen was sorta helping and she did not believe she was having side effects from the medications. 2. Record review of Resident #31's face sheet dated 04/26/23 indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #31 had diagnoses of Parkinson's disease (disorder of the central nervous system that affects movement and often includes tremors), adjustment disorder with mixed anxiety and depressed mood (feeling unmotivated, irritable and difficulty with concentrating) and chronic kidney disease (disease of the kidneys leading to renal failure). Record review of Resident #31's MDS dated [DATE] indicated a BIMS score of 8 indicating mildly impaired. The MDS indicated Resident #31 was understood and was able to understand others. The MDS indicated Resident #31 felt down or hopeless on 2-6 days and little interest in doing things on 7-11 days over the last 2 weeks. The MDS indicated Resident #31 had diagnoses of anxiety and depression. Record review of the care plan dated 01/21/2021 indicated Resident #31 had socially inappropriate and disruptive behavior that had been observed by staff causing the resident to fall. The goal was to maintain appropriate behavioral functioning by the next evaluation. The interventions included to encourage family to visit and to approach the resident in a warm and positive manner. The care plan indicated Resident #31 had a potential for drug toxicity due to clonazepam to control Parkinson's symptoms. The goal was for Resident #31 to be free of side effects from medications by next evaluation. The interventions included to monitor for side effects and effectiveness of the medication, contact the physician as needed, monitor the resident for tremors and document, observe the resident's gait for steadiness, balance, muscle coordination, and the ability to position and turn. Record review of the physician orders dated 04/2023 indicated Resident #31 was taking clonazepam 0.5mg by mouth twice daily due to Parkinson's. Record review of Resident #31's medication administration record indicated she was taking clonazepam 0.5mg by mouth twice daily for Parkinson's at 8:00 AM and 8:00 PM. Record review of the pharmacy recommendation form dated 03/05/2023 by the consultant pharmacist, indicated the psychoactive medication clonazepam 0.5mg twice a day was due for review, and to evaluate Resident #31 for a trial dosage reduction. The suggested change was to decrease clonazepam 0.5mg to daily. Physician A indicated to continue clonazepam 0.5mg twice daily. No indication or rationale was provided for continued use. During an interview on 04/26/23 at 8:59 AM, the ADON stated the GDRs were done monthly by the pharmacist. The ADON stated she was responsible for completing the GDR's and after she reviewed the report, it was then sent to clinic for the prescribing physician to sign. The ADON stated a staff nurse went to the clinic weekly to pick up documentation from the prescribing physicians. The ADON stated she, was not responsible for Physician A not providing a rational on the pharmacy recommendation form and she could not tell Physician A what to do. The ADON stated, if the resident was already on the medication and they were looking at reducing it, then she did not think there would be any consequences in not providing a rational, because the resident was being treated and not losing anything. The ADON stated, If they thought something needed to be changed, then they would notify Physician A and he would take care of it. During an interview on 04/26/23 at 9:37 AM, the DON stated the rationales should have been documented either on the pharmacy recommendation form or on a progress note. The DON stated Physician A knew his patients better than the staff and it could not harm the resident in any way that the rational was not provided. The DON stated staff would have pursued Physician A's recommendation if they thought it needed to be changed. During an interview on 04/26/23 at 1:36 PM, Physician A stated he usually indicates a rational on the pharmacy recommendation form and he usually does what the pharmacist recommends. Physician A stated he must have gotten in a hurry that day and just forgot to write a rational on Resident #31's form. Physician A stated if there was a concern with Resident #31, then the nurse would have added her comments on the form for him to look at or notified him verbally because the nurses were good at notifying him of any changes or recommendations that needed to be done. Physician A indicated the rational was used to communicate why changes in the medication were made. During an interview on 04/26/2023 at 3:54 AM, the ADON stated the system in place for pharmacy recommendations, which included GDRs was placing the pharmacy recommendation in the physician's folder and taking them to the physician's office once time weekly. The ADON stated each week, when a new folder was dropped off, the facility staff would ask if anything was ready to be picked up. The ADON stated the physician's had not been provided education on GDR recommendations and providing a clinical rationale for the continued use of a psychotropic medication. The ADON stated it was important to ensure clinical rationales were provided for continued use of psychotropic medications because it was regulatory. During an interview on 04/26/2023 at 4:03 PM, the DON stated education had not been provided to the physician's regarding documenting clinical rationales for continued use of psychotropic medications. The DON stated GDRs were important because it was regulatory. During an interview on 04/26/23 at 5:30 pm, the Administrator indicated the nurses were responsible for the pharmacy recommendation forms and she expected them to be done accurately. Record review of the facility's policy on, Tapering Medications and Gradual Drug Dose Reduction dated 7/2022 indicated . When a medication is tapered or stopped, the staff and practitioner shall document the rationale for any decisions to restart a medication or reverse a dose reduction.

