Every finding on record at Cedar Ridge Center

Based on observation, record review and staff interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional food safety standards. Additionally, the facility failed to follow proper sanitation practices for the kitchen. This practice had the potential to affect more than a limited number of residents. Facility census: 115 Findings include: a) Healthcare Services Group (HCSG) policy #22 titled Ware washing states: All dishware, service ware, and utensils will be cleaned and sanitized after each use. All dish machine water temperatures will be maintained in accordance with manufacturer recommendations for high-temperature or low-temperature machines. Temperature and / or sanitizer concentration logs will be completed, as appropriate. HCSG policy #25 titled Authorized Kitchen Personnel stated: All authorized personnel must wear appropriate head coverings while in the kitchen or production (hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained). HCSG policy #19 titled Food Storage states: All Time / Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. A follow-up visit to the kitchen on 06/17/26 at 11:59 AM revealed the dish machine temperature log lacked recorded temperatures for today's breakfast dishes. The HCSG District Manager (DM) #6 verified that they were not recorded today. She stated I had to send two employees home today for poor attitudes. The handwashing sink had a substance in it that looked like coffee grounds. The Dietary Account Manager #11 stated, It is coffee grounds that must have fallen out of the trash can. There was one (1) package of shredded mild cheddar cheese located in the walk-in refrigerator that was not sealed tightly. The HCSG DM #6 verified this finding and stated, I will take care of it. At 12:06 PM this surveyor noticed Dietary Aide #8 not wearing a hair restraint over his face. He had facial hair that was not being covered while working in the kitchen. I let Health Care Services Group Dietary Manager #6 know this, and she told Dietary Aide #8 to, Go put on a beard net.

Based on record review and staff interview the facility failed to follow physician's orders to ensure residents received proper treatment and care to maintain mobility. This was true for one (1) of one (1) residents reviewed related to positioning and wearing splints/orthotics. Resident Identifiers: Resident # 10. Facility Census: 115. Findings Included: a) Resident #10 Resident #10 has a diagnosis code of M24.571, which is a contracture of the right ankle. Resident #10 has orders that state Medex boots to Bilateral Lower Extremity (BLE) licensed nurse to remove and assess skin integrity every shift. It was observed on 06/18/2026 at 12:05 PM no boots were on Resident #10. The Treatment Administration Record (TAR) reviewed for June 2026 revealed that the assessment was done and boots removed at the following times: 01:17, 10:40, and 19:05. This was signed off by Employee #67. Resident #10's tasks were also reviewed for 06/18/26: Preventative skin care (protectors heel/elbow) were documented at 10:40 AM and 7:05 PM by Employee #102 these items were completed. It was observed during the 10:40 AM time that Resident #10 was not wearing anything on either foot. Then on 06/22/26 at 10:30 AM, it was observed Resident #10 was not wearing Medex boots on either lower extremity. In an observation with the Nursing Home Administrator (NHA), on 06/22/2026 at 11:45 AM, this was confirmed. Speaking with the NHA, the Medex boots could not be found to put on the resident. Employee #114 noted the boots were applied to resident at 11:04 AM, but this was observed to not be true. When speaking with Director of Nursing on 06/22/2026 at 12:37 PM, it was discussed she will have discussion with Medical Director to disconinue this order because Resident #10 was non compliant; however, the tasks or TAR did not show that.

Based on observation, record review and staff interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. There was an issue with lawncare equipment that could potential injure a resident being present and accessible to residents in the courtyard and a screw protruding through the arm rest on a resident's wheelchair. Resident identifiers: #34 and #102. Facility Census: 115. Findings included: a) Resident #34 Observation of Resident #34 in the courtyard at approximately 11:30 am revealed Resident #34 was opening a storage bench and taking out what appeared to be pruning shears. He used the pruning shears to clear out some weeds away from the gazebo. He then returned the shears to the storage bench. The resident left the courtyard. The surveyor went to the courtyard and opened the storage bench and found there was one (1) pair of Pruning Shears, one (1) hand held metal [NAME] shovel with a pointed end, one (1) hand held shovel with a rounded end, and a small rake. The surveyor then asked the Director of Nursing and the Nursing Home Administrator to come into the courtyard at 11:47 am on 6/22/26 and they agreed the items did not need to be in the storage bench in the courtyard. They confirmed the courtyard is not locked and was accessible to all residents. The Director of Nursing Confirmed there were several residents who would be able to get into the courtyard without the staff assistance. b) Resident # 102 On 06/15/26 at 1:35 PM It was observed that Resident #102's wheelchair with rips and tears all across the seat pad and had a screw coming through her left arm pad. Resident #102 stated it scratched her arms and her wheels had metal wheels inside the circle and bumped her knuckles. In an interview with the facility Director Of Nursing (DON) at 1:40 PM, she confirmed a screw was protruding through the left arm pad and stated she would get the resident another wheelchair. At 3:30 PM the DON reported the facility removed the w/c and ordered a temporary replacement.

Based on observation, record review and staff interview the facility failed to ensure the medical record was complete and accurate. This was true for four (4) of 41 sampled resident reviewed during the long term care survey. Resident #10's medical record was inaccurate pertaining to Medex Boots. Resident #11's medical record was inaccurate pertaining to a left arum support cushion. Resident #101 and #117's medical record was inccurate pertaining to amount of house supplement consumed. Resident Identifiers: #101, #117, #10, and #11. Facility Census: 115. Findings included: a) Resident #117 An observation of Resident #117 in her room beginning at appx 10:30 am on 06/22/26 found the resident was resting quietly with her eye closed. Her house supplement was on her bedside table, and the resident had not drunk it. A review of her Medication Administration Record at this time found the percentage drunk had not been documented. At approximately 10:57 am the MAR was again reviewed and showed the nurse had documented the resident had drunk 100 percent of her house supplement. The house supplement was still sitting on the resident's bedside table. An interview with the Licensed Practical Nurse (LPN) assigned to Resident #117 at 11:00 am on 06/22/26 when asked if the brown liquid in the cup on the residents bedside table was her house supplement she stated, I think that was left over from breakfast. When the LPN was asked why she documented 100 percent when none had been drunk from the cup she stated, Well what I do is I'll go back later and get it and change it if I need to. b) Resident #101 An observation of Resident #101 sitting in her room in her wheelchair with her house supplement on her bed side table. The DON had assisted the resident in drinking her supplement but at least 25 percent of the supplement remained in the cup. In her room beginning at approx. 10:30 am on 06/22/26 the resident was found resting quietly with her eyes closed. Her house supplement was on her bedside table and was not drunk. Her house supplement was on her bedside table and was not drunk. A review of her Medication Administration Record at this time found the percentage drunk had not been documented. At approximately 10:57 am the MAR was again reviewed and showed the nurse had documented the resident had drunk 100 percent of her house supplement. The house supplement was still sitting on the resident's bedside table. During interview with the Licensed Practical Nurse (LPN) assigned to Resident #101 at 11:00 am on 06/22/26 when asked if the brown liquid in the cup on the residents bedside table was her house supplement she stated, I think that was left over from breakfast. When the LPN was asked why she documented 100 percent when none had been drunk from the cup she stated, Well what I do is I'll go back later and get it and change it if I need to. d). Resident #11. Facility failed to ensure Resident # 11's accuracy of records and provision of care related to left arm supporting cushion to wheelchair and accurate care and documentation of left arm trough. Survey observation on 06/16/26 at 10:30 am revealed no left arm trough present on the wheelchair. Review of treatment record for Resident # 11 states to monitor left arm trough for placement and skin check to ensure patient safety every shift. Treatment record review revealed it was signed every shift by a licensed nurse from 06/01/26 through 06/22/26. An Interview with the DON confirmed that no trough was present on Resident #11's wheelchair and confirms the nurses initials are present on the treatment records. c) Resident #10 Resident #10 had a diagnosis code of M24.571, which was a contracture of the right ankle. Resident #10 had orders that stated: Medex boots to Bilateral Lower Extremity (BLE) licensed nurse to remove and assess skin integrity every shift. It was observed on 06/18/2026 at 12:05 PM no boots were on Resident #10. The Treatment Administration Record (TAR) was reviewed for the month of June 2026, and it revealed the the assessment was done and boots removed at the following times: 1:17 AM, 10:40 AM and 7:05 PM. This was signed off by employee # 67. Resident #10's tasks were also reviewed for 06/18/26. Preventative skin care (protectors heel/elbow) were documented at 10:40 AM and 7:05 PM by Employee #102 that these items were completed. It was observed during the 10:40 AM time that Resident #10 was not wearing anything on either foot. Then on 06/22/26 at 10:30 AM, it was observed Resident #10 was not wearing Medex boots on either lower extremity. In observation with Nursing Home Administrator (NHA), on 06/22/26 at 11:45 AM, this was confirmed. In speaking with NHA, the Medex boots could not be found to put on the resident. Employee #114 noted the boots were applied to resident at 11:04 AM, but this was observed to not be true. When speaking with Director of Nursing on 06/22/2026 at 12:37 PM, it was discussed that she will have discussion with Medical Director to discontinue this order because Resident #10 was non compliant.

Based on record review, resident interviews and staff interviews, the facility failed to provide food that accommodates resident preferences and appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice. Resident identifiers: #32, #40 and #9.Facility Census: 115. Findings Included: a) Dining and Food Preferences policy statement:During a record review of the facility dining and food preference policy statement #8 indicated Upon meal service, any resident/patient with expressed or observed refusal of food and/or beverages will be offered an alternative selection of comparable nutrition value. and policy statement #9 stated The alternative meal and/or beverage selection will be provided in a timely manor. b) Resident #32 Upon facility entrance interview with Resident #32, on 06/16/26 at 12:30 PM, she stated she liked boiled eggs but kept getting scrambled. She stated she doesn't get the food she orders because the kitchen staff never answers the phone. She stated she makes sure to order before the cut-off time. She said, I don't think they check the messages down there. c) Resident #40 In an interview on 06/16/26 at approximately 3:45P M Resident #40, reported The food here is terrible. They serve too much fish and chicken. I try to call the kitchen but nobody answers the phone down there. I have to leave messages but I still don't get what I asked for. He stated he left a message on the kitchen voicemail on Sunday (06/15/26) requesting a fried bologna sandwich for Monday's (06/16/26) lunch, ensuring his order was placed before the 10 am cut-off time, but he received the regular tray instead of the fried bologna sandwich he wanted. d) Resident #9 Resident #9 was also interviewed on 06/17/26 at approximately 10:55 AM. She reported she was having issues with not getting what she ordered for meals and had called the kitchen to place orders for the meals but no one answered the kitchen phone. She had left messages but still did not receive what she had ordered. In an Interview with the Administrator on 06/18/26 at 10:45 AM. He stated he would check with the kitchen to find out why residents complained the kitchen was not answering and why they were not receiving their orders. On 06/18/26 at 1:55 PM the administrator returned and reported he had discovered the kitchen phone line for the residents to call in the preference orders for their meals was disconnected from the wall which confirmed resident's requests and preferences were not being met.

Based on observation, policy review and staff interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections regarding resident ambulatory equipment and the screening for tuberculosis. This failed practice was a random opportunity for discovery. Resident identifiers: #102, #126, #37, #110, #36 and #98. Facility Census: 115 Findings included: a) Resident #102 Resident wheelchair, Geri-chair and rollator/walker: During an interview with Resident #102 on 06/16/2026 at 3:33 PM, it was found that Resident #102's wheel chair (w/c) had rips and tears across the front edges of the seat exposing the inner padding. In an interview with the Director of Nursing (DON) on 06/16/2026 at 3:45 PM, she confirmed the exposed padding of Resident # 102's w/c she removed the chair and stated she would order her a new one. b) Resident #36 During a facility walk through on 06/17/26 at 10:35 AM, with the facility administrator found and confirmed, Resident #36's Rollator/walker seat with exposed inner padding due to a tear in the right side of the plastic seat covering. c) Resident #98 During a facility walk through on 06/17/26 at 10:35 AM with the facility administrator it was observed that Resident # 98's Geri-chair had tears down both sides of the back rest, also exposing the inner padding. The issues above create porous surfaces that cannot be cleaned effectively, fostering an environment for bacteria growth. d) Resident #126 Resident #126 was admitted on [DATE]. Review of the immunization tab revealed no documentation of the administration of the TB Two Step skin test. e) Resident #37 Resident #37 was admitted on [DATE]. Review of the immunization tab revealed no documentation of the administration of the TB Two Step skin test. f) Resident #110 Resident #110 was admitted on [DATE]. Review of the immunization tab revealed no documentation of the administration of the TB Two Step skin test. Interview with DON 06/23/26 at 11:00 am confirmed that NO TB Two Step PPD skin tests were administered at the time of admission per the facility TB policy. Genesis policy states: All patients will be screened for tuberculosis (TB) on admission to the Center, according to Centers for CDC and local /state Health Department regulations, and recommendations. Policy IC 500 Effective Date: 09/01/04. Revision date: 09/15/25. CDC guidance indicates .Skin tests should be administered to all new residents and employees as soon as their residency or employment begins unless they have documentation of a previous positive reaction. A two-step procedure is advisable for the initial testing of residents and employees in order to establish a reliable baseline

Based on record review, policy review, resident interviews and staff interviews, the facility failed to ensure all food was temped before leaving the kitchen, to ensure safe and appetizing temperatures of the food to prevent foodborne illness. The facility failed to ensure all foods were palatable. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: #14 and #63. Facility census: 115Findings include: a) Healthcare Services Group (HCSG) policy #6 titled Food Quality and Palatability stated: Food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive, and served in a manner, form, and texture to meet resident's needs. Proper safe and appetizing temperature: Food should be at the appropriate temperature as determined by the type of food to ensure resident's satisfaction and minimize the risk for scalding and burns. HCSG policy #16 titled Food Preparation states: All foods are prepared in accordance with the FDA Food Code. On 06/17/26 at 12:25 PM, the surveyor asked the Dietary Account Manager #11 to see the food temperature logs for the month of June 2026. After review, this surveyor noticed that the kitchen was only taking the temperatures of the main and the alternate meal items and not the always available items. This surveyor asked Dietary Account Manager #11 if any resident had ordered any food items off of the always available menu this month. He stated Not that I am aware of, I do not take the orders. The surveyor asked to see the food temperature logs for the month of May 2026, and they also did not have any recorded food temperatures for the always available menu items. The surveyor asked Dietary Account Manager #11 if any resident had ordered any items off of the always available menu in the month of May 2026 and he stated Only the cold sandwiches and we do not temp them. This surveyor then asked Dietary Account Manager #11 if any resident had ordered a hot food item off of the always available menu this year (2026) and he stated, I have already answered your questions, we have made hot always available menu items this year, but I do not remember when we did. This surveyor requested copies of the food temperature logs for this year (2026), but they had no recorded temperatures for any of the always available menu items. b) Resident #14 On 06/15/26 at 2:45 PM, Resident #14 stated, the food is bad and is burnt often. Test Tray # two (2) On 06/18/26 at 12:30 PM, a test tray was delivered to the survey team. The fiesta corn was flavorless and overcooked. This was true for three (3) out of (3) surveyors that tasted the fiesta corn. c) Resident #63 On 06/22/26 at 11:25 AM, Resident #63 came to the surveyors and stated the food is overcooked often.

Based on observations, resident interviews and staff interviews the facility failed to ensure a safe clean and homelike environment. Various cosmetic imperfections were found and two (2) residents did not have bed linens. These were random opportunities for discovery and have the potential to effect more than an isolated number of residents. Room identifiers: #15, #16, #24, #28, #32, #33, #35, #36, #37, #39, and #42. Resident identifiers: #76, and #130. Facility Census: 115. a) A facility walk through on 06/17/26 at 10:35 AM, with the facility administrator found and confirmed the following environmental issues in Resident Rooms #15, #16, #24, #28, #32, #33, #35, #36, #37, #39, and #42: b) room [ROOM NUMBER]: The caulking around the sink and countertop was cracked with missing pieces and had dark, discolored debris buildup. Bathroom toilet base was blackish with missing pieces, Missing paint chips around entry door and bathroom door, Resident's wheel chair cushion with heavy food crumb and dirt buildup underneath. c) room [ROOM NUMBER]: The caulking around the sink and counter top was cracked with missing pieces and had a dark discolored debris build up, Bathroom toilet base caulking was blackish in color with missing pieces, Bathroom corners had a dirty build up of debris and cob webs around the wall edges, Chips of paint missing on the bathroom back wall. d) room [ROOM NUMBER]: Whitish stain on the privacy curtain, reddish stain on the sheet of bed #2, caulking around the sink and counter top was cracked with missing pieces and had a dark discolored debris build up. e) room [ROOM NUMBER]: The caulking around the sink and countertop was cracked with missing pieces and had dark, discolored debris build up. f) Room # 28: The caulking around the sink and countertop was cracked with missing pieces and had dark, discolored debris buildup. Bathroom corners had a dirty build up of debris and cobwebs around the wall edges. g) room [ROOM NUMBER]: Caulking around the sink and countertop was cracked with missing pieces and had dark, discolored debris build up. Bathroom corners had a dirty build up of debris and cobwebs around the wall edges. There was an approximate 2-inch tear in the linoleum flooring just inside the bathroom door. h) Room # 33: Wallpaper had rips and tears on the back wall behind resident-2's bed. There was an approximate 2-3 inch tear in the linoleum flooring in front of the toilet. Entire bathroom walls had missing paint chips. Entire bathroom walls had missing paint chips. i) room [ROOM NUMBER]: Caulking around the sink and countertop was cracked with missing pieces and had dark, discolored debris buildup. There were black stains in the sink, and the tile just inside the bathroom door was cracked and broken. j) Room # 37: Caulking around the sink and countertop was cracked with missing pieces and had dark, discolored debris build up. floor baseboard behind sink peeling off the wall, Bathroom toilet base was blackish with missing pieces. Bathroom corners had a dirty build up of debris and cobwebs around the wall edges. Paint chips were missing on the bathroom back wall. The bathroom floor tiles were cracked. k) room [ROOM NUMBER]: Caulking around the sink and countertop was cracked with missing pieces and had dark, discolored debris build up. brownish stains in the sink and on the floor under the sink counter, outside of the bathroom door with brownish colored splashes, l) room [ROOM NUMBER]: Caulking around the sink and countertop was cracked with missing pieces and had dark, discolored debris buildup. The caulking around the toilet base was blackish with missing pieces. Bathroom corners had a dirty build up of debris and cobwebs around the wall edges. There was an approximate 2 inch size hole in the bathroom door. m) Resident #76 06/17/26 9:23 AM a tour with the Director of Nursing (DON) at 4:47 pm on 06/16/26, found that Resident #76. and Resident #130 did not have sheets on there bariatric bed. Resident #76 stated that they often run out of sheets big enough for the bed. She stated they just look at her and say, Your just going to wet them anyway. n) Resident #130 Resident #130 stated he did not know why he did not have a sheet today but they never put one on the bed. While on the tour the director of nursing (DON) checked the linen cart and there was only one sheet on the cart. We then went to laundry and several sheets were available but had not been placed on the unit for use

Based on observation, record review, policy review, and staff interviews, the facility failed to store and dispose of garbage and refuse properly. Trash was found on the sidewalk outside the facility service entrance. The lid for the kitchen trash can was off during three (3) different observations of the kitchen, during the survey process. This failed practice had the potential to affect more than a limited number of residents at the facility. Facility census: 115. Findings include: a) Healthcare Services Group policy #28 titled Environment states: All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. All trash will be contained in covered, leak proof containers that prevent cross-contamination. An observation on 06/17/26 at 12:01 PM revealed the trash can located in the kitchen near the handwashing sink was full of garbage and the lid was not secured. The Dietary Account Manager #11 closed the lid. Some coffee grounds from the overflowing trash had spilled into the handwashing sink. At 12:11 PM on 06/17/26, an observation revealed the trash can in the kitchen near the handwashing sink was full of garbage and the lid was not secured. The Dietary Account Manager #11 closed the lid again. An observation on 06/17/26 at 12:21 PM revealed the trash can near the kitchen handwashing sink was full of garbage and the lid was not secured. The Dietary Account Manager #11 closed the lid again and moved the trash container out of the kitchen into the service hallway. An observation on 06/23/26 at 11:55 AM revealed a clear bag of trash on the sidewalk outside the service entrance door. The bag remained there until 12:15 PM. Two (2) staff members Employee Registered Nurse #74 and Physical Therapist #19 confirmed the bag on the ground outside the service entrance door. Employee # 19 removed the bag and placed it into the dumpster. In an interview with the Facility Administrator on 05/23/26 at 12:20 PM, he acknowledged the bag of trash was left outside the service entrance door.

The facility failed to revise care plans for Resident #115 and Resident #11 and failed to ensure an interdisciplinary approach to care planning for Resident #91. Resident identifiers: #115, #111 and #91. Facility census: 115.Findings included: a) Resident # 11 The Care-plan dated 05/05/25 indicated an e cigarette must be kept and charged at the nursing station.During an interview with Resident #11 on 6/16/26 at 11:00 am he stated he no longer used the e cigarette. Resident # 11 stated he only used smokeless tobacco. An interview with the Director of Nursing (DON) on 06/17/26 at 10:00 am verified the resident was only using smokeless tobacco as evidenced on the facility smoking list. b) Resident 115 Resident #11 had cataract procedure resulting in MD orders to wear an eye shield to left eye on 04/07/25. During survey observations on 06/16/26 11:00 am and 06/18/26 at 10:00 am Resident #115 was not wearing an eye shield on her left eye. Resident #115 stated the procedure was last year. The DON confirmed that Resident #115 did not have current MD orders to wear a left eye shield. The care plan had not been revised. c) Resident #91 06/16/2026 10:04 AM Resident #91 stated that she did not participate in care planning and they did not come to her room for care plan meetings. On 06/22/26 at 1:50 PM a review of the Electronic Medical Record found only two (2) notifications of care plan meetings. During the review, it was found that no representative from Dietary (RD) attended these meetings. Social Services (SS) #3 informed the survey team that there were no care plan meetings for the past several months. According to SS #3 the two Social Workers involved have been terminated and QA reviewed all care plans beginning June 1st. The facility provided a copy of the Policy & Procedure for care plans. SS #3 provided copies of care plans that had meetings since June 1 and there was no dietary representation for these care plan meetings. An interview with the NHA at 2:50 PM on 06/22/26 confirmed a systemic failure with care plans. The NHA was unaware of issues with the former social workers (SWs). He has adjusted the daily standup meeting reports so that he will know when care plans/MDS's are completed. They currently do not have a Dietary Manager for representation on the Interdisciplinary Team

Based on observation, record review and staff interviews, the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that meets their daily nutritional and special dietary needs, taking into consideration each resident's preferences and physician's orders. Resident identifier: #22. Facility census: 115 Findings include: a) Resident #22 On 06/16/26 at 1:13 PM the south short meal cart arrived for lunch, and at 1:15 PM, Resident #22's meal tray was served without the additional sandwich and additional serving of fruit per the physician's orders dated 05/19/26. Resident #22's meal tray was served without the additional sandwich and additional serving of fruit per the physician's orders dated 05/19/26. This order was put in place due to Resident #22 having significant weight loss. Resident #22 was admitted on [DATE] at 106 pounds. Her last documented weight was on 06/10/26 and she weighed 86.2 pounds. She had lost a total of 19.8 pounds, which is 18.7% of her total body weight since admission. The most recent care plan also showed this intervention for weight loss. When this surveyor brought this to the Nursing staff's attention, Unit Manager #18 went to the kitchen to get the missing food items. When I asked Unit Manager #18 what the kitchen staff said she stated, They said they were unaware of this order. Unit Manager #18 then said, I will write a new communication slip, and send it to them now. The quarterly nutritional assessment was completed this morning (06/16/26) at 11:50 AM by the Dietetic Tech, and it showed that Resident #22 was underweight, had a current significant weight loss and had an order for an assorted sandwich and assorted fruit with every lunch and dinner meal.

