Every finding on record at Charter House Inc

Based on interview and record review, the facility failed to implement an effective system for medication order transcription, laboratory monitoring, medication availability, and medication administration for 4 of 4 residents reviewed for medication errors (R1, R2, R3, R4). Failures included medication order transcription failures, missed laboratory monitoring, omitted anticoagulants and antiplatelet medications, medication availability failures, failure to implement medication order changes, and delayed medication administration.Findings include:R1:R1's Risk Watch document, incorrectly dated 2/7/26, identified on the future date of 2/19/26, the health care provider (HCP) notified the Director of Nursing (DON) an INR lab ordered for 2/16/26 had not been completed. The document further identified that a subsequent order for warfarin (blood thinning medication) was not obtained resulting in R1 missing three doses of warfarin and the facility's internal investigation process was initiated after notification by the HCP. Immediate actions included notification of the house supervisor, resident, and on-call physician, and a new order was obtained. The document further identified the facility's internal investigation process was initiated after notification by the HCP.Facility reported incident (FRI) dated 2/19/26 at 2:05 p.m., identified the health care provider (HCP) notified the Director of Nursing (DON) an International Normalized Ratio (INR) (blood test used to measure how long it takes blood to clot and whether blood thinner medication is working safely and effectively) lab ordered for 2/16/26 had not been completed. The FRI further identified a subsequent order for Warfarin was not obtained resulting in R1 missing three doses of warfarin. The document identified the facility had initiated an internal investigation regarding the medication error.Facility 5-day investigation report summary dated 2/26/26, identified review of R1's care plan, electronic medical record (EMR), medication administration record (MAR), medication orders, and medication administration policies. The report identified care plan interventions directing staff to administer medications as ordered and obtain and monitor INR labs as ordered were not followed. Interview with nurse practitioner (NP)-A identified R1 had an INR scheduled for 2/16/26; however, the results were never sent to the provider care team and NP-A was unsure whether R1 had been receiving Warfarin. Interview with LPN-A identified she missed the INR order because it was typically completed by night shift and she did not question the warfarin order because she did not realize it had been ordered on previous days. The report identified R1's INR scheduled for 2/16/26 was not obtained and warfarin was not administered until 2/19/26 when the omission was identified by the provider. The allegation was verified through review of the EMR and staff interviews identifying the INR test was not completed per provider order and care plan. Nursing leadership initiated corrective actions on 2/20/26 including staff education regarding order transcription accuracy, two-person verification, INR testing tracking, and related policies. Additional prevention interventions included review of INR competency records, refresher training, review of EMR safeguards, audits of newly transcribed orders for compliance with the two-person verification process, staff coaching and re-education for identified variances, and ongoing monitoring of order transcription and point-of-care testing competencies.Informal coaching documentation dated 2/25/26 identified LPN-A was placed on administrative leave related to a missed point-of-care INR resulting in R1 missing doses of warfarin. Nurse manager (NM)-A reiterated the importance of reviewing the medical record including labs and treatments for each resident. NM-A stated the lab order was present; however, LPN-A stated it did not appear on her dashboard. Follow-up coaching dated 2/27/26 identified adjustments were made within the EHR dashboard settings to display lab orders as the default view.Facility education provided on 3/16/26 through 3/18/26 included order transcription processes within the Unity EMR system including drafting orders, entering frequencies, stop dates, and activation of orders. However, review identified the education did not include a monitoring or double-check system to ensure ordered INR labs were completed and residents requiring anticoagulation management had active warfarin orders in place to prevent missed doses.After review of the facility investigation, the facility identified corrective actions including INR tracking, audits, staff education, and two-person verification related to anticoagulation management and order transcription; however, the facility was unable to provide evidence of audits or monitoring systems regarding following physician ordered INRs had been implemented.R1's face sheet printed 5/18/26, identified