Based on interview and record review, the facility failed to provide pharmaceutical services to determine that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for 1 of 3 medication carts (nurse cart 5/6) reviewed for controlled medications. The facility did not ensure LVN's B, E, F, G, H, K, L, M, N counted controlled drugs every shift change. This deficient practice could result in an inaccurate controlled medication count, drug diversion, and decreased therapeutic effects from medications. Findings included: During a record review and random count observation of nurse cart 5/6 with LVN B revealed missing signatures for Off duty and On duty for 4/9/2023, 4/10/2023, 4/11/2023, 4/14/2023, 4/18/2023, 4/19/2023, 4/20/23, 4/21/2023, 4/22/2023, 4/23/2023, 4/24/2023, and 4/25/2023 of the narcotic count sheet. Record review of a facility in-service dated 03/21/2023 titled Medication Destruction indicated LVN B, LVN E, RN F, and LVN G were in serviced on counting controlled drugs every shift change. During an interview on 4/26/2023 at 10:28 a.m., LVN E stated she should have signed the narcotic count sheet after counting the controlled drugs with the nurse before and after her shift on 4/9/2023. LVN E stated, I forgot to sign. LVN E stated this failure could potentially cause a drug diversion. An attempted telephone interview on 4/26/2023 at 10:34 a.m. with RN F, was unsuccessful. During a telephone interview on 4/26/2023 at 10:41 a.m., LVN H stated she should have signed the narcotic count log after counting the controlled drugs with the nurse after her shift on 4/9/2023. LVN H stated she forgot to sign. LVN H stated this failure could potentially cause a drug diversion. An attempted telephone interview on 4/26/2023 at 10:48 a.m. with LVN M, was unsuccessful. An attempted telephone interview on 4/26/2023 at 10:51 a.m. with LVN K, was unsuccessful. During a telephone interview on 4/26/2023 at 12:47 p.m., LVN N stated she should have signed the narcotic count sheet after counting the controlled drugs with the nurse before and after her shift on 4/22/2023 and 4/23/2023. LVN N stated, I forgot. LVN N stated this failure could potentially cause a drug diversion. During a telephone interview on 4/26/2023 at 1:00 p.m., LVN L stated she should have signed the narcotic count sheet after counting the controlled drugs with the nurse before and after her shift on 4/18/2023, 4/19/2023, and 4/18/2023. LVN L stated this failure could potentially cause a drug diversion. During a telephone interview on 4/26/2023 at 1:09 p.m., LVN B stated she should have signed the narcotic count sheet after counting the controlled drugs with the nurse before and after her shift on 4/10/2023, 4/11/2023, 4/14/2023, 4/19/2023, 4/20/2023, and 4/24/2023. LVN B stated, I don't know why it was overlooked. LVN B stated this failure could potentially cause a drug diversion. During an interview on 4/26/2023 at 10:53 a.m., LVN G stated she was responsible for counting and signing the narcotic count sheet with the on duty nurse at the end of her shift on 4/21/2023. LVN G stated, honestly I forgot. LVN G stated this failure could potentially cause a drug diversion. During an interview on 4/26/2023 at 9:15 a.m., the DON stated she expected nurses to signed at the beginning and at the end of their shift after they completed count with the incoming and off-going nurse. The DON stated nurses were trained upon hire and as needed in serving. The DON stated her and the ADON were responsible for randomly checking the narcotic count sheets for accuracy in documentation. The DON stated the last audit was done on 4/7/2023 with the pharmacy consultant. The DON stated a couple of signatures were missing on the narcotic sheet for March and April. The DON stated nurses not ensuring narcotic count sheets were signed at the beginning and at the end of their shift after they completed count with the incoming and off-going nurse could result in drug diversion. During an interview on 4/26/2023 at 4:49 p.m., the Administrator stated she expected narcotic sheets to be signed at the beginning and end of their shift after they completed count with the incoming and off-going nurse. The Administrator stated this failure could result in drug diversion. Record review of the undated facility's policy titled, Controlled Drug Policy and Procedure indicated, . 1. To provide physical facilities and method of operation for the administration and control of narcotics, which will meet the requirements of State and Federal narcotic enforcement agencies 2. To ensure maximum safety for patients and nursing personnel . Narcotic Count and Inventory . 1. Controlled drugs were counted every shift by the nurse and/or MA coming on duty with the nurse and/or MA going off duty .