Based on record review and staff interview the facility failed to ensure residents received proper treatment and care to maintain mobility and good foot health. This was true for Two (2) of Two (2) residents reviewed related to foot health. Resident Identifiers: Resident #27 and #22. Facility Census: 115. Findings include: a) Resident #27 06/16/2026 8:56 AM Interview with Resident #27. He stated I need to see a podiatrist. His feet look bad. 06/17/26 9:31 AM I asked the DON to go and speak to Resident #27 with me and for her to look as his feet. After speaking to Resident #27 and looking at his feet, she agreed that the facility is not following the Physicians orders, or the care plan for Residents #27 Activities of Daily Living (ADL) care of his feet. She stated I will get him an appointment scheduled with a podiatrist today. Resident #27 has a physician order for: Podiatry obtain consult as needed / indicated and treatment for patient for health and comfort. Resident #27 care plan states: Focus: Resident requires assistance / is dependent for ADL care. Date Initiated: 07/18/25 Current: other skin issues to left Dorsum 1st Digit, Redness to left great toe. Date Initiated: 07/18/25 Goal: Residents ADL care needs will be anticipated and met throughout the next review period. Date Initiated: 07/18/25 Interventions: Provide resident with max assist of 1 staff for personal hygiene (grooming). Date Initiated: 07/25/25 Observe skin condition daily with ADL care and report abnormalities. Date Initiated: 07/18/25 Off load / float heels while in bed. Date Initiated: 07/18/25 Provide wound treatment as ordered. Date Initiated: 10/24/25 b) Resident #22 06/17/26 at 11:05 AM I asked the DON to go and speak to Resident #22 with me and for her to look at her feet. After speaking to Resident #22 and looking at her feet, she agreed that the facility is not following the Physicians orders or the care plan for Residents #22 ADL care of her feet. She stated I will get her toenails clipped. 06/18/26 at 10:55 AM The DON stated we will get Resident #22 toenails clipped today.

Based on record review, staff interview and resident interview the facility failed to provide necessary safety to a resident who eloped the facility. Resident #18 eloped from the facility on 03/08/26 at approximately 9:00 AM. No action was taken by the facility until 1:30 PM, although a staff member seen Resident #18 walking down the street at approximately 9:00 AM. This neglectful practice placed Resident #18 in immediate risk for serious harm and or death. Resident identifier: #18 Facility Census: 113.The State Agency (SA) determined the facility's failure to act on a known elopement resulted in an Immediate Jeopardy situation when: staff witnessed Resident #18 walking down a public street at approximately 9:00 AM on 03/08/26 but failed to intervene or report the sighting. The facility remained unaware of the resident's absence and took no search or recovery actions for 4.5 hours, until 1:30 PM. This deficient practice created a likelihood for serious injury, harm, or death, as Resident #18 was left unsupervised in an unsecured community environment for an extended period. The SA determined this failed practice to be Past non-compliance, as the facility had corrected and put procedures/educations in place prior to surveyors entering the facility. Findings Include:a) Record ReviewA timeline of Resident #18's reported elopement on 03/08/26 was provided by the facility and was reviewed. The following is the timeline provided: 7:20 am Food cart delivered to the unit. (Resident #18 states he ate breakfast)8:00 am Breakfast tray was delivered to the resident room. Resident#18 was seen laying in bed.9 am Activities assistant #139 identified resident outside of the facility.9:01 am Activities assistant notified Social Worker #140 of resident location.9:05 am Activities assistant #139 clocked into shift9:06 am Documentation shows medication received.9:15 am Received medication around (per nurse statement)9:30 am Assigned CNA (Certified Nursing Assistant) began round (cna statement)10:30 am Assigned CNA answered the call light for Resident #18's roommate who wanted vienna sausages in his snack closet. CNA stated she assumed the resident was in the bathroom due to being independent for ADL's. 1:30 pm Activities assistant notified MOD (Manager on Duty) that resident was not at smoke break.1:54 pm Notified Administrator by MOD of missing resident.2:09 pm Administrator notified authorities.5:57 pm Resident located CIC ( Change in Condition) completed03/09/2026- Elopement books audited.03/09/2026- Elopement education and drills.03/09/2026- Investigation initiated, statements collected.03/13/2026- Five Day Investigation submittedFurther record review completed on 03/17/26 revealed Resident #18 had a Brief Interview for Mental Status (BIMS) score completed on 12/02/25 and his score was a 14 which indicates the resident is cognitively intact. The elopement evaluation score on this same date is 0 which indicates the resident is at low risk for elopement. On 12/03/25, the physician deemed Resident #18 lacked capacity to make health care decisions. Resident's MDS (Minimum Data Set) (section P) on 12/09/25 is marked no for wander/elopement alarm used less than daily. Initial Care Plan on 12/16/25 has a focus stating Resident/Patient is at risk for or is experiencing adjustment issues related to Change in customary lifestyle and routines and/or difficulty accepting placement in center. Date initiated 12/05/25. Goals for this focus state, Resident/Patient will demonstrate improved coping skills to adjust to changes in circumstances or new environment by next review. Interventions for this care plan are: Encourage family members/friends to visit or call resident/patient to support his/her adjustment. Provider resident/patient with opportunities for choice during care/other activities to provide a sense of control. Encourage resident/patient to make decisions independently and provide positive feedback. Encourage expression of thoughts and feelings associated with the change or loss.The hours per patient day report (HPPD) was reviewed for 03/08/26 and it was 2.89 and the census for that day was 114. InterviewsA phone interview was completed on 03/17/26 at 11:40 AM. Resident #18, who stated he was trying to get to [NAME], WV to attend to personal business and a phone call would not suffice. Resident #18 continued to state he hitchhiked to South [NAME], WV to find out the Greyhound Bus Station was not open. So he started walking to hopefully find a ride. The resident states a man pulled up to him while walking and asked if he needed a ride and if he was hungry, so he joined the man in his car and rode to Hardee's in South [NAME] and that was when the girl from the nursing home picked him up.In an interview with both Nursing Home Administrator (NHA) and Director of Nursing (DON) on 03/17/26 at 2:35 PM, both parties explained the timeline and confirmed the event did take place. Both confirm a delay in supervision of resident care for approximately five hours from roughly 9:15 AM to 1:55 PMIn an interview with Licensed Practical Nurse (LPN) #93, (who was responsible for taking care of Resident #18 on the day of the elopement), on 03/17/26 at 4:00 PM, it was noted that elopement timeline matches up with the time line the NHA provided. Employee #93 stated the resident was given morning medicine at the time listed on the elopement timeline. Employee stated a brief conversation of exchanging pleasantries with Resident #18 that specific morning as well. On 03/17/26 at 4:25 PM, CNA #52 stated, Resident #18 was in the room during breakfast at 7:00 AM, When I (CNA #52) went into the room around 10:30 AM to give Resident #18's roommate Vienna sausages, Resident #18 was not there; I thought he was in the bathroom. CNA #52 continued to state, 'We delivered lunch at 12:00 PM and when I went to get the tray, I thought he was out smoking. Later, Activity Assistant #139 stated he wasn't out there smoking and was still gone, we started to look for him. During an phone interview on 03/17/26 at 4:40 PM with Activity Assistant #139, (who was terminated from her position for this incident) said, She clocked in at 9:03 to 9:05 that morning. I saw (Resident #18 name) at around 9:00 AM at the store. I immediately called our manager on duty to tell her. I told her. I did not mention or question anything because I have been told to report to my supervisors which is what I did. I did what I was told. I was fired on ground of neglect because I did not report the neglect to the Administrator or Director of Nursing (DON).During a phone interview with Licensed Social Worker (LSW) #140 on 3/17/26 at 4:47 PM, (The LSW was terminated for the incident.) The employee verified they were the Manager on Duty for the day and clocked in at 7:00 AM. The LSW said, she did not realize anything was going on until around 2:00 PM. I called the Activity Assistant first because she was running late. The LSW was in the middle of talking to other residents and I pulled the phone away from my ear to hear what they were saying and I missed her saying that he was at the store.The Immediate Jeopardy was issued on 03/17/26 at 5:25 PM. This was a a past non- compliance tag and signed off by the NHA at this time. A Plan of Correction was completed by the facility and provided. In-services on elopement of a patient, abuse/neglect policy, and elopement drill was started on 03/09/26 and all staff educated/in-services and post tests were completed on 03/16/26. The following questions were asked by the State Agency (SA) team on 03/17/26 at approximately 2:00 PM;Can you give the residents the door code?If you see a resident walking around outside, what do you do?Were you provided training regarding resident elopements?The Following staff members were interviewed by the SA, their interviews found;~Nursing assistant (NA) and Central Supply Clerk # 14- Answered all questions appropriately. ~Licensed Practical Nurse (LPN) #42-Answered all questions appropriately. ~Registered Nurse (RN) #16- Answered all questions appropriately. ~NA #50- Answered all questions appropriately. ~Housekeeper ##135- Answered all questions appropriately.Plan of Correction Review of the facilities plan of correction was completed on 03/17/26 at approximately 3:30 PM and found the following in-services, educations, and post tests were started 03/08/26:Resident # 18's care plan was edited on 03/08/26 to show risk of elopement. First in-service provided to all staff read as follows; Cedar Ridge Center In-Service Sign-in Sheet3/8/26(Director of nursing name here)II OPSlll Elopement of Patient.pdfAssessment/Evaluation:Identify patient's elopement risk upon admission, re-admission, quarterly, or with a significant change in condition as defined by RAI Manual criteria utilizing the nursing assessment, social services assessment, and other disciplinary assessments. For patients identified as at risk, an interdisciplinary elopement prevention patient-centered care plan will be developed withpatient participation and patient representative (hereinafter representative) when applicable. Obtain a current photograph of the patient. Complete the Elopement Risk Identification form for all patients at risk of elopement and place in a binder that is easily accessible to staff in designated area(s). Witnessed Attempted or Actual Elopement: Staff witnessing a confused patient or an identified elopement risk patient attempting to leave the Unit and/or Center unaccompanied will intervene as appropriate to redirect the patient to a safe area and prevent elopement. Unwitnessed Elopement:- If the door alarm goes off & noresidents are in sight- what do you do? Complete a head check to ensure all residents are accounted for to identify if any resident is missing. Notify the supervisor that the patient is missing. Supervisor will alert all staff of missing patient with anannouncement to activate missing patient protocol. A designee from each unit and department will report to the location that announced the missing patient to learn of the patient's name, when the patient was last seen, and a description of the patient. Staff will search: Room to room and all areas of the Center (including occupied and unoccupied spaces): patient rooms, closets, under beds, shower rooms, utility rooms, offices, dining rooms, stairwells, laundry, kitchen (including walk-in refrigerators and freezers), bathrooms, dayrooms/lounges, courtyards, and employee lounges; and Outside building perimeter and grounds. Review Release of Responsibility for Leave of Absence/Therapeutic Leave record to verify if patient is on leave of absence. The supervisor will notify the Administrator and Director of Nursing regarding the status of the search. If the patient is not found after the search of the Center and grounds, notify law enforcement and any state agencies, where applicable. Center may also, if appropriate, notify local hospitals, public transportation providers, etc. Provide law enforcement and other search party members a copy of the Elopement Risk Identification form. Center staff will follow directions and guidance offered by law enforcement. If indicated, Center staff will expand search beyond the Center and grounds into the extended community. Administrator, Director of Nursing, or designee will notify patient representative and physician/advanced practice provider (APP).Follow-up:Once the patient is found:Perform a physical examination and psychosocial evaluation. Notify physician/APPof any changes from baseline. Notify all parties previously contacted (patient representative, law enforcement, etc.) to inform them of the patient's return or status. Review the details associated with the elopement and revise the patient's care plan as indicated to mitigate elopement risk. Review with staff and patient representative. Documentation/Investigation: The nurse will: Document the elopement in the Nurses' Notes including date, time, place, notification, and other pertinent information; Enter the elopement into the PCC Risk Management Portal as a new event within 24 hours of the occurrence. The Elopement Investigation will be completed within five days. Elopement drills will be conducted a minimum of twice per year and documented in TELS.Second in-service provided to all staff read as follows;In-Service Sign in Sheet regarding Cedar Ridge Center All Staff Re-EducationPresenter: (First and Last Name of NHA) NHATopic & Description: Residents have an emergency pack of cigarettes if they are needed, please call the administrator. An email announcement from NHA was sent to all email addresses in the Cedar Ridge Center Address book that reads the following: Hello, I am reaching out to everyone to inform you that the front door code is now changed. Going forward we would like to please allow staff to enter the code to let you out of the facility. When exiting the facility. please be mindful of any surrounding residents that may be trying to exit without staff awareness. Please do not let residents out of the facility and please do not give the residents the code. Doing this allows us to best protect our residents and keep them safe at Cedar Ridge.Posttest's were given to all staff to be completed as part of the facilities educations and in-services first post test reads as follows;Cedar Ridge Posttest: Elopement Prevention and ResponseInstructions: Please select the best answer for each question.1. According to the provided policy, when must a patient's elopement risk be identified or re-evaluated?A. Only upon admission.B. Upon admission, and whenever a staff member witnesses an attempted elopement.C. Upon admission, re-admission, quarterly, or with a significant change in condition as defined by RAI Manual criteria.D. Annually, as part of the mandatory facility audit.2. If a patient is identified as being at risk for elopement, which of the following is an essential follow-up step for the interdisciplinary team?A. Immediately notifying local law enforcement.B. Developing an interdisciplinary, patient-centered care plan with patient and representative participation and applying a wanderguard bracelet.C. Scheduling an elopement drill within 24 hours.D. Completing the Elopement Investigation within five days.3. During an unwitnessed elopement (e.g., door alarm goes off and no residents are in sight), what is the first action staff should take after hearing the alarm?A. Notify the Administrator and Director of Nursing.B. Announce the missing patient protocol to all staff.C. Complete a head check to ensure all residents are accounted for.D. Immediately search the outside building perimeter and grounds.4. If a patient is not found after the initial search of the Center and grounds, what is the next required step for the supervisor?A. Review the Release of Responsibility for Leave of Absence/Therapeutic Leave record.B. Perform a physical examination and psychosocial evaluation on all remaining patients.C. Notify law enforcement and any applicable state agencies.D. Contact the patient's representative and physician/APP.5.Once a patient who eloped is found and returned to the facility, what documentation or follow-up action is required within 24 hours of the occurrence?A. The nurse must document the elopement in the Nurses' Notes and enter the elopement into the PCC Risk Management Portal as a new event.B. The Elopement Investigation must be completed.C. A mandatory Elopement drill must be conducted.D. Law enforcement must be provided with a copy of the Elopement Risk Identification form.Signature: Date: _ Print Name: _Second Post Test reads as follows:Cedar Ridge Center -Post Test Abuse/NeglectInstructions:Read each statement carefully. Circle True (T) or False (F).True I False Questions1. Abuse only occurs when there is intent to harm a resident. True False2. Resident-to-resident altercations do not need to be reported if both residents have dementia. True False3. Verbal threats, yelling, or intimidating language toward a resident can be considered abuse. True False4. Bruising of unknown origin should always be investigated if resident does not have the ability to recall what happened as a potential abuse allegation. True D False5. If a resident cannot explain how an injury occurred, staff may wait to see if it happens again before reporting. True False6. Failure to provide necessary care, such as assistance with meals, can be considered neglect. True False7. Only nurses and administrators are responsible for reporting abuse or neglect. True False8. Staff who witness abuse but fail to report are directly involved and responsible for not protecting residents. True D False9. A resident refusing care means staff are no longer responsible for offering or documenting interventions. True False10. All allegations of abuse must be reported within 2 hours. True False11. Fear of retaliation is an acceptable reason not to report suspected abuse. True False12. Protecting the resident is the first priority when abuse or neglect is suspected. True FalseName/Date:Score:Graded by: The Third Post Test reads as follows: Elopement Post-Test 3/10/26-Cedar Ridge 1.T or F- Residents are not to be given the door code.Answer:2. T or F- If a door alarm is going off, it is OK to turn off the alarm and not check outside. The resident should be fine if they exit.Answer:3. Tor F- If you see a resident walking around outside, you must first ensure their safety and immediately notify your supervisor.Answer:Staff Name/Date: _Grader Name/Date: _Score:Fourth Post Test reads as follows:Cedar Ridge Posttest: Elopement Prevention and ResponseInstructions: Please select the best answer for each question.1. According to the provided policy, when must a patient's elopement risk be identified or re-evaluated?A. Only upon admission.B. Upon admission, and whenever a staff member witnesses an attempted elopement.C. Upon admission, re-admission, quarterly, or with a significant change in condition as defined by RAI Manual criteria.D. Annually, as part of the mandatory facility audit.2. If a patient is identified as being at risk for elopement, which of the following is an essential follow-up step for the interdisciplinary team?A. Immediately notifying local law enforcement.B. Developing an interdisciplinary, patient-centered care plan with patient and representative participation and applying a wanderguard bracelet.C. Scheduling an elopement drill within 24 hours.D. Completing the Elopement Investigation within five days.3. During an unwitnessed elopement (e.g., door alarm goes off and no residents are in sight), what is the first action staff should take after hearing the alarm?A. Notify the Administrator and Director of Nursing.B. Announce the missing patient protocol to all staff.C. Complete a head check to ensure all residents are accounted for.D. Immediately search the outside building perimeter and grounds.4. If a patient is not found after the initial search of the Center and grounds, what is the next required step for the supervisor?A. Review the Release of Responsibility for Leave of Absence/Therapeutic Leave record.B. Perform a physical examination and psychosocial evaluation on all remaining patients.C. Notify law enforcement and any applicable state agencies.D. Contact the patient's representative and physician/APP.5. Once a patient who eloped is found and returned to the facility, what documentation or follow-up action is required within 24 hours of the occurrence?A. The nurse must document the elopement in the Nurses' Notes and enter the elopement into the PCC Risk Management Pqrtal as a new event.B. The Elopement Investigation must be completed.C. A mandatory Elopement drill must be conducted.D. Law enforcement must be provided with a copy of the Elopement Risk Identification form.Signature: Date: PnntName: _It was confirmed that all staff completed in-services, educations, and post tests by 03/16/26.

Based on record review, staff interviews, family interviews, and resident interviews, the facility failed to provide care and services in accordance with professional standards of practice. Resident #46 was walking with Restorative Therapy, without a Gait belt and fell. The State Agency (SA) determined harm occurred to Resident #46; the fall resulted in a break in her left femur and a fracture below her right knee. This failed practice was found true for (1) one of (1) one residents reviewed for falls during the complaint survey process. Resident identifier #46. Facility Census: 113. Findings Include:a) Resident #46A record review on 03/17/26 at 9:30 AM, revealed that Resident #46 had a fall on 02/18/26 and was sent to a local emergency room for pain to her right and left legFurther record review of the Diagnostic Radiology reports from the hospital showed the following:Left Femur: Anterior apex angulated fracture of the distal femur diametaphyseal fracture with impaction.Right Knee: Impaction and comminuted anterior apex angulated fracture distal fifth metaphysis present. Osteopenia noted. During an interview on 03/17/26 at 10:00 AM, Physical Therapy Assistant (PTA) #111, showed the SA where Resident #46 fell and stated, They did not have a gait belt on her while they were walking her.During an interview on 03/17/26 at 10:10 AM, The Director of Rehab (DOR) stated, (Resident #46 name) is blind and needs specific instruction when ambulating. We transferred her to restorative with the recommendation to use a gait belt when walking with her. We always used a gait belt when ambulating with her. On the day of the fall they did not have a gait belt on her. It is for the safety of the resident and the staff when ambulating residents. We must use a gait belt for resident safety.A record review on 03/17/26 at 10:30 AM of the Excel spreadsheet (which the SA was informed is how the Restorative Therapy Department gets its orders and recommendations from therapy) reads as follows: Ambulation, walker, gait belt, wheelchair behind resident, ambulate up to 70 feet with 2-wheeled walker, Range of motion and strengthening exercise.Further record review revealed a Physician's order dated 03/03/26 that read as follows: Restorative Nursing Program: Ambulating and ROM.During an interview on 03/17/26 at 11:30 AM, The DOR stated, When we discharge residents to restorative the physician looks over our notes and recommendations and then puts in an order for Restorative therapy. If the order says Ambulating and Range of Motion, Restorative should refer back to our recommendations on the spreadsheet for what needs to be used for safety.During an interview on 03/17/26 at 11:40AM, Resident #46 who has capacity and a Brief Interview for Mental Status (BIMS) of 15 stated, I was walking with (Restorative Therapy employee named) up front and I said I am getting tired. They had the girl behind me push the wheelchair up closer to me but I guess it wasn't close enough. When I went down, I went down hard. They said I got tangled up in the wheelchair, but they lied. They did not have a gait belt on me. If they would have had that on me I would not have fallen so hard.During an interview on 03/17/26 at 12:01PM, The Director of Nursing (DON) stated, I was not aware of that Excel spreadsheet. The DON confirmed that the recommendations from therapy were not carried over for Restorative Therapy to follow and further stated, We are using gait belts for all ambulation with assistance now.