diagnoses including heart transplant infection, infective endocarditis (serious infection of the inner lining and valves of the heart), presence of heart valve replacement, history of transient ischemic attack/stroke (history of mini-stroke or stroke), chronic heart failure, kidney transplant status, chronic kidney disease, pleural effusion (fluid buildup around the lungs), and atrial fibrillation (irregular heartbeat that increases risk for blood clots).R1's admission Minimum Data Set (MDS) dated [DATE], identified moderate cognitive impairment, a major surgical procedure involving the heart or major blood vessels during the prior inpatient hospital stay requiring active care during the skilled nursing facility stay, and receipt of anticoagulant (blood thinner medication used to help prevent blood clots) and antiplatelet (medications used to help prevent blood clots) medications.R1's nurse practitioner (NP) encounter note dated 2/12/26 identified anticoagulation management for tissue aortic and mitral valves plus recent atrial fibrillation with a goal INR of 2.0 to 3.0 with lifelong duration. Comorbid considerations included infective endocarditis of native allograft mitral and aortic valves with severe regurgitation, likely due to right femoral seroma (fluid collection near the groin blood vessel area). The note further identified status post redo sternotomy (repeat open-heart surgery) with bioprosthetic aortic valve replacement and mitral valve replacement on 1/12/26, complicated by multifocal embolic cerebral and cerebellar infarcts (multiple strokes caused by blood clots traveling to the brain), possible small distal M1 aneurysm versus infundibulum on CTA (possible weakened or bulging blood vessel in the brain identified on imaging), pleural effusions status post thoracentesis, chylothorax (lymphatic fluid leaking into the chest cavity around the lungs), persistent debility (ongoing severe weakness and decreased physical functioning), intermittent bradycardia (episodes of abnormally slow heart rate), and new onset atrial fibrillation with rapid ventricular response (irregular heartbeat causing periods of rapid heart rate). The note further identified R1's INR was 2.0 and R1 was to receive Warfarin 2 milligrams daily with repeat INR scheduled for 2/16/26.R1's care plan dated 2/6/26, identified R1 was at risk for bleeding and excessive bruising related to anticoagulant and antiplatelet therapy. Interventions dated 2/6/26, directed staff to monitor INR lab values within acceptable range as determined by the health care provider and observe, record, and report signs or symptoms of bleeding to the health care provider.R1's physician orders dated 2/7/26, identified an order for Warfarin 2 milligram (mg) tablet, take one tablet by mouth daily. The order further identified R1 was to take warfarin 2 mg daily until INR was completed on 2/9/26 and then continue as directed by the skilled nursing facility based on INR monitoring.R1's anticoagulant management nurse practitioner (NP) visit dated 2/12/26. identified R1's INR was 2.1. The note further identified to continue warfarin 2 mg daily and recheck INR on 2/16/26.R1's medication administration record (MAR) dated 2/16/26 to 2/18/26, identified an order for warfarin 2 mg take one time daily for four days begining 2/12/26, next INR check was on 2/16/26 at 6:00 a.m. After reviewing R1's February 26 MAR, warfarin was not administered from 2/16/26 to 2/19/26 when R1 was discharged from the facility. R1's treatment administration record (TAR) dated 2/16/26 identified an order for INR lab monitoring every one day for one day beginning 2/16/26 related to warfarin management. The TAR identified the INR was ordered on 2/12/26, with a note to recheck INR 2/16/26 at 0500. Review of the TAR identified an equal sign documented on 2/16/26 without staff initials, indicating the INR lab was not completed as orderedR1's NP's Follow Up Visit note dated 2/17/26, identified R1 was anticoagulated with warfarin due to atrial fibrillation with a goal INR of 2 to 3. The note did not address the INR lab ordered for 2/16/26 had not been completed and that R1 had no current orders on hand for warfarin.Email correspondence reviewed from nurse practitioner (NP)-A to director of nursing (DON), administrator, and nurse manager (NM)-A dated 2/19/26 at 8:00 a.m., identified the subject line med error-warfarin. The email identified NP-A had learned R1's INR scheduled for 2/16/26 had not been completed and the results were never sent to her team. The email further identified an INR would be added to the day's labs and NP-A would contact R1's transplant team regarding management of warfarin and INR monitoring.R1's clinical notes reviewed and did not identify any information about R1's missed INR lab on 2/16/26 and did not identify that he missed 3 doses of warfarin from 2/16/26 to 2/18/26.R1's clinical note dated 2/19/26 at 2:16 p.m. identified the facility was notified by the heart transplant service that R1 will