Based on observation, interview, and record review, the facility failed to provide supervision to prevent injury for 1 of 5 residents reviewed for accidents (Resident #3). CNA A did not transfer Resident #3 with two persons as required. During this transfer CNA A fell on Resident #3 resulting in the resident sustaining a fractured leg. This failure could place 54 residents who were dependent or required assistance with transfers at risk of injury. Findings included: Physician orders [REDACTED].#3 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #3 could understand others, make herself understood, and required extensive assistance of two staff members for transfers. Her cognition was moderately impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 12. A care plan revised 2/22/16 indicated Resident #3 required two persons to assist with transfers with no exceptions. An undated task sheet indicated Resident #3 required one staff for assistance with transfers. An incident report dated 3/13/16 indicated CNA A said Resident #3's foot got twisted under CNA A's foot while she was assisting Resident #3 into the recliner. Resident #3 complained of pain to her left knee, ankle, and foot. Resident #3 was assessed, the physician was notified and an order was received for an x-ray to be obtained. Nursing notes for Resident #3 indicated on 3/13/16 at 7:53 p.m, Resident #3 was transported to the hospital for x-rays when a fracture above the left knee was suspected. Nursing notes for Resident #3 dated 3/14/16 at 12:31 p.m., stated Resident #3 returned from the hospital with a [DIAGNOSES REDACTED]. The resident had a soft splint in place to her left leg. During an observation and interview on 3/24/16 at 11:29 a.m., Resident #3 was observed in bed, her entire left leg immobilized in a soft cast. Resident #3 said CNA A picked her up with a gait belt and accidentally fell on her. She said CNA A had not worked with her before, and sometimes prior to this incident, other staff members would transfer her alone. She said she was usually transferred with two staff members. During a telephone interview on 3/24/16 at 3:51 p.m., CNA A said she was terminated due to the incident that occurred with Resident #3. She said on 3/13/16, she was new to Resident #3's hall. She said every morning the charge nurses gave out new task sheets for the residents they would be caring for. She said on 3/12/16 and 3/13/16, Resident #3's task sheets showed Resident #3 required assist times one. She said she transferred Resident #3 with no issues on 3/12/16, but on 3/13/16 her feet got tangled up and she fell on Resident #3. She said she got Resident #3 into the chair, and then got the charge nurse. She said she showed the charge nurse the task sheet that indicated Resident #3 required one person assistance, and the charge nurse indicated that needed to be updated. She said she was trained to look on the task sheet to determine how to transfer the residents. During an interview on 3/24/16 at 10:57 a.m., the DON said on 3/13/16, CNA A transferred Resident #3 without assistance, fell on Resident #3 and caused a fracture. He said Resident #3 should have been transferred by two staff members according to her care plan. He said at the time the charge nurses updated ADL information sheets and handed those out to the CNAs daily. He said Resident #3's information sheet for 3/13/16 indicated Resident #3 required assist times one. He said Resident #3's care plan said assist time two, and the charge nurses should have based the ADL information sheets on the care plan. A Safe Lifting and Movement of Residents policy revised October 2009 indicated in order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. The policy indicated resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. The CMS 672 dated 3/24/16 indicated 54 residents required assistance with transfers.

Based on observation, interview, and record review, the facility failed to implement interventions to prevent development and worsening of pressure sores for 2 of 5 residents reviewed for pressure sores. (Resident #s 1 and 10) Resident #10 had a Stage II pressure that worsened to a Stage IV. The facility did not provide positioning or pressure relief interventions to prevent worsening his pressure sore. Resident #1 developed a Stage III pressure sore to the back of her right lower leg. These failures contributed to the development of new pressure sores and the worsening of existing pressure sores for Residents #s 1 and 10. These failures could place 6 residents with pressure sores at risk for developing new pressure sores and decline in existing pressure sores. Findings included: 1. Physician orders dated November 2012 indicated Resident #10 was [AGE] years old and had [DIAGNOSES REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #10: *had difficulty hearing but usually understood most conversations and could be understood. *had impaired range of motion to both lower extremities; *required extensive to total assistance for his activities of daily living; *was at risk for developing pressure sores; *had no pressure sores; and *did not receive turning/repositioning. Care plans dated 9/13/12 and updated on 11/5/12 indicated Resident #10's pressure sore would be improved by the next evaluation. Care plan approaches included: *turn every 2 hours; *putting a pillow between the resident's legs while in bed; *resident to wear an air boot, when air boot is not available, wear heel protectors; and *apply blue donut (a cushioning device) above knee. Resident #10's nurses notes dated 9/13/12 indicated he had a Stage II pressure sore to his left lower shin. The note did not include measurements of the wound. Physician orders dated 9/13/12 indicated Resident #10's wound was to be cleansed with normal saline, pat dry, apply hydrogel (provides a moist environment to enhance wound healing), [MEDICATION NAME] pad ( a wound dressing used for partial thickness wounds) and foam dressing, monitor daily. Physician orders dated 9/18/12 indicated Resident #10's wound was to be cleansed with normal saline and hydrogel and collagen applied to the wound daily. Nursing notes dated 9/26/12 indicated Resident #10's wound measured 1.8 x 1.4 cm, depth of less than 0.2 cm with scant clear drainage. Physician orders dated 9/26/12 indicated Resident #10's wound was to be cleansed with normal saline and santyl (a wound debrider) and calcium alginate (used to limit secretions in a wound) applied to the wound daily. Nursing notes dated 10/3/12 indicated Resident #10's pressure sore measured 2.8 x 2.0 cm with a depth of less than 0.2 cm and had moderate drainage. Nursing notes dated 10/4/12 indicated Resident #10's pressure sore had a foul odor. Nursing notes dated 10/10/12 indicated Resident #10's pressure sore measured 2.8 x 3.5 cm with a depth of less than 0.2 cm and had a small amount of clear yellow drainage. Nursing notes dated 10/13/12 indicated Resident #10's pressure sore measured 4.0 x 3.0 cm, had no depth and a moderate amount of foul-smelling drainage and cream/white slough was present