Based on observation, resident interview, staff interview and record review the facility failed to ensure Resident #46 received ongoing opportunities to participate in meaningful activities consistent with her interests, and preferences. Specifically, following a significant change in condition after a fall resulting in multiple fractures, the facility failed to revise the resident's activity care plan and failed to provide consistent, individualized activity interventions. This resulted in a decline in activity participation and social isolations. This failed practice was found true for (1) one of (1) one residents reviewed for quality of life during the complaint survey. Resident identifier #46. Facility Census 113.a) Record review Resident #46A record review on 03/17/26 at 9:30 AM, revealed that Resident #46 had a fall on 02/18/26 and was sent to a local emergency room for pain to her right and left legFurther record review of the Diagnostic Radiology reports from the hospital showed the following:Left Femur: Anterior apex angulated fracture of the distal femur diametaphyseal fracture with impaction.Right Knee: Impaction and comminuted anterior apex angulated fracture distal fifth metaphysis present. Osteopenia noted. A record review on 03/18/26 at 12:00 AM revealed that Resident #46 was sent out to the hospital for the fractures from the fall on 02/18/26 and returned on 02/24/26.Resident #46 had a Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/27/26 indicating an significant change in the resident. Section F of the MDS indicates that it is important for Resident #46 to do things with groups of people, participate in her favorite activities, and attend church services.Further record review revealed an activity care plan that read as follows:Focus:Prefers to go by (Resident #46 name) states that it isimportant that she has the opportunity toengage in daily routines that aremeaningful relative to her preferences.Date Initiated: 04/11/2024Created on: 10/23/2020Revision on: 03/03/2025 Goal: (Resident #46 name) will have opportunities tomake choices related to selfdirected involvement inmeaningful activities throughnext review. Interventions: (Resident #46 name) enjoys in room visits, has expressed interest in joining food committee, sharingher recipes.Revision on: 04/12/2024 (Resident #46 name) request to leave her Christmas tree up year around.Revision on: 04/11/2024 Place objects within residents viewing range.Revision on: 04/11/2024 Encourage and facilitate (Resident #46 name) activity preferences.Revision on: 04/11/2024 Prefers to choose her own clothes.Revision on: 03/03/2025 (Resident #46 name) likes to snack between meals and prefer candy bars, little [NAME] cakes, dr. pepper Revision on: 04/11/2024 It is important for (Resident #46 name) to choose her bedtime and she prefer to go to bed whenever she want. Revision on: 04/11/2024 It is important for (Resident #46 name) to have family or a close friend involved in discussions about her care.) Revision on: 04/11/2024 (Resident #46 name) enjoys listening to music and prefer religious, bluegrass, and/or country. Revision on: 04/11/2024 (Resident #46 name) would like pet visits and prefer cats and dogs. Revision on: 04/11/2024 Prefers to keep up with the news by listening tv and radio.Revision on: 03/03/25 (Resident #46 name) likes to participate in singing, cooking, and/or church with groups of people.) Revision on: 03/03/2025 (Resident #46 name) likes to listen to music, lay down/rest, pray, read, watch TV/movies, by herself in her bedroom, common spaces, outdoors. Revision on: 03/03/2025 It is important for (Resident #46 name) to engage in her favorite activities: church, sewing, cooking, reading, gardening. Revision on: 03/03/2025 It is important for (Resident #46 name) to go outside when the weather is good and enjoy gardening. Revision on: 03/03/2025 (Resident #46 name) would like to participate in religious services/practices such as church.Revision on: 03/03/25 It is important for (Resident #46 name) to vote. Revision on: 04/11/2024 (Resident #46 name) uses a wheelchair for physical limitations.Revision on: 04/11/2024 (Resident #46 name) would benefit from accommodations for visual impairments by using audio books/books on tape, and/or someone to read to them.Revision on: 04/11/2024 b) Interviews During an interview on 03/18/26 at 11:40 AM, Resident #46 who has capacity and a Brief Interview for Mental Status (BIMS) of 15 stated, Nobody understands what this has done to me. I went from being able to stand and pivot and getting in my wheelchair, to now this. I was even walking 100 feet with therapy. Now I can't even get in the wheelchair. I have a rod in my left leg. It was completely broke and have to wear this brace on my right leg cause it is fractured below my knee. I am president of Resident Council, I cannot even go to the meetings now. I love going to church and just being around people all of that has changed. What no one understands is that my family promised my mom after she was gone we would all still get together. My family gets together every other Sunday. I was supposed to make my first appearance. That's what I was working toward and now this. I did not even get to go. I am not sure I ever will. The State Agency (SA) asked, Do the Activity Staff come to visit you. Resident #46 stated, Not very often, and I cannot even go out to the groups I like. Resident #46 was observed to be tearful during the interview.During an interview on 03/18/26 at 12:10 PM, The Director of Recreation (DR) #21 stated, She has not attend group activities since she got back from the hospital. She is non-weight bearing for 10 weeks. Before she attended Resident council, food committee, sometimes parties and socials. Anything we do with her now is in room. The State Agency (SA) asked, Why is she not getting one to one visits? DR #21 replied, She does not get one to one per say, If we do a social visit we do not document that. The SA pointed out to the Administrator and DR #21,that Resident #46 has only had (2) two documented one to one visits since her return from the hospital, and that she has a significant difference in her activity participation, with no interventions added or changed on her care plan since 01/2025. The Administrator and DR #21 confirmed that this is what the documentation revealed.

Based on a record review and staff interviews, it was determined that the facility failed to provide a 30-day discharge notice to a resident prior to their discharge. This failed practice had the potential to affect a minimal number of residents within the long-term care facility. Resident identifier: #98 Facility Census 113. Findings include:On 03/10/26 the State Agency received a complaint indicating Resident #98 was being discharged to a hotel on this date. The complainant indicated the facility told the resident they would pay for the first 28 days but after that the resident was on his own. The complainant indicated the resident did not have any income and was not sure how he would eat or get his medications. Record review completed on 03/18/26 revealed the following:A Social Service note dated 03/06/26 documented discharge planning discussions and a referral to the Take Me Home program at the resident's request.An assessment note dated 03/10/26 indicated discharge plan documentation was completed.A Social Service note dated 03/10/26 at 1:17 PM documented the resident was discharged that day to a Motel in [NAME], with home health services arranged, a wheelchair provided, medications supplied, and a follow-up appointment scheduled.A nursing note dated 03/10/26 at 2:45 PM documented the resident was educated on medications, blood glucose monitoring, emergency response, and home health services prior to discharge.However, there was no evidence in the medical record that Resident #98 was provided a written 30-day notice of discharge prior to leaving the facility.This deficient practice has the potential to affect Resident #98 by limiting the resident's ability to adequately prepare for discharge and exercise rights regarding the discharge process.During an interview on 03/08/26 at 2:00 PM, the Social Worker (SW), in the presence of the Administrator, stated Resident #98 had previously stayed at a hotel for 17 months and chose discharge to the [NAME] area at a motel. The Administrator said the facility paid for the first 28 days at the hotel and provided medications for 14 days. The Administrator further said the resident has a primary care appointment scheduled for 03/19/26 and receives approximately $300 weekly in unemployment benefits, though the resident refused to allow the facility to manage his funds. SW also confirmed the resident was not issued a 30 day notice of discharge.

Based on record review, staff interview, and resident interview the facility failed to provide a program of activities to meet the interest and needs of Resident #46 who has had a significant change in her activity participation. This failed practice was found true for (1) one of (1) one residents reviewed for activities during the complaint survey. Resident identifier #46. Facility Census: 113. Findings Include:a) Resident #46A record review on 03/17/26 at 9:30 AM, revealed that Resident #46 had a fall on 02/18/26 and was sent to a local emergency room for pain to her right and left legFurther record review of the Diagnostic Radiology reports from the hospital showed the following:Left Femur: Anterior apex angulated fracture of the distal femur diametaphyseal fracture with impaction.Right Knee: Impaction and comminuted anterior apex angulated fracture distal fifth metaphysis present. Osteopenia noted. During an interview on 03/18/26 at 11:40 AM, Resident #46 who has capacity and a Brief Interview for Mental Status (BIMS) of 15 stated, Nobody understands what this has done to me. I went from being able to stand and pivot and getting in my wheelchair, to now this. I was even walking 100 feet with therapy. Now I can't even get in the wheelchair. I have a rod in my left leg. It was completely broke and have to wear this brace on my right leg cause it is fractured below my knee. I am president of Resident Council, I cannot even go to the meetings now. I love going to church and just being around people all of that has changed. What no one understands is that my family promised my mom after she was gone we would all still get together. My family gets together every other Sunday. I was supposed to make my first appearance. That's what I was working toward and now this. I did not even get to go. I am not sure I ever will. The State Agency (SA) asked, Do the Activity Staff come to visit you. Resident #46 stated, Not very often, and I cannot even go out to the groups I like. Resident #46 was observed to be tearful during the interview.A record review on 03/18/26 at 12:00 AM revealed that Resident #46 was sent out to the hospital for the fractures from the fall on 02/18/26 and returned on 02/24/26.Resident #46 had a Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/27/26 indicating an significant change in the resident. Section F of the MDS indicates that it is important for Resident #46 to do things with groups of people, participate in her favorite activities, and attend church services.Further record review revealed an activity care plan that read as follows:Focus:Prefers to go by (Resident #46 name) states that it isimportant that she has the opportunity toengage in daily routines that aremeaningful relative to her preferences.Date Initiated: 04/11/2024Created on: 10/23/2020Revision on: 03/03/2025 Goal: (Resident #46 name) will have opportunities tomake choices related to selfdirected involvement inmeaningful activities throughnext review. Interventions: (Resident #46 name) enjoys in room visits, has expressed interest in joining food committee, sharingher recipes.Revision on: 04/12/2024 (Resident #46 name) request to leave her Christmas tree up year around.Revision on: 04/11/2024 Place objects within residents viewing range.Revision on: 04/11/2024 Encourage and facilitate (Resident #46 name) activity preferences.Revision on: 04/11/2024 Prefers to choose her own clothes.Revision on: 03/03/2025 (Resident #46 name) likes to snack between meals and prefer candy bars, little [NAME] cakes, dr. pepper Revision on: 04/11/2024 It is important for (Resident #46 name) to choose her bedtime and she prefer to go to bed whenever she want. Revision on: 04/11/2024 It is important for (Resident #46 name) to have family or a close friend involved in discussions about her care.) Revision on: 04/11/2024 (Resident #46 name) enjoys listening to music and prefer religious, bluegrass, and/or country. Revision on: 04/11/2024 (Resident #46 name) would like pet visits and prefer cats and dogs. Revision on: 04/11/2024 Prefers to keep up with the news by listening tv and radio.Revision on: 03/03/25 (Resident #46 name) likes to participate in singing, cooking, and/or church with groups of people.) Revision on: 03/03/2025 (Resident #46 name) likes to listen to music, lay down/rest, pray, read, watch TV/movies, by herself in her bedroom, common spaces, outdoors. Revision on: 03/03/2025 It is important for (Resident #46 name) to engage in her favorite activities: church, sewing, cooking, reading, gardening. Revision on: 03/03/2025 It is important for (Resident #46 name) to go outside when the weather is good and enjoy gardening. Revision on: 03/03/2025 (Resident #46 name) would like to participate in religious services/practices such as church.Revision on: 03/03/25 It is important for (Resident #46 name) to vote. Revision on: 04/11/2024 (Resident #46 name) uses a wheelchair for physical limitations.Revision on: 04/11/2024 (Resident #46 name) would benefit from accommodations for visual impairments by using audio books/books on tape, and/or someone to read to them.Revision on: 04/11/2024 A review of Resident #46's activity participation records from 01/01/2026 to present revealed that she was participating in out of room activities before her fall with fractures and significant change and has no out of room participation since her readmission from the hospital. The participation records also revealed that since her significant change she has only had (2) two one to one visits both occurring on 03/04/26. During an interview on 03/18/26 at 12:10 PM, The Director of Recreation (DR) #21 stated, She has not attend group activities since she got back from the hospital. She is non-weight bearing for 10 weeks. Before she attended Resident council, food committee, sometimes parties and socials. Anything we do with her now is in room. The State Agency (SA) asked, Why is she not getting one to one visits? DR #21 replied, She does not get one to one per say, If we do a social visit we do not document that. The SA pointed out to the Administrator and DR #21,that Resident #46 has only had (2) two documented one to one visits since her return from the hospital, and that she has a significant difference in her activity participation, with no interventions added or changed on her care plan since 01/2025. The Administrator and DR #21 confirmed that this is what the documentation revealed.

Based on record review, and staff interview the facility failed to update an activity care plan after Resident #46 had a significant change in her participation. This failed practice was found true for (1) one of (1) one residents reviewed for activities during the complaint survey process. Resident identifier #46. Facility Census 113.Findings Include:a) Resident #46A record review on 03/17/26 at 9:30 AM, revealed Resident #46 had a fall on 02/18/26 and was sent to a local emergency room for pain to her right and left legFurther record review of the Diagnostic Radiology reports from the hospital showed the following:Left Femur: Anterior apex angulated fracture of the distal femur diametaphyseal fracture with impaction.Right Knee: Impaction and comminuted anterior apex angulated fracture distal fifth metaphysis present. Osteopenia noted. During an interview on 03/18/26 at 11:40 AM, Resident #46 who has capacity and a Brief Interview for Mental Status (BIMS) of 15 stated, Nobody understands what this has done to me. I went from being able to stand and pivot and getting in my wheelchair, to now this. I was even walking 100 feet with therapy. Now I can't even get in the wheelchair. I have a rod in my left leg. It was completely broke and have to wear this brace on my right leg cause it is fractured below my knee. I am president of Resident Council, I cannot even go to the meetings now. I love going to church and just being around people all of that has changed. What no one understands is that my family promised my mom after she was gone we would all still get together. My family gets together every other Sunday. I was supposed to make my first appearance. That's what I was working toward and now this. I did not even get to go. I am not sure I ever will. The State Agency (SA) asked, Do the Activity Staff come to visit you. Resident #46 stated, Not very often, and I cannot even go out to the groups I like. Resident #46 was observed to be tearful during the interview.A record review on 03/18/26 at 12:00 PM revealed, Resident #46 was sent out to the hospital for the fractures from the fall on 02/18/26 and returned on 02/24/26.Resident #46 had a Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/27/26 indicating an significant change in the resident.Further record review revealed an activity care plan that read as follows:Focus:Prefers to go by (Resident #46 name) states that it isimportant that she has the opportunity toengage in daily routines that aremeaningful relative to her preferences.Date Initiated: 04/11/2024Created on: 10/23/2020Revision on: 03/03/2025 Goal: (Resident #46 name) will have opportunities tomake choices related to self directed involvement inmeaningful activities throughnext review. Interventions: (Resident #46 name) enjoys in room visits, has expressed interest in joining food committee, sharingher recipes.Revision on: 04/12/2024 (Resident #46 name) request to leave her Christmas tree up year around.Revision on: 04/11/2024 Place objects within residents viewing range.Revision on: 04/11/2024 Encourage and facilitate (Resident #46 name) activity preferences.Revision on: 04/11/2024 Prefers to choose her own clothes.Revision on: 03/03/2025 (Resident #46 name) likes to snack between meals and prefer candy bars, little [NAME] cakes, dr. pepper Revision on: 04/11/2024 It is important for (Resident #46 name) to choose her bedtime and she prefer to go to bed whenever she want. Revision on: 04/11/2024 It is important for (Resident #46 name) to have family or a close friend involved in discussions about her care.) Revision on: 04/11/2024 (Resident #46 name) enjoys listening to music and prefer religious, bluegrass, and/or country. Revision on: 04/11/2024 (Resident #46 name) would like pet visits and prefer cats and dogs. Revision on: 04/11/2024 Prefers to keep up with the news by listening tv and radio.Revision on: 03/03/25 (Resident #46 name) likes to participate in singing, cooking, and/or church with groups of people.) Revision on: 03/03/2025 (Resident #46 name) likes to listen to music, lay down/rest, pray, read, watch TV/movies, by herself in her bedroom, common spaces, outdoors. Revision on: 03/03/2025 It is important for (Resident #46 name) to engage in her favorite activities: church, sewing, cooking, reading, gardening. Revision on: 03/03/2025 It is important for (Resident #46 name) to go outside when the weather is good and enjoy gardening. Revision on: 03/03/2025 (Resident #46 name) would like to participate in religious services/practices such as church.Revision on: 03/03/25 It is important for (Resident #46 name) to vote. Revision on: 04/11/2024 (Resident #46 name) uses a wheelchair for physical limitations.Revision on: 04/11/2024 (Resident #46 name) would benefit from accommodations for visual impairments by using audio books/books on tape, and/or someone to read to them.Revision on: 04/11/2024 A review of Resident #46's activity participation records from 01/01/2026 to present revealed that she was participating in out of room activities before her fall with fractures and significant change and has no out of room participation since her readmission from the hospital. The participation records also revealed that since her significant change she has only had (2) two one to one visits both occurring on 03/04/26. During an interview on 03/18/26 at 12:10 PM, The Director of Recreation (DR) #21 stated, She has not attend group activities since she got back from the hospital. She is non-weight bearing for 10 weeks. Before she attended Resident council, food committee, sometimes parties and socials. Anything we do with her now is in room. The State Agency (SA) asked, Why is she not getting one to one visits? DR #21 replied, She does not get one to one per say, If we do a social visit we do not document that. The SA pointed out to the Administrator and DR #21,that Resident #46 has only had (2) two documented one to one visits since her return from the hospital, and that she has a significant difference in her activity participation, with no interventions added or changed on her care plan since 01/2025. The Administrator and DR #21 confirmed that this is what the documentation revealed.

Based on record review and staff interview, the facility failed to manage pain in accordance with professional standards of practice. This deficient practice had the potential to affect one (1) of two (2) residents reviewed for the care area of pain. Resident Identifier: #14. Facility census: 117. Findings included:a) Resident #14 The facility's policy titled Pain Management with effective date 01/01/04 and revision date 03/24/25 stated that reasons for as needed (PRN) pain medications would be documented. Review of Resident #14's physician's orders showed the resident was receiving the following scheduled pain medications: -Morphine sulfate extended relief tablet, 10 mg, three (3) times a day for pain, ordered 01/18/26-Morphine sulfate extended relief tablet, 60 mg, two (2) tablets, three (3) times a day for pain, ordered 01/31/26 Resident #14 also had an order to document the pain level and non-pharmaceutical interventions for pain every shift. Pain was assessed on a score of 0-10, with 0 being no pain and 10 being the highest pain imaginable. Resident #14 was also ordered the following PRN pain medication on 12/16/25.: Morphine sulfate, 30 mg, every six (6) hours as needed for pain. Review of Resident #14's medication administration record (MAR) for February 2026 showed the resident received PRN morphine sulfate six (6) times in February. There was no documentation of the resident's pain level before administration of the medication. The medication was documented as effective in relieving the resident's pain. Resident #14 received PRN morphine sulfate on the following dates at the following times: -02/01/26 at 4:16 PM; pain assessments performed that day documented pain levels of 0.-02/10/26 at 1:13 PM; pain assessments performed that day documented a pain level of 0 for day shift and 1 for night shift.-02/11/26 at 11:15 AM; pain assessments performed that day documented a pain level of 0 for day shift and 1 for night shift.-02/12/26 at 11:27 PM; pain assessments performed that day documented pain levels of 0.-02/13/26 at 6:00 PM; pain assessments performed that day documented pain levels of 3. On 02/18/2026 at 9:03 AM, the Director of Nursing (DON) confirmed Resident #14's pain level had not been documented before administration of PRN pain medications. She stated she had revised the resident's MAR to include a place for the pain level and non-pharmacological interventions to be recorded before the medication administration. No further information was provided through the completion of the survey process.

Based on observation and food tray temperatures, the facility failed to serve food to residents that was palatable and at an appetizing temperature. Based on resident interview and staff interview, the facility failed to ensure hot foods were served hot and cold foods were served cold. This failed practice was true for one (1) of one (1) hallways tested for food tray temperatures throughout the complaint survey process. Resident #35. Facility census: 117.Findings include: a) The facility was not taking and documenting all food temperatures prior to sending the food to the residents. The facility was also sending cold food out above the FDA Food Code temperature of 41 degrees Fahrenheit. The Healthcare Services Group policy 016 titled Food Preparation shows the following: All foods are prepared in accordance with the FDA Food Code. Cold foods at 41 degrees F or below and hot foods at 135 degrees F or above before it leaves the kitchen.This surveyor asked for a copy of the service line checklist dated 02/01/2026 - 02/15/2026 that shows the temperature of the food items that are prepared and what the temperatures are before the kitchen staff sends the food to the residents. They were all missing temperatures and there were eleven total cold food items that were documented at 42 degrees Fahrenheit before the items left the kitchen. b) Resident #91 stated during an interview on 02/16/2026 at 11:37 AM that food was not always hot when it was served to him.Resident #60 stated during an interview on 02/16/2026 at 1:29 PM, The food is not hot when I get it. Resident #9 stated during an interview on 02/16/2026 at 12:30 PM, The food sucks.At 12:58 pm, the dietary manager took the temperature of room [ROOM NUMBER]-A meal tray. The temps were as follows: Spaghetti w meat sauce 120.7 degrees FGreen Beans 112.1 degrees FVanilla ice cream 23.5 degrees F The hot foods are supposed to be 120 degrees F or above at point of service per the FDA food code. The cold foods are supposed to be at 41 degrees F or below before it leaves the kitchen. Per the FDA food code and the facilities policy & procedure this was not followed.