in the wound bed. Nursing notes dated 10/17/12 indicated Resident #10's pressure sore measured 4.0 x 3.8 cm with a depth of 0.6 cm, had a moderate drainage with slight odor. The note indicated the muscle tissue was seen in the wound bed and the wound was a Stage IV. Physician orders dated 10/23/12 indicated Resident #10 was to have an air boot on his left lower leg to offload pressure when he was in bed. Nursing notes dated 10/24/12 indicated Resident #10's wound measured 4.5 x 4.0 cm, had an unknown depth due to gray slough and had a small cream/yellow drainage. During an observation on 11/4/12 at 4:44 p.m., Resident #10 was lying in bed receiving incontinent care. His legs were severely contracted at the knees, the right leg pulled up further causing the right heel to touch the left leg at the pressure sore area. A pillow was between his knees nothing was on Resident #10's heels to prevent them from pressing into the pressure sore. Physician orders dated 11/4/12 indicated Resident #10's wound was to have a sterile dressing change every three days and a [DEVICE] with xeroform dressing to the bone only and [MEDICATION NAME] dressing at 150 mm/hg continuously. Physician orders dated 11/5/12 indicated Resident #10 could have heel protectors in bed until a replacement air boot arrived. During an observation on 11/6/12 at 9:58 a.m., Resident #10 was lying in bed. He had a pillow between his legs. He did not have heel protectors or an air boot. The treatment nurse measured the pressure sore on Resident #1's left lower leg at 4.0 x 4.0 cm. 4.0 cm of bone was visible at the base of the wound. There was gray-brown drainage in the [DEVICE] and reservoir. The treatment nurse did not replace the pillow between the resident's legs prior to leaving the room. During an interview on 11/6/12 at 2:01 p.m., the ADON said she requested an occupational therapy screen for positioning Resident #10 on 10/17/12 to avoid further pressure to the sore on his left leg. She said she had not received a response from the request. During an interview on 11/6/12 at 2:41 p.m., the therapy manager said the screen request for Resident #10 was still on the assignment board to be done. She said the screen had not been done as of this date. During an interview on 11/6/12 at 3:09 p.m., the ADON said Resident #10's air boot deflated on 10/28/12. She said a replacement had been ordered but was on back order. 2. Physician orders dated October 2012 indicated Resident #1 was [AGE] years old, readmitted [DATE], with [DIAGNOSES REDACTED]. The orders indicated Resident #1 had an immobilizer on her right leg and required staff to inspect the skin on her leg under the immobilizer daily while applying barrier cream to her skin. The most recent MDS dated [DATE] indicated Resident #1 could make herself understood, could comprehend others, required extensive assistance with bed mobility and extensive to total dependence for all her ADL care. Her MDS indicated she was at risk for developing pressure sores and had two Stage II pressure sores during this assessment that she did not have during her previous assessment. A care plan updated 10/10/12 indicated Resident #1 did not have any problems with her skin but was at risk for pressure sores due to her decreased mobility and required total assistance from staff. Care plan interventions included a pressure relief device to bed and chair and "float ankle". Resident #1's September through November 2012 physician's orders did not address the duration her right knee immobilizer was to be used. A physician's order dated 9/15/12 indicated Resident #1 was to receive barrier cream to skin beneath leg (knee) immobilizer every day. During an observation and interview on 11/5/12 at 8:40 a.m., Resident #1 had an immoblizer on her right leg/knee. There was no padding between the immoblizer and Resident #1's leg to prevent pressure. RN A removed the immobilizer. Resident #1 had an approximate 2 x 1.5 cm open pressure sore on the lower back side of her leg. The pressure sore wound bed was covered with approximately 30% gray stringy slough (a layer of dead tissue). The remaining wound bed contained pink/red granulation tissue. The skin surrounding the wound bed was pink to dark purple/red. RN A touched this skin surrounding the wound which blanched. She said the discoloration around the wound was due to pressure from the dressing. RN A said Resident #1's pressure sore was due to pressure and poor positioning from the knee immobilizer. Resident #1's pressure sore records indicated the following: *10/24/12 - size 2.5 x 1.2 cm (day first observed). *10/31/12 - 1.0 x 2.0 cm/depth of 0.2 cm (unstageable)/50% necrotic tissue *11/6/12 - 2.3 x 1.4 cm /depth 0.2 cm with scant drainage/25% necrotic tissue. The treatment administration records dated October 2012 indicated Resident #1 received "barrier cream" beneath her leg stabilizer every day for the month of October 2012. During an interview on 11/6/12 at 9:55 a.m., RN A was said on 10/24/12 they found Resident #1's pressure sore with slough (dead tissue). RN A said they should have found the breakdown sooner since her leg received daily skin treatments. During an interview on 11/6/12 at 10:45 a.m., the ADON said Resident #1 had received a skin assessment on 10/21/12 and no skin breakdown was seen on her leg. She said the nurses that provided treatment on 10/22/12 and 10/23/12 had told her they had not looked at the back of Resident #1's leg when the barrier cream was applied beneath her immobilizer. During an interview on 11/6/12 at 1:30 p.m., LVN B said she was unsure if she looked at the back of Resident #1's leg on 10/22/12 and 10/23/12 when the barrier cream was applied. She said Resident #1 complained of pain when her leg was raised. During an interview on 11/6/12 at 1:45 p.m., hospice RN D reviewed Resident #1's hospice notes from 9/15/12 - 10/24/12 and none of the documentation indicated hospice staff were aware Resident #1 had a pressure sore on her right leg. During an interview on 11/6/12 at 2:05 p.m., RN C said a daily skin assessment, elevation of the extremity, monitoring for swelling, checking circulation and assessment of the resident's pain daily should be initiated for a resident with a cast, immobilizer or fractured extremity. An undated Pressure sore policy said, "...Purpose: To maintain optimal skin conditions for residents who are at risk for pressure sores. Identify anyone having a potential to develop pressure sores, skin inspections at least weekly, apply redistributing devices depending on risk, positioning schedule established as needed, provide nutritional support, evaluate medications, care plan and inservice as need arises." The National Pressure sore Advisory Panel at <http://www.npuap.org/pr2.htm>, accessed 11/12/12, noted the following pressure sore definitions: Stage II: Partial thickness loss of dermis presenting as a shallow open sore with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Unstageable:Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.The CMS 672 dated 11/4/12 indicated 6 residents had pressure sores.

Based on observation, interview and record review, the facility failed to supervise to ensure safe smoking procedures were implemented for 2 of 7 residents reviewed for smoking safety. (Resident #s 2, 25) Resident #2 was paralyzed from the waist down and smoked unsupervised. He fell asleep and dropped a cigarette on his leg causing a burn. The facility did not implement changes in supervision and monitoring to prevent future occurrences. Resident #25 had [DIAGNOSES REDACTED]. He smoked unsupervised and wandered into an outbuilding. The facility did not implement changes in supervision and monitoring to prevent future occurrences. This failure was identified as an Immediate Jeopardy 12/01/11 with potential for serious injury or death to Resident #s 2 and 25. While the Immediate Jeopardy was removed 12/2/11, the facility remained out of compliance at a pattern of no actual harm with potential for more than minimal harm due to the facility's need to monitor and evaluate the effectiveness of the corrective actions. This failure could place 7 residents who smoked at risk for serious injury. Findings included: 1.) Physician orders [REDACTED]. His medications included hydrocodone four times a day (pain medication), Zyprexa daily (antipsychotic), Ambien daily and Soma three times per day (hypnotics), Valium three times per day (antianxiety), Lyrica twice daily and Cymbalta daily (antidepressant). The Drug Information Handbook for Nursing, 12th edition, noted the following: *Page 1047, 1049; Zyprexa is an antipsychotic medication that is moderate to highly sedating *Page 1518, Ambien is a hypnotic that is associated with abnormal thinking and behavior changes. *Page 233, Soma is a hypnotic that may impair physical or mental abilities. *Page 405, Valium is an antianxiety agent that may impair physical or mental abilities. The Nursing 2011 Drug Handbook, page 51-52, indicated hydrocodone was a pain reliever that may cause dizziness, sedation, impaired thinking, and visual disturbances. Resident #2's care plan dated 08/04/11 did not address his ability to safely smoke unsupervised. The plan noted Resident #2 had impaired thought processes due to a history of depression and required staff assistance due to [DIAGNOSES REDACTED]. A smoking assessment dated [DATE] noted Resident #2 was alert, capable of holding a cigarette, able to use smoking supplies safely, able to light his own cigarette, able to call for assistance, able to move without assistance, had a history of [REDACTED]. Resident #2 was assessed as being able to smoke unsupervised. Nursing notes dated 10/06/11 at 9:45 p.m. indicated Resident #2 returned from smoking outside and reported he fell asleep and burned his left leg. "Burn with skin open area 1.5 x 1 cm on left leg above knee." There was no documentation of physician notification or treatment order, reassessments, or revised care plan. Resident #2 refused interviews with or observations by the surveyors. Skin assessments for Resident #2's burn area indicated: *10/06/11, 1.5 x 1 cm, a burn area with a treatment of [REDACTED]. The anatomical diagram noted this wound was on the left inner lower thigh approximately 2 inches from the area documented to be an "open area" caused by a brace. *10/11/11, 1 x 1 cm, treatment of [REDACTED]. *10/18/11, 1 x 1 cm, treatment antibiotic ointment and foam dressing, healing During an interview on 11/30/11 at 12:00 p.m., the ADON said there would not be an incident report about Resident #2's injury because she assessed the area and it was not a burn. The area was old scar tissue and she had forgotten to correct the documentation. The ADON said the facility did not write incident reports on areas caused by braces or pressure areas. She said the facility did not have a specific policy for documentation of burns. Resident #2's most recent MDS dated [DATE] indicated he required extensive assistance with ADLs and transfers and had limitations to his lower extremities, chronic pain, and depressed mood. The resident had no cognitive impairment and resisted care. A smoking assessment dated [DATE] noted Resident #2's orientation status was unsupervised, he was alert, capable of holding a cigarette, able to use smoking supplies safely, able to light his own cigarette, able to call for assistance, able to move without assistance, had a history of [REDACTED]. Resident #2 was assessed as being able to smoke unsupervised. There was no evidence of the 10/6/11 burn incident on this assessment. During an interview on 12/01/11 at 8:00 a.m., the DON said new smoking assessments were completed for smoking residents because of the new provider letter regarding smoking safety. During an interview on 12/01/11 at 11:30 a.m., the SW said she completed the resident smoking assessment on Resident #2 on 11/17/11 and was not aware of the incident on 10/06/11 involving a cigarette burn. During the following observations, Resident #2 was smoking alone and unsupervised: *11/28/11 at 12:50 p.m. *11/29/11 at 7:30 a.m. *11/30/11 at 12:15 p.m. 2.) Physician orders [REDACTED]. His medications included Aricept, Lexapro, and Depakote. The Drug Information Handbook for Nursing, 12th edition, noted the following: *Page 443, 444; Aricept is a medication used to treat dementia and can cause dizziness, tremors, irritability and restlessness. *Page 514, 515; Lexapro is an antidepressant that may cause dizziness, light headedness, impaired concentration and weakness. *Page 1465, 1466; Depakote is an anticonvulsant that may cause dizziness, abnormal thinking, and sedation. A care plan conference note dated 10/10/11 by the social worker indicated Resident #25's wife had concerns regarding her husband's behaviors. On a visit the previous day, he had not recognized her for an hour. She also had concerns about him urinating on the floor and his poor vision. Nursing notes dated 10/19/11 at 12:30 p.m. indicated Resident #25 was outside smoking and wandered into an outbuilding where he was found by staff. This note said the resident was not trying to wander off, but was confused. There