Based on observation and staff interview, the facility failed to ensure Resident #31, #37, #105 and #53 had an accident-free environment. Excessive gaps were found with no gap fillers at the foot of three (3) residents' beds. One (1) resident had his arm entrapped between the mattress and side rail. Excessive gaps in danger zones on a resident bed can lead to serious injuries including death. This created an immediate jeopardy situation that began on 05/13/25 at 10:00 AM and ended on 05/14/25 at 12:00 PM. Resident identifiers: #31, #37, #105 and #53. Facility census: 104. Findings include: a) On 05/13/25 between the hours of 9:30 AM through 10:00 AM, observations of all the beds in the facility revealed that the mattresses had no gap fillers and there were gaps greater than approximately 5 inches in resident beds. This allowed for a space at the foot of the bed that could allow the entrapment of Resident #31, Resident #37, and Resident #53. On 05/13/25 at approximately 11:40 a.m., an interview with the Maintenance Assistant (MA) on 05/13/25 at approximately 11:40 a.m. verified these findings. The facility was notified of the Immediate Jeopardy (IJ) at 12:40 PM on 05/13/25. The facility submitted their first abatement plan of correction (POC) at 1:49 PM on 05/13/25. The state agency requested changes and the second abatement POC was submitted on 05/13/25. The plan of correction was accepted on 05/13/25 at 3:33 PM. The plan of correction stated, Maintenance Director fixed the gap at the foot of beds for Resident #31, #37, and #53 on 05/13/25 and used the bed safety measuring tool to ensure it passed. All residents of the facility have the potential to be affected. The Maintenance Director/designee conducted an audit on 5/13/25 utilizing the bed safety tool to ensure the head/foot of beds passed according to manufacturer guidelines with any corrective action immediately upon discovery. The Director of Nursing (DON)/designee conducted an audit on 5/14/25 of residents beds that require gap filler to ensure it is in place with any corrective action immediately upon discovery. Re-education was provided by the Nursing Home Administrator (NHA) to the maintenance department on 5/13/25 regarding the use of the bed safety measuring device to be used to conduct the inspection as they evaluate gaps and potential entrapment risks between head/foot of beds with a post-test by the NHA/designee prior to the beginning of the next shift to work. New maintenance staff will be provided education, including post-test during orientation by the NHA/designee. Re-education was provided by the DON/designee to all the nursing staff on 5/13/25 regarding residents that require gap fillers on the bed to ensure the placement with a post-test to validate understanding. Any nursing staff not available during this time frame will be provided re-education, including post-test by the DON/designee prior to the beginning of the next shift to work. New nursing staff to be provided education, including post-test during orientation by the DON/designee. The Maintenance Director/Designee will monitor resident beds with any change in bed frame, mattress or bedrail utilizing the bed safety measuring device starting 5/13/25 to ensure the head/foot of beds pass according to manufacturer guidelines daily for 2 weeks including weekends and holidays then 5 times a week for 4 weeks, then 3 times a week for 4 weeks, then randomly thereafter. The DON/designee will monitor residents with gap fillers on bed starting 5/14/25 to ensure the placement of gap filler daily for 2 weeks including weekends and holidays, then 5 times a week for 4 weeks, then 3 times a week for 4 weeks then randomly thereafter. Results of monitors will be reported by the DON/designee monthly to the Quality Improvement Committee (QIC) for any additional follow-up and or in-servicing until the issue is resolved then randomly thereafter as determined by the QIC committee. After observation of the implementation of the abatement POC, the IJ was abated at 12:00 PM on 05/14/25. b) Resident #105 Medical Record review revealed Resident #105 was a [AGE] year-old admitted for long term care. He had the following diagnoses: diabetes, hypokalemia, dementia, dysphagia, thyroid disorder and history of falls. He lacked capacity and had a Brief Interview for Mental Status (BIMS) score of 5. A score of 5 indicated severe cognitive impairment. Medical Record Review (MRR) revealed Resident #105 had a fall on 04/19/25 at 5:10 AM. This fall resulted in an injury to the left arm related to entrapment of the arm between mattress and rail. Nurse Aide #135 was assigned to the resident on 04/19/25. According to Nurse Aide #135's statement the resident was last seen in bed on 04/19/25 between 2:30 AM and 3:00 AM. On 05/14/25 during an interview with the administrator, the administrator stated NA #135 left the facility at 3:03 AM on 04/19/25 without letting her supervising nurse know. Nurse Aide #135 was terminated because of the investigation completed by the facility. Witness statements that were collected by the facility and reviewed by the survey team revealed the resident's bed was at waist level when he was found following the fall. Following the fall Resident #105 was transferred to the Emergency Department (ED) and found to have an arterial tear to the left arm. He received surgical intervention to repair the artery and muscle. Review of the facility's investigation revealed Resident #105 was found on 04/19/25 at 5:10 AM. A statement dated 04/19/25 written by Nurse Aide #64 stated, When I walked into (Resident #105's) room I saw (Resident #105) laying in the floor face down with his left arm stuck between the bed and bed rail. His left arm was extended over his head and his arm was twisted. I ran over to him and tried to remove his arm from the bedrail, but it was so tight I couldn't do it by myself. I yelled for (Licensed Practical Nurse #97) and she came in to help me try to remove his arm from the bed rail again and we were unsuccessful. LPN #97 yelled for (name of staff) who was working on third assignment, and she came in and began to assist us. After a few seconds (name of staff) and I were able to free his arm from the bed. During this time (Nurse Aide #121) came in the room and said she was going to get the lift and lift pad so we could safely get him off of the floor and back into the bed so we could check him out. While we waited on her to get back with the lift and lift pad I was holding (Resident #105's) right hand and (name of staff) was holding his left hand. (name of staff) asked Resident #105 to squeeze her hand with his left hand and he was unable to do so. I asked him to squeeze my hand with his right hand and he successfully did. When we got him out of the floor with the lift we noticed that he had a knot coming from his left armpit. LPN #97 tried to call the doctor who advised her to call 911. I did notice when I first went into his room that his bed was placed way higher than normal. I frequently work second assignment and know he has a tendency to roll out of the bed I make sure his bed is to the floor all the way down. His call light and bed remote were both in the floor. His headboard was placed against the wall with both rails up. I do not remember seeing him have on any anti-slip socks at the time of his fall. We checked his brief once he was in bed and he was dry. A bed safety evaluation was performed on 01/27/25. Review of evaluation revealed Step #5 (Risk Factor Evaluation and #7 (Check for Zones of Entrapment) were not completed. There was no documentation in Step #5 and #7. On 05/13/25 at 5:30 PM the Administrator said after this incident they went through the building and assessed all residents' bed/bed rails for the space between the mattress and the side rail. Observations made by the survey team during the investigation did not reveal any potential entrapment areas between the mattress and side rails.

Based on record review and staff interview the facility failed to provide an environment for residents free from neglect and physical harm for one (1) of four (4). This failed practice caused physical harm to Resident #105. Resident #105 fell out of bed and injured his left arm. The failed practice was determined by the state survey team to have been corrected prior to entrance and will be cited at past non-compliance. Resident identifier: #105. Facility census: 104. Findings include: a) Resident #105 Medical Record review revealed Resident #105 was a [AGE] year old admitted for long term care. He had the following diagnoses: diabetes, hypokalemia, dementia, dysphagia, thyroid disorder and history of falls. He lacked capacity and had a Brief Interview For Mental Status (BIMS) score of 5. A score of 5 indicated severe cognitive impairment. Review of an internal investigation completed by the facility revealed Resident #105 had a fall on 04/19/25. According to the facility's investigation this fall resulted in an injury to the left arm related to entrapment of the arm between mattress and rail. Nurse Aide #135's statement reflected that Resident #105 was last seen in bed on 04/19/25 between 2:30 AM and 3:00 AM. Nurse Aide #135 was assigned to the resident on the night of 04/19/25. Nurse Aide #135 was terminated as a result of the investigation completed by the facility. A review of a statement collected by the facility from Nurse Aide (NA) #64 revealed she clocked in on 04/18/25 at 7:00 PM. NA #64 said that NA #135 left at 3:00 AM. NA #135 advised NA #64 that she had finished her round and that everyone had been checked and changed. According to NA #64, NA #110 was supposed to come in at 3:00 AM but had called in to report he was running late. NA #121 came over from south to help NA #64 deal with the fact that NA #110 had not shown up for work. NA #64, NA #121 completed checks on their respective assigned hallways and then went to cover NA #110's assignment. Review of the facility's investigation revealed Resident #105 was found by NA #64 on 04/19/25 at 5:10 AM. A statement dated 04/19/25 written by Nurse Aide #64 stated, When I walked into (Resident #105's) room I saw (Resident #105) laying in the floor face down with his left arm stuck between the bed and bed rail. His left arm was extended over his head and his arm was twisted. I ran over to him and tried to remove his arm from the bedrail but it was so tight I couldn't do it by myself. I yelled for (Licensed Practical Nurse #97) and she came in to help me try to remove his arm from the bed rail again and we were unsuccessful. LPN #97 yelled for (name of staff) who was working on third assignment, and she came in and began to assist us. After a few seconds (name of staff) and I were able to free his arm from the bed. During this time (Nurse Aide #121) came in the room and said she was going to get the lift and lift pad so we could safely get him off of the floor and back into the bed so we could check him out. While we waited on her to get back with the lift and lift pad I was holding (Resident #105's) right hand and (name of staff) was holding his left hand. (name of staff) asked Resident #105 to squeeze her hand with his left hand and he was unable to do so. I asked him to squeeze my hand with his right hand and he successfully did. When we got him out of the floor with the lift, we noticed that he had a knot coming from his left armpit. LPN #97 tried to call the doctor who advised her to call 911. I did notice when I first went into his room that his bed was placed way higher than normal. I frequently work second assignment and know he has a tendency to roll out of the bed I make sure his bed was to the floor all the way down. His call light and bed remote were both in the floor. His headboard was placed against the wall with both rails up. I do not remember seeing him have on any antislip socks at the time of his fall. We checked his brief once he was in the bed and he was dry. On 05/14/25 during an interview with the administrator, the administrator stated NA #135 left the facility at 3:03 AM on 04/19/25 without letting her supervising nurse know. The Administrator stated during an interview, on 05/14/25, that it was her expectation that all residents were visually observed and provided if care if needed at least every (2) hours. It was confirmed that this resident was not checked on for over two (2) hours. Following the fall Resident #105 was transferred to the Emergency Department and found to have an arterial tear to the left arm. He received surgical intervention to repair the artery and muscle. The resident did not return to the facility. The facility provided a copy of an In-Service Sign-In Sheet dated 04/21/25. The topic and description was Shift to Shift report (walking around) must take place at the end of your shift with the oncoming CNA/Nurse. If you leave the floor for lunch, break or your shift is over you must report to your nurse/supervisor that you are leaving so your assignment can be reallocated to who is covering for you. On 05/14/25 the administrator stated NA #135 left the facility at 3:03 AM on 04/19/25 without letting her supervising nurse know. A review of the facility's investigation revealed Nurse Aide #110 was scheduled to report to work at 3:00 AM on 04/19/25. Investigation revealed that NA #110 had called in to report he would be arriving for work late and later that morning called in to report he would not be there for the entire shift. During an interview on 05/14/25 at approximately 10:35 a.m., the Administrator stated, During our investigation, we discovered the issue and immediately began to correct the issue. We done separate training related to this finding. Education was completed to all NAs by 05/01/25. The facility provided a copy of an In-Service Sign-In Sheet dated 04/21/25. The topic and description was Shift to Shift report (walking around) must take place at the end of your shift with the oncoming CNA/Nurse. If you leave the floor for lunch, break or your shift is over you must report to your nurse/supervisor that you are leaving so your assignment can be reallocated to who is covering for you. The Administrator said after this incident they went through the building and assessed all residents' bed/bed rails for the space between the mattress and the side rail. Observations made by the survey team during the investigation did not reveal any potential entrapment areas between the mattress and side rails. A bed safety evaluation was performed on 01/27/25. Review of evaluation revealed Step #5 (Risk Factor Evaluation and #7 (Check for Zones of Entrapment) were not completed. There was no documentation in Step #5 and #7. A fall risk assessment was completed on 01/28/25. Results of assessment were that Resident #105 was a fall risk and was care planned for fall risks. Documentation review revealed that all NAs were provided education on correct procedure when performing a shift-to-shift report (walking around). Sign-in sheets for the in-service were reviewed and staff interviews with Nurse Aide (NA) #110, #79, #12, and #77 verified training completed. On 05/14/25 at approximately 12:19 p.m., interview with Nurse Aide (NA) #110. The surveyor asked the NA to explain the shift-to-shift report process. NA #110 correctly explained the process. On 05/14/25 at approximately 1:13 p.m., conducted an interview with Nurse Aide (NA) #79. Asked the employee what procedure they would follow if they had to leave or at change of shift. NA #79 stated, I would notify who is in charge and I would give a report to whoever is taking care of my residents. Education was completed and verified by a signature sheet on 04/21/25. On 05/14/25 at approximately 1:41 p.m., the surveyor conducted an interview with Nurse Aide (NA) #12. The surveyor asked the employee what procedure they would follow if they had to leave or at change of shift. NA #12 stated, I would give a report to oncoming CNA and do a walk around. Education was completed and verified by a signature sheet on 04/21/25. On 05/14/25 at approximately 1:47 PM, the surveyor conducted an interview with Nurse Aide (NA) #77. NA #77 was asked what procedure they would follow if they had to leave or at the change of shift. NA #77 stated, I would give report and do a walk around. If I had to leave, I would notify who was in charge. Education was completed and verified by a signature sheet on 04/21/25

Based on water temperature measurement and staff interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. The hot water temperature in the hand washing sink located in the main dining room was at an unsafe temperature for resident use. The water temperature in the hand sink in the main dining room was tested with facility equipment by the facility's maintenance director at approximately 2:30 PM on 04/16/25 the temperature was 139.2 degrees Fahrenheit. The water temperature in the sink in the main dining room at 2:56 PM was obtained in the same manner mentioned above and was 125 degrees Fahrenheit. The state agency (SA) felt this put any resident who was able to wash their hands in this sink at an immediate risk for serious injury and/or death and created an Immediate Jeopardy (IJ) situation. The SA notified the facility of the IJ at 3:56 PM on 04/16/25. The SA accepted the facility's plan of correction (POC) at 4:07 PM on 04/16/25. After staff interviews, reviewing the education and facility water temperature measurements for all resident areas, and observing the water was turned off to the main dining room the SA abated the IJ at 6:12 PM on 04/16/25. This failed practice to effect the following residents who were identified by the facility as the residents who could potentially access the hand sink in the main dining room, #166, #14, #216, #44, #81, #66, #49, #71, #96, #34, #104, #167, #87, #21,#84, #8, #168, #53, #7, 80, #51, #62, #31, #1, #22, #101, #28, #11, #57, #59, #91, #35, #107, #73, #27, #40, #10, #72, #102, #45, #46, #19, #8, #93, #61, #82, #48, #43, #3, #106, #47, #60, #217, #266, #6, #15, #52, #108, #29, #77, #83, #50, #108, #29, #77, #83, #50, #58, #26, #64, #68, #12, #74, #103, #78, #39, #6, #17, #88, and #30. Facility Census: 111. Findings Included: a) On 04/16/25 at approximately 2:20 PM the surveyor noticed a hand sink in the main dining room. Because this hand sink is accessible to residents, the surveyor felt the hot water in the sink The water was hot to the touch. The surveyor could not comfortably keep her hand under the stream without withdrawing due to the risk of burns. The maintenance director was asked to come to the dining room to measure the temperature of the hot water in the hand sink. The water temperature in the hand sink in the main dining room was tested with facility equipment by the facility's maintenance director at approximately 2:30 PM on 04/16/25 the temperature was 139.2 degrees Fahrenheit. The water temperature in the hand sink in the main dining room at 2:56 PM was obtained in the same manner mentioned above and was 125 degrees F. (Please note the maintenance director immediately turned off the hot water to the hand sink after the first measurement at 2:30 PM. He turned the water back on to obtain this measurement.) The maintenance director was asked which tank the hot water to the hand sink came from. He indicated initially it was the same tank that fed the resident rooms and shower rooms. He was then asked to obtain temperatures in the back shower room, which was 98.7 degrees F, and in room [ROOM NUMBER] which was 95.0 degrees F. It was immediately after these readings that the second reading from the hand sink in the main dining room was obtained and was 125 degrees F. An interview with the Maintenance Director at approximately 2:45 PM confirmed he does not routinely check the temperature in the hand sink in the dining room. He indicated that he checks the water temperature in the shower rooms and resident rooms. When asked what tank fed the hand sink in the dining room, he indicated it was the same tank that fed resident areas. However, the water temperatures obtained in the shower room and room [ROOM NUMBER] were both less than 100 degrees Fahrenheit. He stated, I'm going to have to look in the attic to determine what tank this water is coming from. The facility self-identified the following residents were able to wash their hands in the main dining hand sink without the assistance of staff: Resident #166, #14, #216, #44, #81, #66, #49, #71, #96, #34, #104, #167, #87, #21,#84, #8, #168, #53, #7, 80, #51, #62, #31, #1, #22, #101, #28, #11, #57, #59, #91, #35, #107, #73, #27, #40, #10, #72, #102, #45, #46, #19, #8, #93, #61, #82, #48, #43, #3, #106, #47, #60, #217, #266, #6, #15, #52, #108, #29, #77, #83, #50, #108, #29, #77, #83, #50, #58, #26, #64, #68, #12, #74, #103, #78, #39, #6, #17, #88, and #30. According to Table 1 in the Guidance to Surveyors related to comfortable/safe water temperatures, found in Appendix PP of the CMS State Operations Manual, a third (3rd) degree burn can occur at 120 degrees F with an exposure time of five (5) minutes, at 124 degrees F with an exposure time of three (3) minutes, at 127 degrees F with an exposure time of one (1) minute, at 133 degrees F with an exposure time of 15 seconds, and at 140 degrees F with an exposure time of 5 seconds, noting that burns can occur even at water temperatures below that level depending on the exposed individual's condition and the length of exposure. The facility submitted the following plan of correction to the AS (typed as written): F689 The Maintenance Director (MD) turned the water off to the dining room sink on 4/16/25 immediately upon discovery. The Nursing Home Administrator (NHA) posted an out of service sign on the dining room sink on 4/16/25 at 2:45pm. All the residents of the facility have the potential to be affected. The Director of Maintenance/designee completed an audit on 4/16/25 of water temperatures from point of use on each resident room, resident care areas, and shower rooms to ensure water temperature is 110 degrees or below with any corrective action immediately upon discovery. Re-education was provided by the Nursing Home Administrator (NHA) /Designee to all maintenance employees starting on 4/16/25 to ensure water temperatures from point of use in the facility is 110 degrees or below. A Post-test to validate understanding. Any maintenance employees not available during this time frame will be provided re-education, including post-test and return demonstration by DON/designee upon the beginning of next shift to work. New maintenance employees will be provided education, including post-test during orientation by the DON/designee. The Maintenance Director (MD) /Designee will monitor facility water temperatures from point of service on each hallway a random room, resident care areas, and shower rooms starting on 4/16/25 to ensure water temperatures are 110 degrees or below daily across all shifts for 2 weeks including weekends and holidays, then 3 times a week for 2 weeks then randomly thereafter. Results of monitors will be reported by the Unit Manager (UM)/designee monthly to the Quality Improvement Committee (QIC) for any additional follow-up and or in-servicing until the issue is resolved, then randomly thereafter as determined by the QIC committee. An additional interview with the Maintenance Director at Approximately 6:00 PM confirmed the hot water tank which fed the hand sink in the main dining room was tied in with the tank that fed the kitchen. He stated, It would have been hotter because the kitchen water has to be hotter.

Based on observation, record review, and staff review, the facility failed to ensure Resident #111 received respiratory care to ensure Resident #111's airway remained intact and was able to be reestablished immediately if the tracheotomy tube would become dislodged. This was true for one (1) resident reviewed for the care area of Respiratory care during the long term care survey process. The facility failed to ensure they had the supplies at bedside to replace Resident #111's tracheotomy canula. The physician orders and Resident #111's care plan dictated the supplies were to be kept at bedside. When the staff was asked were the supplies were to replace the canula were located, it took greater than 15 minutes to find the needed supplies in the supply closet. They were not kept at bedside as directed in the physician order and care plan. The failure to replace Resident #111's tracheotomy cannula timely could result in the immediate loss of a secure airway leading to severe hypoxia, anoxic brain injury, cardiopulmonary arrest and potentially death. Medical literature affirms that timely intervention is critical. Delayed recognition or failure to reestablish the airway with in minutes can cause irreversible harm. The State Agency (SA) determined this failure put Resident #111 in an Immediate Jeopardy (IJ) situation. The facility was notified of the immediate jeopardy at 5:03 PM on 04/15/25. The facility submitted and the SA accepted a plan of correction (POC) at 5:20 PM. After observation of implementation of the POC the IJ was abated at 6:27 PM on 04/15/25. After the IJ was abated and the immediacy was removed, but a deficient practice remained for Resident #97. Resident #97 was ordered to have continuous oxygen but it was not in place. After the abatement the scope and severity was decreased from a J to a D. Resident Identifiers: #111 and #97. Facility Census: 111. Findings Included: a) Resident #111 Resident #111 was admitted to the facility on [DATE]. The resident record contained the following physician orders related to trach care: -- Type of Trach 6.5 size of trach 6 spare trach kept at bedside and ambu bag at bedside. A review of the residents care plan found the following care plan interventions related to the trach included: -- Keep a spare trach/orturator trach kit at bedside. Added to the care plan 03/24/25. -- Type of trach: 6.5 size of trach 6 keep spare trach and ambu bag at beside. Added to the care plan on 03/24/25. Observations of Resident #111 with the Director of Nursing (DON) at approximately 11:45 am found the resident did not have a size six (6) trach at her bed side. She was then asked if she could show the surveyor that she had one in the facility. She summoned the Respiratory Therapist (RT) who looked in the supplies they were unable to locate a size 6. The RT then went to Resident #111's room to see what size trach was currently in place. The RT determined it was a size 7.5 instead of a 6.5. He was then able to locate the size 7 trach kit which would have been the size down. It took greater than 15 minutes to locate the trach kit which according to the physicians orders and care plan should have been located at bed side. He agreed it needed to be at bed side and not in the storage area. An additional interview with the RT, on 04/15/25 at 1:25 PM, confirmed he was one who ordered the wrong size trach. He stated that when she arrived the hospital did not send orders with her regarding the size of her trach. He stated that he looked at it and they are new and have different numbers. He stated that he looked at the chart and made an error when putting in the orders and the care plan. When asked what type of circumstances would cause the trach to dislodge the RT stated, A deep cough moving around just about anything could make it pop out. An interview with Licensed Practical Nurse #60 (LPN), confirmed if the trach would come out he would hold the oxygen over the hole and call a Registered Nurse. He confirmed, he was not allowed to replace the trach. A review of the facility's procedure related to Tracheotomy Tube Change/reinsertation,found primary licensed staff inserts the new tube. The DON indicated this meant an LPN can reinsert the new tube. She stated he knew that so I don't know why he told you that. Further review of the procedure for Tracheotomy Tube Change/reinsertation found the following, .9. Verify size of trach that patient has in place to assure appropriate tube size and type. 10. Verify the two replacement trachs, current size and one size below, are available at bedside along with manual resuscitator . An additional interview with the RT at, 04/15/25 at 2:26 PM, revealed he should have ordered a 6un75H in the trach and she should have had a 5un70h at bedside. He stated that he went by the diameter of 7.5 instead of the size of the trach. However the ordered reflected a 6.5 not the diameter of 7.5. The RT confirmed the residents trach is uncuffed and they are more likely to dislodge. A follow up interview with the DON after the facility's was notified of the IJ confirmed it took greater than 15 minutes to find the correct size trach. She stated, But we was not in an emergency situation. She felt they would have found it quicker had the trach been dislodged however the chaos of any emergency likely would cause further delay. She agreed the spare trach should have been at bedside. b) Facility's Plan of Correction The facility's plan of correction read as follows (typed as written): The Director of Nursing (DON)/designee placed the emergency trach as ordered by the resident's 11 bedside on 4/15/25 @ 500pm. All residents with tracheostomies of the facility have the potential to be affected. As of 4/15/25 no other residents with tracheostomies in the facility at this time. Re-education was provided by the Director of Nursing(DON)/Designee to all licensed nurses starting on 4/15/25 to ensure residents with a tracheostomy tube in place will have a spare tracheostomy tube with obturator of the same manufacturer brand and size currently used AND one size smaller at the bedside. A Post-test to validate understanding. Any licensed nurses not available during this time frame will be provided re-education, including post-test and return demonstration by DON/designee upon the beginning of next shift to work. New Licensed nurses will be provided education, including post-test during orientation by the DON/designee. Annual in-servicing will be provided to licensed nurses regarding the care of indwelling urinary catheters. The Unit Managers (UM)/Designee will conduct observations starting on 4/15/25 to ensure residents with a tracheostomy tube in place will have a spare tracheostomy tube with obturator of the same manufacturer brand and size currently used and one size smaller at the bedside daily across all shifts for 2 weeks including weekends and holidays, then 3 times a week for 2 weeks then randomly thereafter. Results of observations will be reported by the Unit Manager (UM)/designee monthly to the Quality Improvement Committee (QIC) for any additional follow-up and or in-servicing until the issue is resolved, then randomly thereafter as determined by the QIC committee. c) Resident #97 The facility failed to provide oxygen via nasal cannula for Resident #97 who was ordered oxygen continuously. On 04/16/25 at 10:25 AM, the state surveyor observed Resident #97 not wearing his oxygen and the concentrator turned off. Resident #97's physician's order stated, Oxygen at 2 L/min via Nasal Cannula continuously. Licensed Practical Nurse (LPN) #60 confirmed the resident was not wearing his oxygen. LPN #60 placed the resident's nasal cannula, turned the oxygen concentrator on, and changed the the liters to two (2) liters per minute from the setting of three (3) liters per minute. LPN #60 stated, It's supposed to be two (2) liters it was three (3) liters. The resident's oxygen saturation level was 96%. 51553