was no documentation of physician or family notification or reassessment. Resident #25's most recent MDS dated [DATE] indicated he was cognitively impaired with disorganized thinking, inattention and problems with behavior. He ambulated independently and required extensive assistance with dressing and bathing. A Resident Smoking Assessment completed 11/04/11 indicated Resident #25 was safe to smoke unsupervised, but he did not remember to turn in his lighter. During an interview on 12/01/11 at 2:00 p.m., the DON said staff would not have written an accident/incident report about Resident #25 on 10/19/11 because he was still on the property and always went out to smoke alone. She said the nurses would not have been required to complete a new assessment because the resident said he was confused and this was "normal" for him. She said he did not have a care plan that addressed safe smoking. She said they only care planned problems, but smoking safely was not a problem for Resident #25. During an interview on 12/01/11 at 2:10 p.m., the ADON said Resident #25 smoked outside unsupervised and she was not aware of other incidents. She said safe smoking was not a problem for him because there were usually other residents and staff smoking in the area. The undated facility smoking policy noted this was a smoke-free facility and residents who smoked would do so "in a safe environment and in a safe manner." A smoking assessment was to be completed to determine whether residents required supervision while smoking. Problematic smoking situations were to be addressed by care plan members and documented in the written care plan. The undated Reporting/Investigating Resident Accident/Incidents Policy indicated: All accidents or incidents involving residents must be thoroughly documented in the resident's medical record. Such documentation, at a minimum must include: a. A description of what happened b. A description of the action taken c. A description of the medical treatment administered d. A description of the resident's response e. A description of the resident's progress f. A description of the preventive measures implemented to prevent from recurring g. Date and time representative and attending physician notified On 12/01/11 at 10:05 a.m., the survey team determined the failure to ensure safety of Resident #s 2 and 25 while smoking constituted an Immediate Jeopardy situation. The administrator was notified of the Immediate Jeopardy situation on 12/01/11 at 10:38 a.m. On 12/01/11 at 3:52 p.m., the facility's Plan of Removal was accepted and included the following: *All seven families of the current smokers and all seven residents who smoke were notified of the following policy change. Notification was made between the hours of 12:30 p.m. and 1:30 p.m. LVN K, did resident notification. The social worker notified families. *Facility's smoking policy is being changed to reflect that we will no longer accept or admit residents who smoke. Policy will also change to reflect that all current residents who smoke will be placed on a two hour supervised smoking schedule. All resident smoking will be supervised. The Director of Nursing will assign supervising employees. Any current resident who refuses to comply with this policy will be asked to relocate and given whatever assistance they may require relocating. *Any suspected smoking incidents will be reported to the facility administrator, (possible incidents (not all inclusive) would include such things as residents falling asleep while smoking, families enabling residents to violate smoking policy, residents dropping ashes on themselves, ect) who will assign a designee to follow up on the incident and report back to the administrator to determine the appropriate action. All incidents will be reported verbally or in writing within 24 hours and all investigations will be complete within 72 hours. *All employees will be in-serviced, face-to-face by facility administrator, on the above policy and smoking regulations prior to their next shift. These in-services will start at 2:00 p.m. on 12-01-11 and continue until all employees have been in-serviced. In-service will include all of the above as well as identifying and reporting smoking incidents. *Facility administrator will follow up in-service by questioning employees on their shift at the monthly fire drill for six months. Follow up will also include random questioning of three different employees weekly for six months as well as in staff meetings. The policy will also be a topic of in-service at least annually or more often if determined to be necessary. It will also be a part of the new employee orientation. *Facility Director of Nursing will also be responsible for monitoring ongoing compliance through direct observation and by verbally questioning employees. Director of nursing or her designee will also be responsible for completion of the Safe Smoking Assessments. The facility did the following: *policy changed to supervised smoking only *resident smoking scheduled *staff in-serviced on the new policy *facility does not except residents who smoke *any suspected smoking incidents will be reported immediately to the administrator *all incidents and investigations completed within 72 hours Interviews with 8 licensed staff, 10 CNAs, 1 housekeeper, 1 laundry staff, and 1 maintenance staff from all shifts indicated they were knowledgeable of the new smoking policy and aware of the changes put in place to prevent accidents while smoking. The survey team determined the facility had implemented its plan of removal sufficiently to remove the Immediate Jeopardy, effective 12/2/11. The administrator was informed on 12/02/11 at 10:29 a.m. there was sufficient evidence to remove the Immediate Jeopardy. The facility remained out of compliance at a pattern of no actual harm with potential for more than minimal harm due to the facility's need to monitor and evaluate the effectiveness of the corrective actions. During an interview on 12/01/11 at 4:00 p.m., LVN H said 7 residents smoked.

Based on observation, interview, and record review, the administrator and DON failed to effectively and efficiently monitor and train staff to enable residents to attain or maintain their highest practicable physical, mental, and psychosocial well-being. The administrator did not supervise and monitor the DON to ensure the DON implemented policies and procedures to prevent accidents for residents who exhibited unsafe actions while smoking unsupervised. The DON did not ensure re-assessment and effective care planning of residents who smoked following incidents of unsafe behaviors while smoking unsupervised and did not provide staff training regarding resident smoking. *Resident #2 was smoking unsupervised, dropped a lighted cigarette in his lap, resulting in a burn to his upper leg. *Resident #25 was found outside smoking unsupervised and wandered into an out building. This failure was identified as an Immediate Jeopardy 12/01/11 with potential for serious injury or death to Resident #s 2 and 25. While the Immediate Jeopardy was removed 12/2/11, the facility remained out of compliance at a pattern of no actual harm with potential for more than minimal harm due to the facility's need to monitor and evaluate the effectiveness of the corrective actions. This failure could place 7 residents who smoked at risk for serious injury. Findings included: 1.) Physician orders [REDACTED]. His medications included [MEDICATION NAME] four times a day (pain medication), [MEDICATION NAME] daily (antipsychotic),[MEDICATION NAME] times per day (hypnotics), [MEDICATION NAME] three times per day (antianxiety), [MEDICATION NAME] twice daily and [MEDICATION NAME] daily (antidepressant). The Drug Information Handbook for Nursing, 12th edition, noted the following: *Page 1047, 1049; [MEDICATION NAME] is an antipsychotic medication that is moderate to highly sedating *Page 1518,[MEDICATION NAME] a hypnotic that is associated with abnormal thinking and behavior changes. *Page 233,[MEDICATION NAME] a hypnotic that may impair physical or mental abilities. *Page 405, [MEDICATION NAME] is an antianxiety that may impair physical or mental abilities. The Nursing 2011 Drug Handbook, page 51-52, indicated [MEDICATION NAME] was a pain reliever that may cause dizziness, sedation, impaired thinking, and visual disturbances. Resident #2's care plan dated 08/04/11 did not address his ability to safely smoke unsupervised. The plan noted Resident #2 had impaired thought processes due to a history of depression and required staff assistance due to [MEDICAL CONDITION]. A smoking assessment dated [DATE] noted Resident #2 was alert, capable of holding a cigarette, able to use smoking supplies safely, able to light his own cigarette, able to call for assistance, able to move without assistance, had a history of [REDACTED]. Resident #2 was assessed as being able to smoke unsupervised. Nursing notes dated 10/06/11 at 9:45 p.m. indicated Resident #2 returned from smoking outside and reported he fell asleep and burned his left leg. "Burn with skin open area 1.5 x 1 cm on left leg above knee." There was no documentation of physician notification or treatment order, re-assessment or revised care plan. Resident #2 refused interviews with or observations by the surveyors. A nursing note for Resident #2 dated 10/6/11 at 4:00 p.m. indicated an open area "from brace" above the left knee with documentation of physician notification and treatment order. During an interview on 11/30/11 at 12:00 p.m., the ADON said there would not be an incident report about Resident #2's injury because she assessed the area and it was not a burn. The area was old scar tissue and she had forgotten to correct the documentation. The ADON said the facility did not write incident reports on areas caused by braces or pressure areas. The facility did not have a specific policy. Resident #2's most recent MDS dated [DATE] indicated he required extensive assistance with ADLs and transfers and had limitations to his lower extremities, chronic pain, and depressed mood. The resident had no cognitive impairment and resisted care. A smoking assessment dated [DATE] noted Resident #2's orientation status was unsupervised, he was alert, capable of holding a cigarette, able to use smoking supplies safely, able to light his own cigarette, able to call for assistance, able to move without assistance, had a history of [REDACTED]. Resident #2 was assessed as being able to smoke unsupervised. There was no evidence of the 10/6/11 burn incident. During an interview on 12/01/11 at 8:00 a.m., the DON said new smoking assessments were completed for smoking residents because of the new provider letter regarding smoking safety. During an interview on 12/01/11 at 11:30 a.m., the SW said she completed the resident smoking assessment on Resident #2 on 11/17/11 and was not aware of the incident on 10/06/11 involving a cigarette burn. During the following observations, Resident #2 was smoking alone and unsupervised: *11/28/11 at 12:50 p.m. *11/29/11 at 7:30 a.m. *11/30/11 at 12:15 p.m. 2.) Physician orders [REDACTED]. His medications included [MEDICATION NAME], and [MEDICATION NAME]. The Drug Information Handbook for Nursing, 12th edition, noted the following: *Page 443, 444; [MEDICATION NAME] is a medication used to treat dementia and can cause dizziness, tremors, irritability and restlessness. *Page 514, 515; [MEDICATION NAME] is an antidepressant that may cause dizziness, light headedness, impaired concentration and weakness. *Page 1465, 1466; [MEDICATION NAME] is an anticonvulsant that may cause dizziness, abnormal thinking, and sedation. A care plan conference note dated 10/10/11 by the social worker indicated Resident #25's wife had concerns regarding her husband's behaviors. On a visit the previous day, he had not recognized her for an hour. She also had concerns about him urinating on the floor and his poor vision. Nursing notes dated 10/19/11 at 12:30 p.m. indicated Resident #25 was outside smoking and wandered into an outbuilding where he was found by staff. The note indicated he was not trying to wander off, but was confused. There was no documentation of physician or family notification or reassessment. Resident #25's most recent MDS dated [DATE] indicated he was cognitively impaired with disorganized thinking, inattention and problems with behavior. He ambulated independently and required extensive assistance with dressing and