Based on observation, record review and staff interview, the facility failed to ensure orders and interventions were followed to control pain for Residents #42 and #87. This was true for two (2) of six (6) residents reviewed for pain management during the survey process. Resident identifiers: #42, #87. Facility census: 111. The State Agency (SA) determined physical harm was caused to Resident #42 when the facility failed to check on, and assess, Resident #42 for pain, for approximately 50 minutes, despite him yelling out the entire duration, until surveyor intervention. At which time, it was discovered by Licensed Practical Nurse (LPN) #36, Resident #42 was in pain and requested pain medication. Furthermore, physical harm was determined based upon the review of the Medication Administration Record (MAR), orders, and care plan, which revealed the resident had not gotten the correct dose of pain medication, had not received any nonpharmacological interventions for pain as ordered, and was not receiving interventions for pain management that were in place in his care plan. Findings Include: a) Resident #42 Resident #42 received hospice services due to an end stage diagnosis of History of CVA (cerebrovascular accident). Resident #42 has an order for: Morphine Sulfate (Concentrate) Solution 20 MG/ML. Give 10 mg by mouth every two (2) hours as needed for pain/dyspnena. Give 0.50 ML. Hold for Sedation 0.50 ml, every two hours as needed for pain. At approximately 11:30 AM on 4/13/25, during observations in the North hall of the facility, Resident #42 was observed to be yelling out. Review of the resident's record on 04/13/25, revealed indicators for pain were yelling out, restlessness, tenseness. Resident #42 was observed to be yelling out again at approximately 1:30 PM, 2:40 PM, and 3:08 PM. At approximately 9:05 PM on 4/14/25, Resident #42 was heard yelling out in his room. His door was pulled around, almost shut completely, left barely cracked open. This surveyor stood in front of the resident's door until approximately 9:45 PM. No one entered the room to check on the resident during this time period. All three (3) Nurse Aides (NA), #13, #15, #21, assigned to that side of the facility, walked by and Licensed Practical Nurse (LPN) #36 was on the medication cart in the hallway. At approximately 9:45 PM someone could be heard yelling from inside the room, Please help me. Still, no staff member entered the room to check on the resident. At approximately 9:50 PM, this surveyor told LPN #36 Someone in the room is yelling for help. The LPN stated, He's usually confused, but I'll check on him. Upon entering the room, Resident #42 was still yelling out. LPN #36 asked Resident #42 if he was in pain and he indicated he was. She asked him what he needed, and he held up his index finger and thumb, as if he was holding something between them. The nurse asked Do you need your pain medication? Resident #42 indicated he did. LPN #36 administered the pain medication at approximately 9:55 PM. Approximately 20 minutes later, the resident was found to be calmer and yelling out less. LPN #36 was asked what the resident's indicators of pain were. LPN #36 stated his indicators were yelling out, tenseness, and restlessness. LPN confirmed the resident exhibited all symptoms at this time. LPN was asked how the resident communicated pain, to which she stated he was nonverbal and the staff look for things such as yelling out, tenseness, restlessness. LPN #36 stated at this point, the resident should be assessed for pain. Upon review of the resident's Medication Administration Record (MAR) for the month of April 25, on 04/15/25, it was noted zero (0) nonpharmacological interventions for pain management had been implemented, as the entire month, up to 04/15/25 was empty. It was also noted, from the resident's MAR, he was administered morphine at 8:25 PM on 04/13/25 and did not receive it again until 9:52 PM on 4/14/25, going over 24 hours without receiving it. Review of the narcotic sheet on 04/15/25, for the morphine, indicated on 04/9/25 at 8:45 PM, 0.25 ml of morphine was signed out on the log and administered to the resident. 0.25 was signed out and administered at 5:24 AM on 04/10/25. Resident #42 was given half of his ordered dose at this time, as he had an active order for 0.5 ml of Morphine at the time of administration. Progress notes for those days stated the resident was administered 0.5 ml on both occasions, despite the narcotic log stating 0.25 ml was signed out. Upon review of the resident's care plan, the following interventions were noted regarding pain management: Observe for pain. Attempt non-pharmacologic interventions to alleviate pain and document effectiveness. Administer pain medication as ordered and document effectiveness/side effects. Observe for pain and administer as ordered per MD and position for comfort. Resident and HCS will achieve the highest possible level of peace by the time of death as evidenced by alleviated pain and resident exhibited calmness. Assess for pain, restlessness, agitation, constipation and other symptoms of discomfort. Medicate as ordered and evaluate effectiveness. Provide non-pharmacological approaches to aide in decreasing discomfort. Offer non-pharmacologic interventions prior to PRN pain medication administration. Observe for non-verbal signs/symptoms of pain and medicate as ordered. Observe for nonverbal signs of pain: increase in agitation, grimace, resistance to care. During an interview with the Director of Nursing (DON) on 04/16/25 at approximately 4:00 PM, it was confirmed, based on observations and review of the narcotic log and MAR, Resident #42's care plan was not being implemented regarding his pain management. He had received the incorrect dose of morphine (0.25 ml instead of the prescribed 0.5 ml); He did not receive nonpharmacological interventions for pain management as ordered. The DON also confirmed LPN #36 expressed to her Resident #42 was in pain upon the DON's arrival to the facility at approximately 9:50 PM on 04/14/25, as the nurse told the DON she was preparing to administer the resident's morphine. b) Resident #87 A review of Resident #87's medical record on the morning of 04/16/25 found the resident was ordered Hydrocodone 5-325 by mouth every 6 hours for pain, The medication administration record for the month of 03/2025 and the month of 04/2025 along with the controlled substance log coinciding with these month was requested. Upon review of the MAR and the controlled substance log it was found on 04/06/25 at 6:00 PM the medication was initialed as administered but was not signed out on the controlled substance log. This indicated the medication was not administered because it was not removed from the medication card. This same situation occurred again on 04/13/25 for the 6:00 am dose. This was confirmed with Corporate Registered Nurse (CRN) #132 at 5:00 PM at on 04/16/25. 49467

Based on staff interview and record review the facility failed to follow the diet order for a resident on a pureed diet. The wrong texture of diet was provided which resulted in a choking incident for Resident #112. This failed practice was found true for (1) of (3) residents reviewed for diet order accuracy during the survey process. Resident identifiers #112. Facility Census 111. The State Agency (SA) determined this placed the resident in a past non-compliance immediate Jeopardy (IJ) situation. Resident #112 was provided regular texture food, which caused her to choke. The resident late died. The SA called the past noncompliance IJ starting on 08/14/24 and ending on 08/22/24. The facility was notified of the IJ at 2:05 PM on 08/26/24. Findings Include: a) Resident #112 A record review on 08/26/24 at 12:05 PM, found Resident #112 was ordered the following diet: Dysphagia pureed texture, thick liquids-nectar consistency. Further record review revealed a care plan which read as follows: Focus: Resident exhibits or is at risk for impaired swallowing related to Parkinson's disease and diagnosis of dysphagia. Has a history of choking. Goals: Resident will not experience further episodes of choking through the next review. The Resident will be free from signs/symptoms of aspiration through the next review. Interventions: - Dependent with all meals. - Obtain swallow study. - Obtain speech evaluation as ordered. - Provide a regular puree consistency diet as ordered. - Provide nectar consistency liquids as orders; grandson is not compliant with thick liquids. - Encourage small sips/bites and cue as needed. - Monitor for signs/symptoms of aspiration such as coughing, watery eyes, choking, moist sounding voice. Further record review revealed a nurses note which read as follows: Date: 08/14/24 Heard resident coughing. Observed resident with blue lips. Patted back to help dislodge resident, then went to Heimlich maneuver times (3) three with no effects. Registered Nurse (RN) attempted heimlich maneuver to no effect. Yelled for help and Licensed Practical Nurse (LPN) came over along with the RN from the South side. Resident is encouraged to cough with little effect. Nasal cannula applied at (2) litters. Emergency Medical Technician (EMT) arrived at this time to take over. Notified the on call nurse, The Director of Nursing (DON) , Hospice, the doctor, and family. b) Hospital A review of the (local hospital named) record from 08/14/24 to 08/15/24 reads as follows: History of present illness: Patient is an [AGE] year old female with past medical history of dysphagia, dementia, and Parkinson's. Resident on a puree diet who presents to the emergency department by Emergency Medical Services (EMS) for chief complaint of suspected food bolus. Per EMS patient is supposed to be on a pureed diet secondary to dysphagia, dementia, and Parkinson's but at Cedar Ridge nursing home the patient was supposedly given a Pinky nail sized piece of pepperoni per EMS. After she was given the piece of pepperoni she was found to be cyanotic with an oxygen saturation in the low 50's thus EMS was called. Patient presented to the emergency department on 15 Liters (L) non-rebreather and otherwise found to be tachypneic at 22 with appropriate oxygen saturation. Patient is a do not resuscitate (DNR)/ Do not incubate (DNI). Per EMS patient is nonverbal at baseline thus not able to provide a review of symptoms. Attestation statement: (Resident # 112 named) [AGE] year old female seen in conjunction with (Doctor named). Patient presented as discussed above. Patient had declined in respiratory status after possible dysphagia/aspiration concerns. Respiratory status appeared to have some improvement but then appeared to decline again. Medical Power of Attorney (MPOA) contacted who wanted to uphold DNR/DNI aside from potential GI procedure indicated. Immediately after phone discussion patient had further respiratory decline despite non-invasive efforts and went into cardiac arrest. Heimlich maneuver without success. Patient again discussed with MPOA who did want to uphold patients wishes of DNR/DNI status. Patient declared deceased at 1:45AM. c) Facility investigation summary A review of the facilities reporting and investigation on 08/26/24 at 1:30 PM, found the following summary of the 5-day follow-up completed on 08/20/24: On 08/14/24 (Resident #112 named) was seated at the nurses' station with Nursing Assistant (NA) #99, NA was feeding resident snacks when she began choking. LPN on duty was seated behind the nurses station and immediately intervened and began emergency interventions. EMS was called and the resident was transferred to the emergency room for further evaluation. This allegation of neglect was reported to the Office of Health Facilities Licensure and Certification (OHFLAC), Adult Protective Services (APS), the Nurse Aide Registry and the Ombudsman, and an investigation was initiated. NA #99 was suspended pending the results of this investigation. Resident is an [AGE] year old female admitted to Cedar Ridge Center for long-term care services. Resident lacks the capacity to make medical decisions and has a Brief Interview for Mental Status (BIMS) score of (7) seven. She has medical diagnosis of Lewy Body Dementia, Parkinson's Disease, Peripheral Vascular Disease, Dysphagia, Hyperlipidemia, and Anxiety. Resident requires assistance with Activities of Daily Living (ADL) and has a history of falling due to poor safety awareness related to her diagnosis. The alleged perpetrator was interviewed regarding this allegation on 08/15/24. NA #99 stated she was sitting with (Resident #112 named) at the nurses' station on the night of 08/14/24 because she was attempting to get out of bed unassisted. NA #99 stated she gave Resident #112 some pudding, but the resident appeared to still be hungry. She stated after the resident ate her pudding; she gave her a small cup of water (around six ounces) to wash down her pudding. Around 30 minutes later, NA #99 then gave the resident a small piece of pepperoni, about the size of her pinky nail, and shortly after the resident began showing signs of choking. No other staff members working on the night of the event witnessed NA #99 feed Resident #112 the pepperoni. However, NA #99 told staff she did after the resident began choking. When questioned as to why she fed the resident off her prescribed diet, NA #99 stated she thought the resident would enjoy having something to eat different from what she was normally served. The only other food resident received on the night of 08/14/24 was her prescribed supplement and the cream out of an oatmeal cream pie which was the correct consistency for her diet. Resident's prescribed diet was a regular dysphagia diet, puree texture and nectar thick liquids. Upon review of the resident's medical record, the diet order was entered correctly and available for direct care staff to see on her [NAME]. NA #99 had education in her employee file regarding proper techniques assisting with dining/feeding residents and performing relief from choking. Resident #112 was transferred to the emergency room (ER) for further evaluation. According to documentation obtained from the ER, the resident initially presented at the ER with appropriate oxygen saturation. Upon presentation, the resident was without respiratory distress , and appeared to be tolerating oral secretions appropriately. She was moved to a room and had an initial episode of retching/coughing and was found to be desatating on a non-rebreather mask. After the doctor contacted resident's MPOA to confirm her DNR status, and MPOA was agreeable to reversing DNI (do not intubate) status if necessary for GI to provide scope to remove foreign body. The GI department at the hospital failed to return the page, and during this time Resident # 112 became bradycardic and lost her pulse. MPOA was again notified and confirmed DNR status and resident was given morphine for comfort until she expired. The DON/designee conducted an audit on 08/15/24 for all residents to ensure diet orders are correct and accurate and attached to the [NAME] with any corrective action immediately upon discovery. The DON/designee conducted an observation round on 08/15/24 for all residents to ensure the correct diet is being served with any corrective action immediately upon discovery. Re-education was provided by the DON/designee to all staff beginning on 08/15/24 to ensure diet orders are followed and the correct diet is being served. The Unit Managers (UM)/designee will monitor starting on 08/15/24 to ensure diet orders are correct and accurate and attached to the [NAME] and the correct diet is being served. As of 08/22/24 all staff had received their education. This allegation of neglect has been substantiated. NA #99 was terminated as a result of the investigation and the Nurse Aide Registry will be notified. d) Implementation of corrective action Review of NA #99 employment history revealed NA #99 was hired on 04/25/24 and terminated on 08/20/24 at the conclusion of the investigation. All employees working the night of 08/14/24 were interviewed and provided a statement. No one working at the time of the incident saw NA #99 give Resident #112 the pepperoni. However; NA # 99 told staff she fed Resident #112 pepperoni. All employees were provided with an in-service and given a post test. All employees' in-service signatures are accounted for. Inservice high points include: 1. A resident is never to be served a food or beverage item that is not consistent with the resident's prescribed diet. 2. Any staff provides any resident with food or beverage should check [NAME] to ensure snack or food item is consistent with residents prescribed diet. 3. Even if the family is non-compliant with prescribed diet; staff must only serve/food beverages consistent with resident's diet. On 08/26/24 surveyors interviewed the following staff about the in-service and what is the appropriate thing to do when it comes to a resident being served the correct diet: Licensed Practical Nurse (LPN) #20 Housekeeper (HK) #84 Nursing Assistant (NA) # 47 NA #14 All staff interviewed stated they were inserviced on following residents diet and they could find the diet on the [NAME].

Based on observations, resident and staff interviews, the facility failed to ensure Enhanced Barrier Precautions (EBP) were followed for residents with Multidrug-resistant Organisms (MDRO's). Resident identifiers: #12, #17 and #72. Facility census: 110. On 07/18/24 at 3:51 PM an immediate jeopardy (IJ) was called at as this failed practice had the potential to affect all residents residing in the facility. Findings included: a) Resident #12 Resident #12 was admitted on [DATE]. Diagnoses included paraplegic, neurogenic bladder with suprapubic catheter, decubitus ulcers, vascular ulcers both heels, chronic kidney disease, and insulin dependent diabetic. Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/11/24 had a Brief Interview of Mental Status (BIMS) with a score of 15. This indicates intact cognition. The resident had the capacity to make medical decisions. On 07/18/24 at 10:55 AM observed two (2) Nurse Aides (NA's) performing direct resident care of changing urine soaked brief and linens wearing only gloves and no gowns. An EBP sign was on the door. When asked if Resident #12 was on EBP, Registered Nurse (RN) #71 responded I don't know, I will go look, and left the room. On 07/18/24 at 11:00 AM an interview with the NA instructor #25 stated that NA #108 was only there to observe the care being provided. NA #66 stated that she was new and had only been here two (2) weeks. Observed RN #71 and NA #108 reenter room wearing gowns and gloves. An interview with Resident #12 at 11:00 AM on 07/18/24 stated that no staff had worn a gown when providing care. b) Resident #72 An additional interview with Resident #72 on 07/18/24 at approximately 1:00 PM stated that no staff had worn a gown when providing care. Record review revealed a history of ESBL and also currently had a Foley Catheter. c) Resident #17 In reviewing residents who had a Foley and residents were to be on contact precautions, found Resident #17 did have a Foley which was not leaking and initially had an EBP sign on the outside of the door. On 07/18/24 at 11:24 AM an interview with NA #15 stated that the Foley was not leaking and had been changed the day before for Resident #17. An EBP sign was posted on the outside of the door and later changed to contact precautions by the IP on 07/18/24 at approximately 2:26 PM. Resident # 17 had wounds that the drainage could not be contained and had MRSA and ESBL in the wounds and was currently being treated with antibiotics. In addition, 49 residents were on Enhanced Barrier Precautions (EBP) were followed for residents with Multidrug-resistant Organisms (MDRO's) including Methicillin-Resistant Staphylococcus Aureus (MRSA), Carbapenem-resistant Enterobacterales (CRE), Vancomycin-resistant Enterococci (VRE), Extended-spectrumbeta-lactamase (ESBL). c) Resident #72 An interview with Resident #12 at 11:00 AM on 07/18/24 stated that no staff had worn a gown when providing care. An additional interview with Resident #72 on 07/18/24 at approximately 1:00 PM stated that no staff had worn a gown when providing care. Record review revealed a history of ESBL and also currently had a Foley Catheter. An interview with the IP and Corporate RN confirmed the staff had not been using EBP as stated in policy on 07/18/24 at 2:29. The IP stated that she had not been the IP but just a few weeks. On 07/18/24 at 3:51 PM an immediate jeopardy (IJ) was called at F880 at an L as this failed practice had the potential to affect all residents residing in the facility. The Plan of Correction (POC) was received on 07/18/24 at 3:54 PM. After consulting with the State Office the POC was approved and agreed to an abatement on 07/18/24 at 4:17 PM. After the abatement, the L was changed to an F as the failed practice had the potential to affect all residents, staff and visitors. The POC was as follows: The Infection Preventionist (IP) provided education to the nursing staff in (on) Resident #12 regarding the use of EBP during high contact resident care activities on 07/18/24. All residents of the facility have the potential to be affected. The Infection Preventionist/designee conducted an observation round on 07/18/24 to ensure nursing staff is donning Personal Protective Equipment (PPE) for residents who are in enhanced barrier precautions with any corrective action immediately upon delivery. All center staff will be reeducated by the Director of Nursing (DON)/designee on 07/18/24 regarding the facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections including nursing staff is donning appropriate PPE for residents who are in enhanced barrier precautions. A posttest completed to validate understanding. All staff not available during this timeframe will be provided reeducation including posttest by the Director of Nursing (DON)/designee prior to the next scheduled shift. New staff will be provided education and posttest during orientation by the Infection Preventionist (IP)/designee. The DON/designee will conduct an observation round starting on 07/18/24 to ensure nursing staff is donning appropriate PPE for residents who are in enhanced barrier precautions daily across all shifts for 2 weeks, including weekends and holidays, then 5 times a week for 4 weeks then 3 times a week for 4 weeks, the randomly thereafter. Results of monitors will be reported by the Nursing Home Administrator/designee to the Quality Improvement Committee (QIC) monthly for any additional follow-up and or in-servicing until the issue is resolved, then randomly thereafter as determined by the Quality Improvement Committee. A review of the facility policy and procedure titled IC308 Enhanced Barrier Precautions with a revision date of 01/08/24. As of July 2022, the Center Disease Control (CDC) targeted MDRO's are defined as pan-resistant organisms, CRE, CR Pseudomonas, CR Acinetobacter baumaii and Candida auris. Additional MDRO's that might be included based on local requirements: MRSA, ESBL, VRE, MDRO-Pseudomonas aeruginosa and drug resistant Streptococcus pneumoiae. In the procedure section titled Enhanced Barrier Precautions with an effective date of 08/01/23 and revision date of 05/01/24. Enhanced barrier: All residents with any of the following: infection or colonization with a targeted MDRO Chronic wounds and/or indwelling medical devices such as central line, urinary catheter, enteral feeding tube regardless of MDRO colonization status. During high contact resident care activities: providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, central line, urinary catheter, enteral feeding tube . wound care; and skin opening requiring a dressing.

Based on record review and staff interview, the facility failed to ensure four (4) residents were free of significant medication errors. On 07/11/24, the facility reported to the Office of Health Facility Licensure and Certification (OHFLAC), Adult Protective Services (APS), and the Ombudsman that Resident #69, Resident #74, Resident #39, and Resident #108 were administered their 8:00 AM medications twice due to incomplete medication administration documentation. The facility developed and implemented a plan of correction on 07/11/24. The state agency investigated the matter on 07/18/24 and determined on 07/11/24 Resident #69, Resident #74, Resident #39, and Resident #108 were in an Immediate Jeopardy situation due to potential adverse consequences from duplicate medication administration. The stage agency reviewed the facility's plan of correction and documentation and determined the Immediate Jeopardy situation had been abated on 07/14/24 when all education with staff was completed. This was prior to the state agency's investigation which made this past non compliance. Resident identifiers: #69, #74, #39, #108. Facility census: 110. Findings included: a) Facility-reported incident and Plan of Correction On 07/11/24, the facility reported to the Office of Health Facility Licensure and Certification (OHFLAC), Adult Protective Services (APS), and the Ombudsman that Resident #69, Resident #74, Resident #39, and Resident #108 were administered their 8:00 AM medications twice due to incomplete medication administration documentation. Both nurses involved were removed from direct care at the time of the allegation and an investigation was initiated. Poison Control was contacted regarding all four (4) residents. Poison Control recommended emergency room evaluation for Resident #39 and Resident #108. Poison control recommended frequent monitoring in the facility for Resident #69 and Resident #74. The facility's plan of correction initiated 07/11/24 was as follows: The licensed nurse conducted a change in condition on 07/11/24 with notification to the medical provider for all four (4) residents who received duplicate medication. The Nurse Practice Educator conducted an audit on 07/11/24 of all licensed nurses' medication administration competencies to ensure all licensed nurses are competent with medication administration within the last 12 months with any correction action immediately upon discovery. The Unit Managers/designee conducted an audit on 07/11/24 for all residents' medication administration records for July 2024 to ensure free from medication errors with any corrective action immediately upon discovery. Re-education was provided by the Director of Nursing (DON)/Designee to all licensed nurses starting on 7/11/24 on safe medication administration practices including verification of correct, patient, drug, route, dose, time, special consideration, and expiration date with a Post-test to validate understanding. Any licensed nurses not available during this time frame will be provided re-education, including post-test and return demonstration by DON/designee prior to the beginning of the next shift to work. New Licensed nurses will be provided education, including post-test during orientation by the DON/designee. Annual in-servicing will be provided to licensed nurses regarding medication administration. The Unit Managers (UM)/Designee will conduct observations starting on 7/12/24 to ensure all licensed nurses are passing medications according to Genesis medication administration policies including verification of right patient, drug, route, dose, time, special considerations, and expiration dates across all shifts for 2 weeks including weekends and holidays, then 5 times a week for 4 weeks, then 3 times a week for 4 weeks, then randomly thereafter. Results of observations will be reported by the Unit Manager (UM)/designee monthly to the Quality Improvement Committee (QIC) for any additional follow-up and or in-servicing until the issue is resolved, then randomly thereafter as determined by the QIC committee. The facility submitted a five (5) day follow-up investigation on 07/16/24 which verified the allegation. The five (5) day follow-up investigation contained the following additional information: Witness statements were obtained and interviews were conducted with the licensed nurses on duty at the time of the med error. It has been determined that LPN [#106] was not familiar with the unit in which she was passing medications, and was unaware there was a 6:00 AM med pass. LPN [#106] was attempting to pass the medications for the 8:00 AM med pass, and when the computer gave her an error message, she proceeded to pre-pull 8:00 AM medications, not realizing that she failed to change the shift time on her MAR to the correct med pass time. This allegation of neglect will be substantiated and reported to the [NAME] Virginia State Board of Examiners for Licensed Practical Nurses. Prior to her return to work, LPN [#106] will receive education on safe administration practices including verification of correct patient, drug, route, dose, time, special considerations, and expiration date with a Post-test to validate understanding. LPN [#106] will receive seven supervised medication passes and be subjected to random monitoring during medication pass. The facility's inservices regarding medication administration and shift reporting were reviewed. The inservice information, sign-in sheets, and post-tests were reviewed. Medications audits performed by the Unit Managers and Director of Nursing were reviewed. Medication administration was observed on the morning of 07/18/24. The nurses performing medication administration, Licensed Practical Nurse (LPN) #28, LPN #62, LPN #42, and LPN #55, were able to correctly answer questions regarding medication administration and documentation. b) Policy and Procedure The facility's policy titled Medication Administration General Guidelines dated January 2024 gave the following procedures: - Medications were to be administered within 60 minutes of scheduled time - The individual who administered the medication dose was to record the administration on the resident's Medication Administration Record (MAR) immediately following the medication being given. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications. c) Resident #69 Resident #69 was a [AGE] year-old man who has resided in the facility since 2022. He did not have capacity to make medical decisions and an Adult Protective Services worker was appointed as his Health Care Representative. According to the resident's Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 05/29/24, the resident's Brief Interview for Mental Status (BIMS) score was 9, indicating moderate cognitive decline. The resident had diagnoses of dementia, personality disorder, anxiety disorder, depression, alcohol abuse, congestive heart failure, atrial fibrillation, hyperglycemia, hypertension, and peripheral vascular disease. The following progress note was written by Licensed Practical Nurse (LPN) #105 for Resident #69 on 7/11/2024 at 8:36 AM: This nurse was passing 0800 meds and entered another resident room, resident states she already took 0800 meds. This nurse went to [LPN #106] to ask if she passed 0800 meds to some residents. [LPN #106] states she gave some 0800 meds but is unsure of what [Registered Nurse (RN) #43] gave. This nurse notified [LPN #40], [RN #47]. [LPN #40] is to tell [Nurse Practitioner (NP) #104]. The following late entry note was written by the Director of Nursing (DON) on 7/11/2024 at 11:28AM: Resident received duplicate dosing of a.m. medication; provider notified; poison control consulted; order noted to obtain blood pressure q 1 hour x 4; Resident blood pressures obtained per order; po fluids encouraged and consumed. RP [resident representative] notified of medication error and plan of care. According to the resident's Medication Administration Record (MAR), Resident #69 was scheduled to receive the following medications daily at 8:00 AM: - Amlodipine 5 mg, one (1) time a day for hypertension - Aspirin 81 mg, one time a day for hyperlipidemia - Divalproex sodium, extended-release, 500 mg, one time a day for personality disorder - Eliquis (apixaban) 5 mg, two (2) times a day for atrial fibrillation - Metoprolol extended release, 100 mg, one (1) time a day for hypertension - Seroquel (quetiapine) 25 mg, one (1) time a day for depression Of these medications, the following could have adverse consequences with over dosages: - Amlodipine, which could cause hypotension. - Metoprolol, which could cause hypotension, bradycardia, bronchospasm, and cardiac failure. - Seroquel, which could cause slowed tachycardia, hypotension, heart block, arrhythmias, and drowsiness or sedation. - Eliquis, which could cause risk of bleeding. - Divalproex, which could cause coma, heart block, and somnolence. (Source: medication product label, available on-line from the Food and Drug Administration at www.accessdata.fda.gov.) The following note was written by Nurse Practitioner # 104 on 7/12/2024 at 5:50 PM, [AGE] year-old male with history of dementia, anxiety, depression, personality disorder, chronic systolic heart failure, A-fib [atrial fibrillation], COPD [chronic obstructive pulmonary disease], hyperlipidemia and alcohol abuse. Patient being seen today for follow-up. Per nursing patient received his a.m. medication twice on 7/11/2024 this included aspirin, Seroquel, divalproex sodium, amlodipine and metoprolol. Poison control was notified and gave recommendations to monitor patient in house including vital signs every hour x 4. Patient resting in bed this a.m. He is alert and appropriate. Denies complaints of dizziness, weakness, vertigo, shortness of breath or chest pain. Patient is stable. He has resumed his current medications. On 07/11/24 at 8:27 AM, the resident's blood pressure was 114/66. The resident's blood pressure was monitored hourly for four (4) hours and frequently after that. The resident's blood pressure stayed within normal range. The top number of the blood pressure (systolic) remained over 100. The bottom number of the blood pressure (diastolic) remained over 60. The resident had skilled nursing evaluations performed on 07/12/24, 07/13/24, 07/14/24, and 07/15/24. The resident had no change in vital signs or mental status following the medication error. Resident #69 was interviewed on 07/15/24 at 10:56 AM. He had no complaints about the facility. When specifically asked about medications, the resident had no complaints. d) Resident #74 Resident #74 was a [AGE] year-old who had resided in the facility since 2015. The resident did not have the capacity to make decisions and a family member was the health care surrogate. The resident had diagnoses of dementia, chronic obstructive pulmonary disease, convulsions, cerebrovascular disease, traumatic hemorrhage of cerebrum, hemiplegia/hemiparesis, bipolar affective disease, and anxiety disorder. According to the resident's Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 06/11/24, the resident's Brief Interview for Mental Status (BIMS) score was 4, indicating severe cognitive decline. On 07/11/24 at 10:09 AM, an SBAR (Situation, Background, Assessment, and Recommendation) summary for providers was completed for Resident #74. The summary stated, Resident was given a duplicate dose of 8 am medications. Nurse called poison control and DON to make aware of the situation Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: Poison control was notified and recommended that patient was stable to monitor at this time. [NP #104] was notified and agreed to monitor resident and not needed to send out at this time. According to the resident's Medication Administration Record (MAR), Resident #74 was scheduled to receive the following medications daily at 8:00 AM: - Acetaminophen, 325 mg, two (2) tablets, every six (6) hours for pain and discomfort - Metamucil fiber, one (1) packet, one time a day for constipation - Paroxetine, 10 mg, one (1) time a day for depression - Potassium chloride, 10 mg, one time a day for hypokalemia - Risperdal (risperidone) 0.5 mg, two (2) times a day for Bipolar - Umeclidinium bromide inhalation, one (1) puff, one (1) time a day for chronic obstructive pulmonary disease - Vitamin D3, 400 units, one (1) time a day for hypovitaminosis D Of these medications, the following could have adverse consequences with over dosages: - Paroxetine, which could cause somnolence, coma, nausea and vomiting, tremor, tachycardia, and confusion. - Potassium chloride, which could cause elevated potassium levels. - Risperdal, which could cause drowsiness or sedation, tachycardia, and hypotension. (Source: medication product label, available on-line from the Food and Drug Administration at www.accessdata.fda.gov.) On 07/12/24 at 6:11 PM, NP #104 wrote the following note: [AGE] year-old male with history of COPD, CVA [cerebral vascular accident], dementia and bipolar disorder. Patient being seen today for follow-up visit. Per nursing patient received his a.m. meds twice yesterday including paroxetine, Risperdal, potassium chloride, and Metamucil. Poison control was notified and patient was monitored in house. Patient resting in bed this a.m. he is alert to person. No acute distress noted. Poor historian due to advanced dementia. The resident had skilled nursing evaluations performed on 07/12/24, 07/13/24, 07/14/24, and 07/15/24. The resident had no change in vital signs or mental status following the medication error. The resident was observed on 07/15/24 at 11:20 AM but was not interviewable. e) Resident #39 Resident #39 was an [AGE] year-old admitted in February 2023. The resident did not have capacity to make decisions due to intracranial hemorrhage and cognitive impairment. A family member was the health care surrogate. According to the resident's Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 05/24/24, the resident's Brief Interview for Mental Status (BIMS) score was 13, indicating the resident was cognitively intact. In addition to intracranial hemorrhage, the resident had diagnoses of major depressive disorder, breast cancer, hypertension, and hyperlipidemia. On 07/11/24 at 8:40 AM, an SBAR summary for providers was completed for Resident #39. The summary stated, Resident was given a double dose of her medications. Poison control called. Sending out to ER for evaluation. According to the resident's MAR, the resident was scheduled to receive the following medications daily at 8:00 AM: - amlodipine besylate, 10 mg, one (1) time a day for hypertension - dicyclomine hydrochloride, 10 mg, twice a day for irritable bowel syndrome - exemestane 25 mg, one (1) time a day for breast cancer - letrozole, 2.5 mg, one (1) time a day for breast cancer - propranolol 20 mg, two (2) times a day for hypertension - Wellbutrin (bupropion) 100 mg, one (1) time a day for depression The poison control center provided a toxic substance review to the hospital emergency room . The review stated amlodipine had a low margin for safety and double doses could cause toxicity in patient on multiple cardiac drugs or with brittle cardiac status. Life threatening hypotension (low blood pressure) could occur. Heart block and bradycardia (slow heart rate) were common. Atrioventricular dissociation (a condition in which the atria and the ventricles operate independently from each other) could persist for nine (9) to 48 hours. Pulmonary edema, drowsiness, confusion, and nausea and vomiting could also occur. According to the toxic review, an established toxic dose for bupropion was not established. The following conditions could occur with bupropion overdose: seizures, tremors, agitation, excitement, confusion, tachycardia (increased heart rate), and acute psychotic reactions, including visual hallucinations. Cardiovascular collapse and cardiac arrest could occur with massive overdoses. As for anticholinergics (dicyclomine) the toxic review stated specified toxic doses had not been established. Drowsiness and tachycardia could occur. The toxic review stated beta-blocking agents (propranolol) could cause hypotension (low blood pressure), bradycardia, seizures, and cardiac dysrhythmias. Cardiac conduction disturbances and cardiovascular shock could occur with severe toxicity. The toxic review also stated the amounts of exemestane and Letrozole ingested by the resident were well below toxic range and significant effects were not expected. According to the emergency room records, the resident reported dizziness. Laboratory testing was within normal limits. The resident was discharged to return to the facility on [DATE] at 2:22 PM. The resident had no changes in vital signs or mental status upon return to the facility. On 07/12/24 at 5:34 PM, NP #104 wrote the following note: [AGE] year-old female with history of major depressive disorder, IBS, hypertension, hyperlipidemia, hypothyroidism, nontraumatic intracranial hemorrhage, cerebral edema, and personal history of malignant neoplasm of the breast. Patient being seen today follow-up for ER [emergency room ] visit. Patient was sent to [hospital name] 7/11/2024 for medical screening at poison control's recommendation due to accidental drug overdose. Per nursing patient received double her morning meds including: Amlodipine, dicyclomine, letrozole, propranolol, Wellbutrin, and exemestane. Patient sitting up in wheelchair this afternoon. She just returned from having a cataract removed from her left eye. She is alert and oriented. She has no acute complaints of pain or discomfort at this time. The resident had skilled nursing evaluations performed on 07/12/24, 07/13/24, 07/14/24, and 07/15/24. Resident #39 was interviewed on 07/15/24 at 11:30 AM. When asked if she had any problems with the care she received, the resident stated she was given her pills twice on Friday morning. She stated she had to go to the emergency room for evaluation. The resident stated, But I was okay .Those kinds of things happen. f) Resident #108 Resident #108 was a [AGE] year-old who was admitted [DATE]. The resident did not have the capacity to make medical decisions due to cognitive impairment. A family member was health care surrogate for the resident. According to the resident's Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 07/02/24, the resident's Brief Interview for Mental Status (BIMS) score was 15, indicating the resident was cognitively intact. The resident had diagnoses of congestive heart failure, atherosclerotic heart disease, Parkinson's Disease, general anxiety disorder, major depressive disorder, and hypertension. On 07/11/24 at 7:00 AM, an SBAR summary for providers was completed for Resident #108. The summary stated, 0800 medications given twice by two separate nurses. poison control notified, physician notified. orders to send resident to ER for evaluation. Resident #108's blood pressure was 91/58 at 7:30 AM on 07/11/24. The resident's most recent recorded blood pressure was 134/78 on 06/04/24. According to Emergency Medical Services (EMS) records, Resident #108 reported feeling tired and dizzy. His blood pressure was noted to be 95-100 systolic, which EMS notes is lower than the resident's baseline blood pressure. The Emergency Medical Technicians inserted an intravenous catheter and began normal saline infusion to increase his blood pressure. According to the resident's Medication Administration Record (MAR), Resident #108 was scheduled to receive the following medications daily at 8:00 AM: - Acetaminophen, 325 mg, two (2) tablets, four (4) times a day for pain - Aspirin, 81 mg, one (1) time a day for coronary artery disease - Carbidopa-Levodopa extended release, 50-200 mg, five (5) times a day for Parkinson's Disease - Carbidopa-Levodopa 25-100 mg, four (4) times a day for Parkinson's Disease - Furosemide 20 mg, one (1) time a day for edema - Isosorbide extended-release tablet, 30 mg, one (1) time a day for hypertension - Paroxetine, 20 mg, one (1) time a day for depression/anxiety - Plavix (clopidogrel) 75 mg, one (1) time a day for coronary artery disease - Sennosides, 8.6 mg, two (2) tablets, one (1) time a day for constipation - Tizanidine, 2 mg, three (3) times a day for muscle relaxant Of these medications, the following could have adverse consequences with over dosages: - Paroxetine, which could cause somulence, coma, nausea and vomiting, tremor, tachycardia, and confusion. - Carbidopa-Levodopa, which could cause heart arrhythmias. - Furosemide, which could cause dehydration, hypotension, and electrolyte imbalances. - Isosorbide, which could cause hypotension, nausea and vomiting, syncope, bradycardia, heart block, coma, and seizures. - Plavix, which could cause increased breathing. - Tizanidine, which could cause hypotension, bradycardia, coma, somnolence, confusion, and respiratory depression. (Source: medication product label, available on-line from the Food and Drug Administration at www.accessdata.fda.gov.) Laboratory testing at the hospital was within normal limits. The resident returned to the facility on [DATE] at 1:57 PM. On 07/12/24 at 5:06 PM, NP #104 wrote the following note: [AGE] year-old male with history of chronic diastolic heart failure, arteriosclerotic heart disease, Parkinson's disease, hypertension and hypothyroidism. Patient being seen today to follow-upfor ER visit. Patient was sent to the ER yesterday 7/11/2024 at [hospital name] for evaluation due to accidental medical overdose after Poison control was consulted and made recommendation. Per nursing patient was given his a.m. medicine x 2 including Zanaflex, Sinemet and isosorbide. Patient was seen and evaluated in ED [emergency department] and later sent back to facility. Patient sitting up in activity room this a.m. He is alert to person/place. Appears at baseline. Patient's vital signs have been monitored. And his regular medication regimen has resumed. The resident had skilled nursing evaluations performed on 07/12/24, 07/13/24, 07/14/24, and 07/15/24. Resident #108 was interviewed on 07/22/24 at 9:45 AM. He had no complaints about the facility. When specifically asked about medications, the resident had no complaints. He acknowledged that he had been evaluated in the emergency room but was unable to provide any additional information about the emergency room visit. g) Staff Interview The Director of Nursing and Administrator were interviewed on 07/15/24 at 3:00 PM. They stated the nurse had given the 8:00 AM medications during the 6:00 AM medications administration pass and had not signed them out as given. Additionally, the nurse had been pulled to another area of the facility and, therefore, had not given report to the on-coming nurse to let her know that medications had been given. The DON stated the nurse had not returned to the facility during the investigation of the incident. If the nurse is permitted to return to the facility after the investigation has concluded, the nurse will have an improvement plan with preceptorship in place. At the time of the Facility Reported Incident investigation on 07/15/24. All staff had been re-educated before their next shift after the incident. Education had begun on 07/11/24 and was completed on 07/14/24.