bathing. A Resident Smoking Assessment completed 11/04/11 indicated Resident #25 was safe to smoke unsupervised, but he, "did not remember to turn in his lighter". During an interview on 12/01/11 at 2:00 p.m., the DON said staff would not have written an accident/incident report about Resident #25 on 10/19/11 because he was still on the property and always went out to smoke alone. She said the nurses would not have been required to complete a new assessment because the resident said he was confused and this was "normal" for him. She said he did not have a care plan that addressed safe smoking. She said they only care planned problems because smoking safely was not a problem for Resident #25. During an interview on 12/01/11 at 2:10 p.m., the ADON said Resident #25 smoked outside unsupervised and she was not aware of other incidents. She said safe smoking was not a problem for him because there were usually other residents and staff smoking in the area. During an interview on 12/2/11 at 9:03 a.m., the DON said the social worker completed smoking assessments. She said she followed up quarterly. She said she smoked so she saw the residents who smoked on a daily basis and would change their care plan if needed. She said she did not provide the staff training regarding residents that smoke. She said nurses passed the Board of Nursing Examiners and should know how to care for residents who smoked. During an interview on 12/2/11 at 9:37 a.m., the administrator said he monitored the DON through daily observations and chart reviews. He said he was not aware of the situation surrounding Resident #2 so he was unable to investigate. The undated facility smoking policy noted this was a smoke-free facility and residents who smoked would do so "in a safe environment and in a safe manner." A smoking assessment was to be completed to determine whether residents required supervision while smoking. Problematic smoking situations were to be addressed by care plan members and documented in the written care plan. The undated Reporting/Investigating Resident Accident/Incidents Policy indicated: All accidents or incidents involving residents must be thoroughly documented in the resident's medical record. Such documentation, at a minimum must include: a. A description of what happened b. A description of the action taken c. A description of the medical treatment administered d. A description of the resident's response e. A description of the resident's progress f. A description of the preventive measures implemented to prevent from recurring g. Date and time representative and attending physician notified On 12/01/11 at 10:05 a.m., the survey team determined the failure to ensure safety of Resident #s 2 and 25 while smoking constituted an Immediate Jeopardy situation. The administrator was notified of the Immediate Jeopardy situation on 12/01/11 at 10:38 a.m. On 12/01/11 at 3:52 p.m., the facility's Plan of Removal was accepted and included the following: *All seven families of the current smokers and all seven residents who smoke were notified of the following policy change. Notification was made between the hours of 12:30 p.m. and 1:30 p.m. LVN K, did resident notification. The social worker notified families. *Facility's smoking policy is being changed to reflect that we will no longer accept or admit residents who smoke. Policy will also change to reflect that all current residents who smoke will be placed on a two hour supervised smoking schedule. All resident smoking will be supervised. The Director of Nursing will assign supervising employees. Any current resident who refuses to comply with this policy will be asked to relocate and given whatever assistance they may require relocating. *Any suspected smoking incidents will be reported to the facility administrator, (possible incidents (not all inclusive) would include such things as residents falling asleep while smoking, families enabling residents to violate smoking policy, residents dropping ashes on themselves, ect) who will assign a designee to follow up on the incident and report back to the administrator to determine the appropriate action. All incidents will be reported verbally or in writing within 24 hours and all investigations will be complete within 72 hours. *All employees will be in-serviced, face-to-face by facility administrator, on the above policy and smoking regulations prior to their next shift. These in-services will start at 2:00 p.m. on 12-01-11 and continue until all employees have been in-serviced. In-service will include all of the above as well as identifying and reporting smoking incidents. *Facility administrator will follow up in-service by questioning employees on their shift at the monthly fire drill for six months. Follow up will also include random questioning of three different employees weekly for six months as well as in staff meetings. The policy will also be a topic of in-service at least annually or more often if determined to be necessary. It will also be a part of the new employee orientation. *Facility Director of Nursing will also be responsible for monitoring ongoing compliance through direct observation and by verbally questioning employees. Director of nursing or her designee will also be responsible for completion of the Safe Smoking Assessments. The facility did the following: *policy changed to supervised smoking only *resident smoking scheduled *staff in-serviced on the new policy *facility does not except residents who smoke *any suspected smoking incidents will be reported immediately to the administrator *all incidents and investigations completed within 72 hours Interviews with 8 licensed staff, 10 CNAs, 1 housekeeper, 1 laundry staff, and 1 maintenance staff from all shifts indicated they were knowledgeable of the new smoking policy and aware of the changes put in place to prevent accidents while smoking. The survey team determined the facility had implemented its plan of removal sufficiently to remove the Immediate Jeopardy, effective 12/2/11. The administrator was informed on 12/02/11 at 10:29 a.m. there was sufficient evidence to remove the Immediate Jeopardy. The facility remained out of compliance at a pattern of no actual harm with potential for more than minimal harm due to the facility's need to monitor and evaluate the effectiveness of the corrective actions. During an interview on 12/01/11 at 4:00 p.m., LVN H said 7 residents smoked.