Based on record review, observations, resident interview, and staff interview, the facility failed to ensure six (6) of twelve (12) residents who were ordered sliding scale insulin received the necessary care and services to maintain their highest practicable physical well-being. For Resident #5, the facility failed to notify the attending physician when the resident's blood sugar was greater than 400 on multiple occasions as directed by the physician's order. Also, Resident #5 was given the incorrect amount of sliding scale insulin based on her blood sugar readings. Furthermore, there was no evidence Resident #5's scheduled insulin was administered as ordered on multiple days with no documented reason why the medication was not given. For Resident #102 the facility failed to notify the physician when Resident #102's blood sugar was greater than 400 on one (1) occasion in (MONTH) of (YEAR). Furthermore, the Medication Administration Record (MAR) had multiple blank spaces in (MONTH) (YEAR) and (MONTH) (YEAR) indicating Resident #102 did not receive his insulin on those dates and at those times. Resident #93 received the wrong dose of sliding scale insulin on five (5) separate occasions since her admission on 09/20/18. Additionally, her MAR was blank indicating she did not get her scheduled insulin on three (3) occasions and on one (1) occasion the MAR was blank indicating she did not get Sliding Scale Insulin Coverage. For Resident #61, the facility failed to notify the physician when Resident #61's blood sugars were greater than 400 on multiple occasions. Also, Resident #61 received the incorrect dosage of sliding scale insulin based on the blood sugar readings. For Resident #12, the facility failed to administer her sliding scale insulin in accordance with the physician's orders on four (4) occasions. For Resident #18, the facility failed to administer his sliding scale insulin in accordance with the physician's orders on multiple occasions. The survey team determined the failure to administer insulins as ordered, and failure to notify residents' physician of high blood sugars as ordered, placed Residents #5, #102, #93, #61, #12 and #18 at immediate risk for serious harm and/or death. The State agency was contacted and agreed that these failures posed an immediate jeopardy (IJ). The facility was notified of the IJ at 2:04 p.m. on 10/04/18. The facility provided a Plan of Correction (P[NAME]) at 4:08 p.m. on 10/04/18 and it was accepted by the State agency at 4:14 p.m. on 10/04/18. The immediacy was removed and the IJ was abated at 5:30 p.m. on 10/04/18 after the survey team observed for implementation of the P[NAME]. Once the IJ was abated and the immediacy removed, deficient practices remained at a scope and severity of E. For Residents #37, #79, and #124, the facility failed to ensure medications were administered to these residents according to the physician orders. The facility failed to administer medications in accordance with physician's orders for Resident #106. Additionally, the facility failed to correctly transcribe the medication duration and parameters specified in the physician's orders onto the Medication Administration Record (MAR) and to ensure the required laboratory testing was being performed to monitor the parameters. The facility failed to ensure peripheral blood glucose testing was performed or documented on several occasions during the month of (MONTH) for Residents #18, #21 and #12. Also, for Resident #18, the facility failed to obtain laboratory testing and to discontinue peripheral blood glucose monitoring as ordered by the physician. Residents #108 and #91 did not have intravenous medications and solutions dated, timed and nurses' initials to indicate when administered. Also for Resident #91, her was antibiotic discontinued without a physician's order and she was not assessed timely for a change in condition. Resident Identifiers: #5, #102, #93, #61, #18, #12, #37, #79, #24, #108, #91, #106 and #21. Facility Census: 114. Findings include: a) Resident #5 A review of Resident #5's medical record beginning at 9:00 a.m. on 10/04/18 found the record contained the following physician orders for insulin: -- Humalog Solution Inject per sliding scale if: - 150 - 200 = 2 units: - 201- 250 = 4 units: - 251- 300 = 6 units: - 301- 350 = 8 units; - 351- 400 = 10 units - notify physician if less than 60 or greater than 400. Subcutaneously four times a day related to Type 2 diabetes mellitus (DM) without complications. This was ordered on [DATE] and was discontinued on 08/17/18. -- [MEDICATION NAME] Solution Inject per sliding scale if: - 150 - 200 = 2 units: - 201- 250 = 4 units: - 251- 300 = 6 units: - 301- 350 = 8 units; - 351- 400 = 10 units - notify physician if less than 60 or greater than 400. Subcutaneously four times a day related to Type 2 diabetes mellitus (DM) without complications. This was ordered on [DATE] and was an active order at the time of this review. -- [MEDICATION NAME] Solution Inject 15 units subcutaneously one time a day related to Type 2 DM without complications. This was ordered on [DATE] and was discontinued on 08/20/18. -- [MEDICATION NAME] Solution Inject 20 units subcutaneously one time a day related to Type 2 DM without complications. This was ordered on [DATE] and discontinued on 08/22/18. -- [MEDICATION NAME] Solution Inject 25 units subcutaneously one time a day related to Type 2 DM without complications. This was ordered on [DATE] and was an active order at the time of this review. A review of the medication administration record (MAR) from 08/01/18 through present found the following occasions when Resident #5's blood sugar was greater than 400 and there was no evidence the physician was notified: -- On 08/18/18, blood sugar was 415 at 11:00 a.m. -- On 08/19/18, blood sugar was 412 at 8:00 p.m. -- On 09/02/18, blood sugar was 487 at 7:00 a.m. -- On 09/03/18, blood sugar was 433 at 9:00 p.m. -- On 09/15/18, blood sugar was 457 at 11:00 a.m. The record was void of any documentation indicating the physician was notified of these blood sugars being greater than 400 as directed by the physician order. Further review of the MAR from 08/01/18 through present found on 09/04/18 at 7:00 a.m. Resident #5's blood sugar was recorded as 352. The resident received 8 units of [MEDICATION NAME], but based on the blood sugar and the sliding scale order, the resident should have received 10 units of [MEDICATION NAME]. Resident #5 also had no blood sugar reading documented on 09/13/18 and 09/14/18 at 9:00 p.m., but she was administered 6 units of [MEDICATION NAME]on both occasions. A final review of the MAR for the Month of (MONTH) (YEAR) found that on 09/27/18 through 09/30/18 Resident #5 was not administered her [MEDICATION NAME] 25 units at 9:00 a.m. The nurses initialed the MAR and circled their initials on each day, but did not provide a rationale as to why the medications was not administered. During an interview with Registered Nurse (RN) #61 at 9:30 a.m. on 10/04/18, these findings were reviewed. She agreed the was no physician notification for the identified dates. She also confirmed Resident #5 received the incorrect dose of insulin on 09/04/18 and that there were no blood sugars documented on 09/13/18 and 09/14/18 at 9:00 p.m., so it could not be determined if the correct dose of insulin was administered. RN #61 was unable to provide any additional information as to why Resident #5 did not receive her scheduled dose of [MEDICATION NAME] on 09/27/18, 09/28/18, 09/29/18 and 09/30/18. She indicated nurses should document the reason on the back of the MAR, but they had not, so she did not know why the resident did not get her insulin. b) Resident #102 A review of Resident #102's medical record at 11:00 a.m. on 10/04/18 found the following physician orders for insulin: -- Basaglar kwikpen Solution Pen Injector Inject 70 unit subcutaneously two times a day related to Type 2 DM without complications. This was an active order at the time of this review. -- Humalog Solution Inject as per sliding scale if: - 01-150 = 0 units. - Call MD (medical doctor) if blood glucose is less than 70; - 151 - 200 = 2 units; - 201 - 250 = 4 units; - 251 - 300 = 6 units; - 301- 350 = 8 units; - 351 + = 10 units. - Call MD immediately for further instruction if blood glucose is greater than 400. - Subcutaneously three times a day related to Type 2 DM without complications. This was an active order at the time of this review. A review of the MAR from 08/01/18 through present found on 08/17/18, Resident #102's blood sugar was 409 and there was no indication in the resident's medical record that the physician was notified of his elevated blood sugars. Further review of Resident #102's medical record found on the following dates Resident 102's MAR was blank, indicating he did not receive, nor was he evaluated for the need, of his sliding scale insulin coverage on: -- 08/08/18 at 6:00 a.m. -- 08/11/18 at 11:00 a.m. and 4:00 p.m. -- 09/06/18 at 6:00 a.m. -- 09/10/18 at 4:00 p.m. -- 09/25/18 at 11:00 a.m. and 4:00 p.m. An interview with RN #61 at 12:07 p.m. on 10/04/18 confirmed that on 08/17/18, Resident #102's blood sugar was above 400 and there was no indication the physician was notified. She also confirmed if the MAR was blank that would indicate the medication was not administered as ordered. c) Resident #93 A review of Resident #93's medical record at 11:30 a.m. on 10/04/18 found she was admitted to the facility on [DATE] and had current physician orders for Insulin: -- [MEDICATION NAME] Insulin inject per sliding scale - 0-140 = 0 units; - 141 - 170 = 2 units, - 171 - 200 = 4 units; - 201- 230 = 6 units; - 231- 260=8 units; - 261- 290 = 10 units; - 291- 320 = 12 units; 321-350 =14 units. - Call MD if less than 70 and greater than 350. This was ordered on admission 09/20/18 and was active at the time of this review. -- [MEDICATION NAME] Give 40 units overnight at 9:00 p.m. was ordered at the time of the resident's admission on 09/20/18 and was active at the time of this review. Review of Resident #93's MAR since her admission found she received the wrong dose of sliding scale insulin on the following dates: -- 09/27/18 at 11:00 a.m. - Resident #93's blood sugar was 145 and she received zero (0) units of insulin when she should have received two (2) units. -- 09/28/18 at 9:00 p.m. - Resident #93's blood sugar was 184 and she received six (6) units of insulin when she should have received four (4) units of insulin. -- 09/29/18 at 7:00 a.m. - Resident #93's blood sugar was 213 and she received eight (8) units of insulin when she should have received six (6) units of insulin. -- 10/01/18 at 9:00 p.m. - Resident #93's blood sugar was 201 and she received four (4) units of insulin when she should have received six (6) units of insulin. -- 10/02/18 at 9:00 p.m. - Resident #93's blood sugar was 210 and she received four (4) units of insulin when she should have received six (6) units of insulin. Further review of the MARs found on the following dates and times the MAR was blank indicating Resident #93 did not receive her scheduled or sliding scale insulin as ordered: [MEDICATION NAME] scheduled at 9:00 p.m. was blank on the following days: -- 09/26/18 -- 09/27/18 -- 09/30/18 [MEDICATION NAME] Sliding Scale Coverage before meals and at bedtime MAR was blank on the following date and time: -- 09/27/18 at 7:00 a.m. An interview with RN #5 at 11:46 a.m. on 10/04/18 confirmed Resident #93 received the incorrect dosage of insulin on the identified dates and times. RN #5 also confirmed that if the MAR was blank, that would indicate the medication was not given. d) Resident #61 Record review found the resident was admitted to the facility on [DATE]. Review of the (MONTH) (YEAR) medication administration record (MAR) found an order for [REDACTED].>[MEDICATION NAME] solution, 100 units (insulin [MEDICATION NAME]), inject as per sliding scale: if blood sugar reading is: - 0-150 give 0 units, - 151-200 give 2 units - 201-250 give 4 units - 251-300 give 6 units - 301-350 give 8 units - 351-400 give 10 units - greater than 400 notify the physician. Subcutaneous 2 times a day related to Type 2 diabetes Mellitus without complications. The start date was 06/05/18. At 11:09 AM on 10/04/18, Register Nurse (RN) #61 reviewed the MAR's for July, August, and (MONTH) (YEAR). RN #61 verified the following: -- (MONTH) (YEAR) - The resident's blood sugar (BS) reading was 354 at 9:00 PM on 07/02/18. The resident received 8 units of insulin instead of 10 as directed by the order. - On 07/11/18, the resident BS was 328 at 9:00 PM. The resident received 10 units of insulin, instead of 8 units as directed by the physician's order. - On 07/17/18 at 9:00 PM, the resident's BS was 420. The resident received 10 units of insulin, but the physician was not contacted as directed by the order. -- (MONTH) (YEAR) - On 08/25/18, the resident's BS was 440 at 9:00 PM. The resident received 10 units of insulin as directed, but the physician was not contacted as directed by the order. - On 08/29/18, RN #61 said the resident's BS was over 400 at 9:00 PM and the physician was not contacted. - On 08/31/18, the resident's BS was over 400 at 9:00 PM and the physician was not contacted. - (MONTH) (YEAR) The resident was readmitted to the facility on [DATE]. A new order for the [MEDICATION NAME]was written: [MEDICATION NAME]SQ per sliding scale, ACHS (before meals and at the hour of sleep) - 0-150 give 0 units, - 151-200 give 2 units - 201-250 give 4 units - 251-300 give 6 units - 301-350 give 8 units - 351-400 give 10 units and notify MD (physician) -- 09/07/18 the resident's blood sugar was 400. The resident received 10 units of insulin. The physician was not contacted as ordered. -- RN #61 verified the resident did not received the sliding scale insulin according to physician's orders at 11:30 AM on 10/04/18. RN #61 did not provide any further information to refute the identified issues on the resident's MAR. e) Resident #18 Resident #18 had an order for [REDACTED]. [MEDICATION NAME]injections were ordered as follows: - If blood glucose was between 141-170, give 1 unit; - If blood glucose was between 171-200, give 2 units; - If blood glucose was between 201-230, give 3 units; - If blood glucose was between 231-260, give 4 units; - If blood glucose was between 261-290, give 5 units; - If blood glucose was between 291-320, give 6 units; and - If blood glucose was between 321-340, give 7 units. According to the Medication Administration Record (MAR) for (MONTH) (YEAR), on ten (10) occurrences, the amount of insulin administered differed from the amount ordered on the insulin sliding scale. On the following dates and times, there was no documentation of insulin injections administered on the resident's MAR, although the insulin sliding scale ordered 1 unit: - 09/07/18 at 4:00 PM, for blood glucose of 150; - 09/08/18 at 8:00 PM, for blood glucose of 148; - 09/20/18 at 8:00 PM, for blood glucose of 149; - 09/21/18 at 11:00 AM, for blood glucose of 142; - 09/21/18 at 8:00 PM, for blood glucose of 147; - 09/22/18 at 8:00 PM, for blood glucose of 144; - 09/23/18 at 8:00 PM, for blood glucose of 152; and - 09/27/18 at 8:00 PM, for blood glucose of 148. -- On 09/03/18 at 8:00 PM, according to the MAR, 6 units of insulin were given for blood glucose of 200, although the insulin sliding scale ordered 2 units. -- On 09/14/18 at 8:00 PM, 2 units of insulin were documented on the MAR as given for a blood glucose of 164, although the insulin sliding scale ordered 1 unit. During an interview on 10/04/18 at 12:35 PM, Unit Manager (UM) #5 was notified of these findings when the amount of insulin administered to Resident #18 differed from the amount of insulin ordered on the insulin sliding scale. UM #5 stated Resident #18 sometimes declined insulin. However, she acknowledged the MAR did not indicate refusals for any of these dates and times. During an interview on 10/08/18 at 11:00 AM, the Clinical Quality Specialist was informed about these findings. She had no additional information regarding the matter. f) Resident #12 Resident #12 had an order for [REDACTED]. Novalog insulin injections per sliding scale were ordered as follows: - If blood glucose was between 70-150, no insulin was to be given; - If blood glucose was between 151-200, give 2 units; - If blood glucose was between 201-250, give 4 units; - If blood glucose was between 251-300, give 6 units; - If blood glucose was between 300-350, give 8 units; - If blood glucose was between 351-400, give 10 units; and - If blood glucose was greater than 400, give 12 units. Review of the resident's MAR for (MONTH) (YEAR) identified the following issues: - On (MONTH) 19, (YEAR) at 9:00 PM, Resident #12's blood glucose was 400. No insulin was documented as given. - On (MONTH) 21, (YEAR) at 9:00 PM, Resident #12's blood glucose was 376. Eight (8) units of insulin were documented as given. The insulin sliding scale ordered 10 units of insulin for a blood glucose between 351-400. - On (MONTH) 24, (YEAR) at 9:00 PM, Resident #12's blood glucose was 374. Eight (8) units of insulin were documented as given. The insulin sliding scale ordered 10 units of insulin for a blood glucose between 351-400. - On (MONTH) 28, (YEAR) at 9:00 PM, Resident #12's blood glucose was 319. No insulin was documented as given. However, 8 units of insulin was documented as given on 09/29/18, although a blood glucose level was not documented. During an interview on 10/04/18 at 12:35 PM, Unit Manager (UM) #5 was notified of these findings. UM #5 stated the 8 units of insulin documented on 09/29/18 may have been administered on 09/28/18 and documented on the wrong day. During an interview on 10/08/18 at 11:00 AM, the Clinical Quality Specialist was informed about these findings. She had no additional information regarding the matter. g) The survey team determined these failures placed Residents #5, #102, #93, #61, #12, and #18 at immediate risk for serious harm and/or death. The State agency was contacted and agreed these failures posed an immediate jeopardy (IJ) to the health and well-being of the residents. The facility was notified of the IJ at 2:04 p.m. on 10/04/18. The facility provided a Plan of Correction (P[NAME]) at 4:08 p.m. on 10/04/18 and it was accepted by the State agency at 4:14 p.m. on 10/04/18. The immediacy was removed and the IJ was abated at 5:30 p.m. on 10/04/18 after the survey team observed for implementation of the P[NAME]. h) Facility's Plan of Correction The facility submitted the following plan of correction in regards to the IJ called on 10/04/18 at 2:94 p.m.: On (MONTH) 4, (YEAR) the Medical Director and Director of Nursing implemented the following plan: 1. Residents who are insulin dependent were reassessed by the Nurses Practitioner/designee with findings reported to the Medical Director for additional interventions upon discovery. Residents have not experienced any negative outcomes. 2. All residents of the facility who receive insulin with coverage have the potential to be affected. Nursing Administration will immediately audit all Medication Administration Records (MAR) for any resident receiving insulin with blood sugar readings greater than 400, amount of sliding scale insulin based on blood sugar readings, for holes in documentation of scheduled insulin with no reason as to why, and blood sugars below set parameters per order without following hypoglycemic protocol since (MONTH) 1, (YEAR) and inform upon discovery the Medical Director of subsequent blood sugars following the event. 3. Practice Development Specialist (PDS) will immediately initiate re-education with posttest to validate understanding on (MONTH) 4, (YEAR) at 2:45pm to all licensed nurses and agency licensed nurses on duty regarding ensuring insulin dependent residents receive quality care according to physician's orders. The nurse will notify the attending physician promptly for blood sugars outside set parameters, ensure correct amount of sliding scale insulin administered per order, properly record on the MAR, complete a progress note to include physician notification and any new orders obtained, and implement the hypoglycemic protocol as written. Licensed Nurses and Agency Licensed Nurses not available during this timeframe will be provided re-education including posttest upon day of return to work. New hires during orientation will receive education with a posttest prior to completion of orientation. The RN Supervisor/designee will monitor each residents' MAR every shift for documentation of insulin administration and physician notification upon discovery of blood glucose levels being outside the parameters daily across all shifts for 14 days including weekends, then 3 x per week x 14 days then randomly thereafter. Findings will be reviewed by the Director of Nursing/ designee daily. 4. Trends identified will be reported monthly by the Director of Nursing/designee to the Quality Improvement Committee (QIC) for any additional follow-up and/or in-servicing until the issue is resolved and randomly thereafter as determined by the QIC. i) Once the IJ was abated and the immediacy removed, deficient practices remained for this requirement at a scope and severity of E. 1. Resident #37 During an interview on 10/02/18 at 11:15 AM, Resident #37 said he had gout and his doctor had ordered him some medication for the gout on Monday, but he did not get the first dose until Thursday. He also stated that on another occasion the Doctor ordered him some eye drops for his dry eyes, but he did not get those for 2 weeks. Medical record review found a physician's order for natural tears to be administered twice a day in both eyes dated 09/25/18. The MAR (Medication Administration Record) indicated Resident #37 did not start getting the eye drops on 09/29/18. This was verified with South Unit Manager #5. She stated she did not know why he did not receive that medication because it is an over the counter stock medication. Additional review of the resident's medical records revealed Resident #37 did not receive: - [MEDICATION NAME] (used for inflammation) as ordered. The physician ordered [MEDICATION NAME] 20 milligrams (mg) for three (3) days, to start on 09/29/18 and end 10/01/18. The only dose documented was on 09/29/18. - Pro Heal (used to help heal wounds) 30 cubic centimeters (cc) by mouth twice daily was ordered on [DATE]. The first dose of this medication was recorded as given on 09/05/18 at 9:00 PM. According to the MAR, there were 16 missed doses from 09/08/18 to 09/24/18. - [MEDICATION NAME] (anti-[MEDICAL CONDITION]/[MEDICATION NAME] drug) was ordered twice a day by mouth on 09/25/18, but the first does was not given until 09/29/18. - [MEDICATION NAME] was ordered to be given every eight (8) hours related to convulsions. According to the MAR. there were two (2) missed doses in the month of (MONTH) (YEAR). 2. Resident #79 Medical record review found no evidence the resident was administered Insulin [MEDICATION NAME] Solution on 08/25/18 at 11:00 AM or 5:00 PM, nor were her blood sugars taken and recorded. On 10/04/18 at 2:30 PM, when these findings were discussed with South Unit Manager #5, she had no explanation for the medication not given and the blood sugars not obtained and/or not documented. 3. Resident #124 Review of the resident's medical records revealed the following: - [MEDICATION NAME] (for itching) one tablet once a day ordered on [DATE], was not started until 07/25/18. - Basaglar 20 units (diabetic medication to control blood sugars) at 9:00 PM was started on 07/07/18. Two (2) doses were missed and/or not documented doses in 20 days. - Humalog Sliding Scale to be given at 7:00 AM, 11:00 AM, 4:00 PM, 9:00 PM (? unable to read the scribed MAR) was not documented on 07/07/18 and 07/08/18 at 9 PM. - Bactrim (antibiotics to treat an infection) was ordered given four (4) times a day. There was no evidence the medication was given at 9 PM on 07/15/18 and 07/16/18. - [MEDICATION NAME] (to treat high blood pressure, heart failure) was not given/documented on 07/10/18. - The Second Step PPD not done and/or documented. On 10/04/18 at 3:15 AM, when asked about these findings, South Unit Manager #5 said she had no answers, other than they did have to let some of the agency nurses go early for this problem. 4. Resident #108 At 11:00 AM on 10/02/18, the resident was observed with an IV (intravenous) of 1/2 normal saline solution. Licensed Practical Nurse (LPN) #128, an agency nurse, verified the bag of saline was not dated, timed, or initial by the nurse to identify when the saline was started. LPN #128 said the IV had already been hung by the time she arrived for work. Review of the resident's physician's orders found the physician ordered 1/2 normal saline at 60 milliliters an hour via Hypodermoclysis (also called interstitial infusion or subcutaneous infusion) for a [DIAGNOSES REDACTED].) The order date was 10/01/18. By not identifying when the infusion was started, the amount of fluid the resident received could not be determined to ensure the correct amount of fluid was infusing. 5. Resident #91 -- Review of the facility's policy entitled Continuous Infusion of Medications and Solutions found the policy included: - 24. Label medication/solution container and administration set with: - 24.1 Date and time - 24.2 Nurses initials. -- The facility received the final laboratory report for a urine culture and sensitively on 09/16/18. The urine culture noted the resident had ESBL (Extended Spectrum Beta-Lactamase) Providencia stuartii in her urine. The physician ordered the antibiotic Meropenem 1 gram intravenously every 12 hours for 7 days. Review of the nursing notes found the antibiotic was never started because the resident refused a PICC (Peripherally Inserted Central Catheter) line according to the nursing notes. RN #61 wrote a nursing note on 09/17/18 and explained to the resident she could die without treatment. The physician was notified and gave orders for the resident to be sent to the emergency room for PICC line insertion. The resident refused again. A nursing note written by Licensed Practical Nurse (LPN) #128, dated 09/17/18, noted the PICC line was, .in place at this time. A handwritten notation to discontinue the Meropenem was made on the medication administration record (MAR). There was no indication of when or by whom this was added to the MAR. At 3:44 p.m. on 10/04/18, RN #61 confirmed the IV was never started. She did know why LPN #128 would write the PICC line was in place on 09/17/18 because there was no PICC line at that time. (The PICC line was never inserted at the facility. The IV line was started when the resident went to the hospital.) RN #61 confirmed she could not find a physician's order to discontinue the antibiotic. She stated the physician was aware the resident was refusing to go to the hospital as she advised the physician on 09/17/18 and wrote in her nurse's note. -- On 10/03/18 at 2:30 PM, the resident told two (2) surveyors her big toe on her right foot was hurting. The nurse surveyor looked at the resident's toe and found the toe was red around the nail. At 2:35 PM on 10/03/18, LPN #128, who was sitting at the nurse's desk, was told the resident had reported her toe was hurting. LPN #128 said she would take a look at the resident. On 10/04/18 at 9:50 AM, the resident said the nurse never came to look at her toe yesterday. At 9:55 AM on 10/04/18, Nurse Practitioner (NP) #137 was asked to look at the resident's toe. After examining the resident's toe, the NP wrote a progress note stating, Right great toe pain .She has pain and redness to right great toe. She is unsure of how long this lasted but states it has been happening for a while. She does have a history of gout but does not receive [MEDICATION NAME] medications. The NP ordered: - A uric acid level on the next lab day, - [MEDICATION NAME] (an antibiotic ointment or cream) with dressing application twice a day to the right great toe for 7 days. - [MEDICATION NAME] 400 mg every 8 hours for 3 days. At 10:15 PM on 10/04/18, RN #61 verified she could find no evidence LPN #128 assessed the resident on 10/04/18 after being asked by the surveyor to check on Resident #91. At 11:00 AM on 10/08/18, Corporate Clinical Quality Specialist (CQS) #157 was advised of this finding. No further information was provided. 6. Resident #106 -- Upon readmission to the facility on (MONTH) 6, (YEAR), Resident #106 was ordered [MEDICATION NAME] ([MEDICATION NAME]), an anticoagulant, 10 mg every day due to [MEDICAL CONDITION]. Review of Resident #106's Medication Administration Record (MAR) demonstrated [MEDICATION NAME] was initialed by the nurse on 09/06/18, which indicated the medication was given. However, [MEDICATION NAME] was not initialed as given on 09/07/18 or 09/08/18. Resident #106 was transferred to the hospital due [MEDICAL CONDITION] on 09/09/18. -- Resident #106 also had an order written [REDACTED]. An additional instruction given in the [MEDICATION NAME] order was to stop the medication when the INR (International Normalized Ratio) was greater than 2. (INR is a laboratory testing of the blood to determine the effectiveness of anticoagulant medication.) The [MEDICATION NAME] order was transcribed onto Resident #106's MAR as [MEDICATION NAME] 80 mg/10.8 ml subq (subcutaneously) every 12 hours. Stop when INR < (less than) 2, rather than greater than 2 as written in the order. The instructions to continue [MEDICATION NAME] for 2 days was omitted from the MAR. Review of Resident #106's MAR for (MONTH) (YEAR) revealed [MEDICATION NAME] was initialed by the nurse at - 8:00 AM on 09/06/18, - 8:00 AM on 09/07/18, and at - 8:00 AM and 8:00 PM on 09/07/18. - The MAR was not initialed for [MEDICATION NAME] on 09/07/18 at 8:00 PM. Resident #106 was transferred to the hospital due [MEDICAL CONDITION] on 09/09/18. Although the physician's order specified [MEDICATION NAME] was to be discontinued when the resident's INR was greater than two (2), there was no indication in the medical record that Resident #106's INR was checked during the period of 09/06/18 through 09/09/18. -- Resident #106 returned to the facility from the hospital on [DATE]. He was prescribed [MEDICATION NAME] ([MEDICATION NAME] - an anticoagulant) 7.5 mg every day. Review of Resident #106's MAR for (MONTH) (YEAR) revealed [MEDICATION NAME] 7.5 mg was initialed by the nurse as given from 09/19/18 through 09/23/18. On 09/24/18, an order was written to change the [MEDICATION NAME] dosage to 8 mg every day. The [MEDICATION NAME] was initialed by the nurse as given on 09/24/18, 09/25/18, 09/26/18, 09/29/18, and 09/30/18. The [MEDICATION NAME] was not initialed by a nurse on 09/27/18 or 09/28/18. -- Upon his readmission to the facility on [DATE], Resident #106 was also prescribed [MEDICATION NAME] sodium ([MEDICATION NAME]) 500 mg twice a day for [MEDICAL CONDITION] Affective Disorder. Review of Resident #106's MAR for (MONTH) (YEAR) revealed the 8:00 PM dosage of [MEDICATION NAME] sodium was not initialed by the nurse as given on 09/20/18, 09/22/18, 09/23/18, 09/27/18, and 09/28/18. During an interview on 10/03/18 at 2:45 PM, when these findings, including the transcription error for [MEDICATION NAME], were discussed with Unit M

Part I -- Based on comments from a random resident, observation, staff interview, review of facility policy "1.84 Smoking", and medical record review, the facility failed to provide a resident environment as free of accident hazards as is possible, as evidenced by allowing Resident #53 to smoke in the "smoker's lounge" while using oxygen. Three (3) other residents were also present in the smoker's lounge at this time. This practice placed more than an isolated number of residents in immediate jeopardy of harm or death due to the potential of combustion of the oxygen. The immediate jeopardy situation was removed when Resident #53 was removed from the smoker's lounge after the surveyor and the facility's administrator verified, at 4:45 p.m., that the resident's oxygen tank was turned on and oxygen was actively flowing through his nasal cannula. The administrator was informed of the immediate jeopardy determination at 4:55 p.m. on 01/04/11, after the survey team conferred by telephone with the program manager of the State survey and certification agency. On 01/04/11 at 5:10 p.m., the administrator stated he was going to remove Resident #53's smoking privileges due to the resident not safely smoking independently. At 5:20 p.m., the administrator was observed by another surveyor removing Resident #53's smoking materials. At 5:28 p.m., the administrator reported Resident #53's care plan was updated to address this issue, and staff was educated regarding this matter. The administrator submitted an action plan to address dependent smokers who also use oxygen. The plan outlined suspension of smoking privileges by Resident #53, evaluation of the remaining independent smokers (with no further smokers having been identified as also using portable oxygen tanks), and that, on 01/05/11, the facility's quality assurance (QA) committee would "hold a special meeting to introduce new policy relating to Independent Smokers who have physician orders that include use of oxygen." Once Resident #53 and his oxygen tank were removed from the smoker's lounge, the immediate jeopardy was removed, leaving the potential for more than minimal harm to more than an isolated number of residents (until the facility's QA committee convened to complete the steps outlined in the facility's action plan). Facility census: 113. (Please note that, beyond the circumstances described in Part I of this deficiency, additional findings of non-compliance with this overall requirement are outlined below in Parts II and III.) Findings include: a) Resident #53 1. On 01/04/11 at 4:40 p.m., this surveyor was informed by a random resident that another resident, who was in the smoker's lounge, was smoking while wearing oxygen. Observation, at 4:42 p.m., found Resident #53 in the smoker's lounge; he was smoking with his portable oxygen tank present and nasal cannula in place. Two (2) other residents were present in the smoker's lounge at this time. At 4:45 p.m., the administrator accompanied this surveyor into the smoker's lounge to check Resident #53's oxygen tank; the portable oxygen tank was observed by the administrator and surveyor to be turned on. At that time, the administrator removed the nasal cannula from the Resident #53 and submerged it in a cup of water; the water was observed by the administrator and surveyor to bubble vigorously. At that time, three (3) other residents were present in the smoker's lounge. Resident #53 and his oxygen tank were then immediately removed from the smoker's lounge. (This action resulted in removal of the hazard constituting immediate jeopardy.) On 01/04/11 at 4:50 p.m., Resident #53 was in administrator's office with administrator and the surveyor present; at that time the resident stated he was aware that his oxygen must be turned off before smoking. The program manager of the State survey and certification agency, when subsequently informed of the resident's use of oxygen in smoker's lounge, verified this practice constituted immediate jeopardy. The determination of immediate jeopardy, due to the potential of combustion of the oxygen, was conveyed to the administrator at 4:55 p.m. on 01/04/11. On 01/04/11 at 5:10 p.m., the administrator stated the facility was going to remove Resident #53's smoking privileges due to the resident not being able to safely smoke independently. On 01/04/11 at 5:20 p.m., the administrator was observed by another surveyor removing Resident #53's smoking materials. The administrator submitted an action plan to address independent smokers who also use oxygen. The plan outlined suspension of smoking privileges by Resident #53, evaluation of the remaining independent smokers (with no further smokers having been identified as also using portable oxygen tanks), and that, on 01/05/11, the facility's QA committee would "hold a special meeting to introduce new policy relating to Independent Smokers who have physician orders that include use of oxygen." 2. Review of the facility policy titled "1.84 Smoking", including the facility-specific addendum dated 06/15/07, revealed: "Cedar Ridge Center will remain a smoking facility for Independent Smokers Only. If a Resident does not qualify as an Independent Smoker based on the outcome of the Smoking Evaluation the Resident will not be permitted to smoke. ..." Review of the facility's Smoking Evaluation tool revealed a series of questions about the resident's medical and cognitive status and behavior. This was followed by a section titled "Evaluation", which gave the following direction: "Supervised smoking is required if 'Yes' answers above." Review of Resident #53's smoking evaluations revealed the following: - On 04/02/10, the assessor (Employee #125 - a registered nurse) marked "Yes" in response to the following questions: "Does the resident use oxygen?" and "Is the resident unable to demonstrate the location of the designated smoking area?" The assessor noted in the "Evaluation" section: "Supervised smoking is required". - On 07/23/10, the assessor (Employee #100 - a licensed practical nurse) marked "Yes" in response to the following question: "Does the resident use oxygen?" The assessor noted in the "Evaluation" section: "Resident is not allowed to smoke " and the reason given was: "resident (sic) on o2 (sic), states he will not be smoking". - On 10/23/10, the assessor (Employee #38 - a registered nurse) marked "Yes" in response to the following questions: "Does the resident use oxygen?" and "Is the resident unable to demonstrate the location of the designated smoking area?" The assessor noted in the "Evaluation" section: "Independent smoking is allowed". Under interventions, the assessor recorded, "resident (sic) turns off oxygen to smoke". In an interview on 01/04/11 at 6:15 p.m., the administrator confirmed that, according to the Smoking Evaluation tool, Resident #53 should not have been allowed to smoke. Review of Resident #53's care plan, on 01/13/11, revealed a revision was made on 01/04/11 to include the following problem statement: "Resident prefers to smoke however starting this date smoking cessation therapy to assist resident to quit habit due to continued need of oxygen and safety." The goal associated with this problem statement was: "Resident will not smoke x 90 days." The interventions to assist the resident in achieving this goal included: "Educate the resident / health care decision maker on the facility's smoking policy. Inform resident of the availability of stop smoking material. assess (sic) for adverse behaviors. resident (sic) to receive nicotine patches 21 mg qd (daily) x 4weeks (sic) then nicotine patch 14mg (sic) x 4weeks (sic), then 7mg (sic) x 4weeks (sic) then d/c (discontinue)." Review of Resident #53's previous care plan, dated 10/27/10, found the interdisciplinary team had not addressed the matter of this resident's smoking, especially in view of the Smoking Evaluation tool dated 10/23/10, in which Employee #38 made an exception by granting this resident the privilege to smoke independently contrary to the directions of the tool. ++++ Part II -- Based on observations, measurement of food temperatures, and staff interview, the facility failed to ensure the resident environment remained as free of accident hazards as possible. The food service supervisor (Employee #12) was observed, beginning at 10:28 a.m. on 01/05/11, carrying steam table pans of hot foods from the facility's kitchen, down halls in which varying numbers of residents and staff were present, to an activities room where the cafe was located. The pans of hot food, which were being transported by hand using pot holders, were covered with foil which would not prevent spillage should the individual transporting the foods lose his balance for any reason. Should a resident attempt to touch the pan or suddenly come in front of the pan, the transporter would not be able to ward off the resident, as both hands were needed to carry the pan. One (1) pan contained meatballs in barbecue sauce measuring 182 degrees Fahrenheit (F), and another pan contained chili measuring 172 degrees F; exposure of skin to a water temperature of 155 degrees F for only 1 second will result in a third degree burn. Because these substances are thicker than water, should these items spill onto skin or clothing, they would cling and prolong the exposure to temperatures sufficient to cause burns. This practice posed an avoidable immediate risk of burns to residents and / or staff who were moving about near the kitchen / dining room, in the South long hall and near the South nursing station. More than an isolated number of residents had the potential to be affected. The administrator was informed of the immediate jeopardy situation at 12:17 p.m. on 01/05/11. At 12:35 p.m. on 01/05/11, the administrator presented an action plan for removal of the immediate jeopardy, which included a policy requiring foods transported to the cafe with the use of a cart. Subsequent observations verified a cart was used for transporting foods from the kitchen to the cafe. The potential for harm was minimized upon implementation of the use of the cart for transporting hot foods from the kitchen to the cafe, with no deficient practice persisting in this matter. (Please note that, beyond the circumstances described in Part II of this deficiency, additional findings of non-compliance with this overall requirement are outlined below in Part III. Facility census: 113. Findings include: a) On 01/05/11 at approximately 10:28 a.m., the facility's food service supervisor was observed walking down the hall carrying a full-size steam table pan; this pan had a capacity of 7 quarts. The employee was using pot holders to carry the pan from the kitchen, through the dining room, down the South long hall past residents and staff, past the South nursing station, to the cafe. The South long hall housed up to thirty-four (34) residents with varying degrees of mobility and cognitive function, and residents from other areas of the building also were present on occasion. At approximately 10:33 a.m., the food service supervisor was observed carrying a half steam table pan through the halls; this pan had a capacity of 10 quarts. It was noted that pot holders were again being used. With the permission of the food service supervisor, this surveyor touched the pan and found the bottom of the pan was hot enough to elicit reflexive withdrawal of the fingers. At 10:35 a.m., the surveyor asked the food service supervisor to take the temperatures of the hot foods in the cafe. He said he would need to get a thermometer. At 10:39 a.m., he returned to the cafe with a thermometer but found the thermometer was not working properly. -- He returned with another thermometer and measured the temperatures of the two (2) items that the surveyor observed him to carry through the hallways using pot holders. - The full-sized steam table pan was approximately half full of meatballs in barbecue sauce. The temperature was measured at 182 degrees Fahrenheit (F). - The half steam table pan was filled with chili to approximately 1-1/2 to 2 inches from the top. The employee measured the temperature of the chili at 172 degrees F. -- The determination of immediate jeopardy was confirmed with the program manager with the State survey and certification agency via telephone and e-mail at 12:02 p.m. on 01/05/11. On 01/05/11 at 12:17 p.m., the administrator was informed of the immediate jeopardy situation in the presence of the survey team. A document was provided with the corrective action described, at 12:35 p.m. on 01/05/11. The document titled "Immediate Action Plan to Address Method of Transportation of Food" described an education contact with the Food Service Director, that hot temperature foods would be transported via cart. The plan also noted: "The Food Service Director will complete an in-service for all dietary employees within 24 hours to ensure all dietary staff members that transport food have been educated to this safety standard." Subsequent observations, made prior to and during the evening meal on 01/05/11, found a cart being used to transport foods from the kitchen to the cafe. ++++ Part III -- Based on observation and medical record review, the facility failed to ensure a resident with an indwelling urinary catheter received care and services to prevent the potential for traumatic removal of the catheter. A resident was observed moving about in a wheelchair with her catheter tubing dragging on the floor near her feet and the wheels of the chair. The resident used her feet to propel herself. One (1) of forty-two (42) Stage II sample residents was affected. Resident identifier: #16. Facility census: 113. Findings include: a) Resident #16 On 01/13/11, Resident #16 was observed going through the hall to the dining room in her wheelchair for lunch. She said she was supposed to use her feet. The tubing from her indwelling Foley urinary catheter was dragging the floor near her feet and also near the left wheel of the chair. This created a potential for her to place her foot on the tubing or for the tubing to be caught under the wheel of the chair, which may have resulted in traumatic removal of the catheter. Review of the resident's medical record, on 01/13/11 at approximately 2:00 p.m., found the catheter had only recently been inserted. A nursing entry, on 01/11/11 at 15:47 (3:47 p.m.), identified the nurse had talked with the physician about the resident not being able to void on her own for the last five (5) days. The physician had ordered the catheter and an appointment with a urologist. .

Based on comments from a random resident, observation, staff interview, review of facility policy "1.84 Smoking", and medical record review, the facility's quality assessment and assurance (QAA) committee failed to identify quality deficiencies of which it was - or should have been - aware which were reflective of system failures in the area of accident hazards, and failed to develop and implement appropriate plans of action to correct these quality deficiencies. On 04/02/10 and 07/23/10, Resident #53 had been assessed as being unsafe to smoke independently due, in part, to his use of oxygen. On 10/23/10, the assessor (Employee #38, a registered nurse) determined he was permitted to smoke independently even though he continued to use oxygen, which was contrary to the directions on the Smoking Evaluation tool, noting that "resident turns off oxygen to smoke". This Smoking Evaluation also was marked by the assessor to indicate that Resident #53's care plan had been updated to address this; however, review of the care plan in effect for Resident #53 at the time of the immediate jeopardy found no mention of smoking. On the afternoon of 01/04/11, Resident #53 was found to be smoking in the facility's "smoker's lounge" with his oxygen tank turned on and oxygen actively flowing through his nasal cannula. This practice placed Resident #53 and three (3) other residents who were present in the smoker's lounge in immediate jeopardy of harm or death due to the potential of combustion of the oxygen. The immediate jeopardy situation was removed when Resident #53 was removed from the smoker's lounge after the surveyor and the facility's administrator verified, at 4:45 p.m., that the resident's oxygen tank was turned on and oxygen was actively flowing through his nasal cannula. In subsequent interviews, the administrator reported having been aware that Resident #53 had been observed outside smoking with his oxygen on and that he (the administrator) would periodically monitor the resident to be sure his oxygen was turned off. The administrator also confirmed that, based on the results of his Smoking Evaluation, Resident #53 should not have been permitted to smoke. An interview with the director of nursing (DON) revealed that smoking issues frequently came up in the facility's QAA committee meetings, but specific issues regarding Resident #53 had never been discussed. Facility census: 113. Findings include: a) Resident #53 1. On 01/04/11 at 4:40 p.m., this surveyor was informed by a random resident that another resident, who was in the smoker's lounge, was smoking while wearing oxygen. Observation, at 4:42 p.m., found Resident #53 in the smoker's lounge; he was smoking with his portable oxygen tank present and nasal cannula in place. Two (2) other residents were present in the smoker's lounge at this time. At 4:45 p.m., the administrator accompanied this surveyor into the smoker's lounge to check Resident #53's oxygen tank; the portable oxygen tank was observed by the administrator and surveyor to be turned on. At that time, the administrator removed the nasal cannula from the Resident #53 and submerged it in a cup of water; the water was observed by the administrator and surveyor to bubble vigorously. At that time, three (3) other residents were present in the smoker's lounge. Resident #53 and his oxygen tank were then immediately removed from the smoker's lounge. (This action resulted in removal of the hazard constituting immediate jeopardy.) On 01/04/11 at 4:50 p.m., Resident #53 was in administrator's office with administrator and the surveyor present; at that time the resident stated he was aware that his oxygen must be turned off before smoking. The program manager of the State survey and certification agency, when subsequently informed of the resident's use of oxygen in smoker's lounge, verified this practice constituted immediate jeopardy. The determination of immediate jeopardy, due to the potential of combustion of the oxygen, was conveyed to the administrator at 4:55 p.m. on 01/04/11. On 01/04/11 at 5:10 p.m., the administrator stated that facility was going to remove Resident #53's smoking privileges due to the resident not being able to safely smoke independently. On 01/04/11 at 5:20 p.m., the administrator was observed by another surveyor removing Resident #53's smoking materials. On 01/04/11 at 5:28 p.m., an interview with the administrator revealed that, during the "summer time", Resident #53 had been observed outside smoking with his oxygen on; the administrator stated he would periodically monitor the resident to be sure his oxygen was turned off. The administrator further stated that Resident #53's care plan was updated, and staff was educated regarding this matter. -- 2. Review of the facility policy titled "1.84 Smoking", including the facility-specific addendum dated 06/15/07, revealed: "Cedar Ridge Center will remain a smoking facility for Independent Smokers Only. If a Resident does not qualify as an Independent Smoker based on the outcome of the Smoking Evaluation the Resident will not be permitted to smoke. ..." Review of the facility's Smoking Evaluation tool revealed a series of questions about the resident's medical and cognitive status and behavior. This was followed by a section titled "Evaluation", which gave the following direction: "Supervised smoking is required if 'Yes' answers above." Review of Resident #53's smoking evaluations revealed the following: - On 04/02/10, the assessor (Employee #125 - a registered nurse) marked "Yes" in response to the following questions: "Does the resident use oxygen?" and "Is the resident unable to demonstrate the location of the designated smoking area?" The assessor noted in the "Evaluation" section: "Supervised smoking is required". - On 07/23/10, the assessor (Employee #100 - a licensed practical nurse) marked "Yes" in response to the following question: "Does the resident use oxygen?" The assessor noted in the "Evaluation" section: "Resident is not allowed to smoke", and the reason given was: "resident (sic) on o2 (sic), states he will not be smoking". - On 10/23/10, the assessor (Employee #38 - a registered nurse) marked "Yes" in response to the following questions: "Does the resident use oxygen?" and "Is the resident unable to demonstrate the location of the designated smoking area?" The assessor noted in the "Evaluation" section: "Independent smoking is allowed". Under interventions, the assessor recorded, "resident (sic) turns off oxygen to smoke". - In an interview on 01/04/11 at 6:15 p.m., the administrator confirmed that, according to the Smoking Evaluation tool, Resident #53 should not have been allowed to smoke. - Review of Resident #53's care plan, on 01/13/11, revealed a revision was made on 01/04/11 to include the following problem statement: "Resident prefers to smoke however starting this date smoking cessation therapy to assist resident to quit habit due to continued need of oxygen and safety." The goal associated with this problem statement was: "Resident will not smoke x 90 days." The interventions to assist the resident in achieving this goal included: "Educate the resident / health care decision maker on the facility's smoking policy. Inform resident of the availability of stop smoking material. assess (sic) for adverse behaviors. resident (sic) to receive nicotine patches 21 mg qd (daily) x 4weeks (sic) then nicotine patch 14mg (sic) x 4weeks (sic), then 7mg (sic) x 4weeks (sic) then d/c (discontinue)." - Review of Resident #53's previous care plan, dated 10/27/10, found the interdisciplinary team had not addressed the matter of this resident's smoking, especially in view of the Smoking Evaluation tool dated 10/23/10, in which Employee #38 made an exception by granting this resident the privilege to smoke independently contrary to the directions of the tool. -- 3. On 01/13/11 at 2:05 p.m., an interview with the DON (Employee #46) revealed that smoking issues frequently come up in QAA committee meetings, but specific issues regarding Resident #53 had never been discussed.