be admitted to the hospital from his afternoon appointment. During an interview on 5/19/26 at 3:22 p.m., nurse manager (NM)-A stated R1's INR lab due on 2/16/26 at 6:00 a.m. was missed by licensed practical nurse (LPN)-A resulting in R1 missing three doses of warfarin. NM-A stated the facility investigation identified the root cause was LPN-A did not have pending labs displayed within the My Unity dashboard and the facility lacked a double-check system to identify missed INR testing. NM-A stated if the INR was missed, the corresponding warfarin order would also be missed. NM-A further stated there was no reminder on the MAR identifying a resident receiving warfarin required ongoing INR monitoring and staff were required to have the correct dashboard settings enabled to view pending laboratory orders. NM-A stated the missed INR from 2/16/26 would not continue to display the following day if not completed. NM-A stated facility interventions included review of residents receiving warfarin to identify additional missed INR labs, immediate staff education regarding medication order procedures and reporting requirements, and facility-wide education from 3/16/26 through 3/18/26 regarding order transcription processes. NM-A further stated the facility could not provide evidence of ensuring dashboard settings displayed pending laboratory orders or validating completion of ongoing audits reportedly initiated following the medication error.During an interview on 5/19/26 at 3:29 p.m., director of nursing (DON) stated the Risk Watch incident report incorrectly identified the event date as 2/7/26 and clarified the correct date should have been 2/19/26. DON stated nurse practitioner (NP)-A emailed facility leadership on 2/19/26 regarding a significant medication error involving missed warfarin doses for R1. DON stated R1's INR obtained on 2/19/26 was 3.2. DON stated the INR order due on 2/16/26 was listed on the TAR; however, LPN-A missed the lab order resulting in R1 missing three doses of warfarin. DON stated the facility removed LPN-A from the schedule and provided re-education. DON stated the facility investigation identified the root cause was failure to complete the INR laboratory order as prescribed by the provider, resulting in missed warfarin doses. DON further stated provider orders were expected to be completed as ordered.R2:R2's After Visit Summary (AVS) dated 4/14/26 through 4/17/26 identified R2 was status post right total knee arthroplasty (right total knee replacement surgery). The AVS further identified R2 received anticoagulation treatment while hospitalized to prevent blood clots or deep vein thrombosis (DVT) (blood clot usually occurring in the legs) and was to continue Aspirin 81 milligrams (mg) twice daily for DVT prophylaxis 30 days following surgery.R2's face sheet printed 5/18/26 identified diagnoses including aftercare following right joint replacement, infection/inflammatory reaction related to an internal orthopedic prosthetic device/graft, hypertensive heart disease with heart failure, chronic heart failure, pulmonary hypertension (high blood pressure affecting the lungs and heart), morbid obesity, and obstructive sleep apnea (a condition causing interrupted breathing during sleep).R2's admission Minimum Data Set (MDS) dated [DATE], identified no cognitive impairment, a recent knee replacement surgery requiring ongoing skilled nursing care, and receipt of antiplatelet medications.R2's care plan dated 4/17/26, identified R2 was at risk for abnormal ecchymosis (bruising) or bleeding related to anticoagulant and/or antiplatelet medication use. Interventions dated 4/17/26 directed staff to administer medications as ordered, observe for side effects, and observe, record, and report abnormal bruising or signs and symptoms of bleeding to the health care provider.R2's Risk Watch document, incorrectly dated 4/17/26, identified on 4/20/26 an order in RightFax was not transcribed resulting in R2 missing three doses of Aspirin 81 milligrams. The document identified LPN-A was not aware of the order in RightFax. Interventions included education and discussion with nurses to ensure RightFax was checked daily, and orders were transcribed. Immediate actions included assessment of R2, transcription of the order, discontinuation of aspirin, and provider notification.Although the Risk Watch document documented discontinuation of aspirin and reported only three missed doses, subsequent MAR review identified the aspirin order was not appropriately reactivated and R2 experienced a prolonged interruption in ordered DVT prophylaxis.R2's MAR identified R2 received aspirin 81 mg from 4/17/26 through the morning dose on 4/20/26. Review identified the aspirin order was re-entered on 4/20/26; however, the order was again discontinued the same day and was not reactivated on the MAR through 5/14/26.Review of R2's April 2026 MAR identified R2 missed 22 doses from 4/20/26 at 8:00 p.m. through 4/30/26 at 8:00 p.m., due to no active order on the MAR.Review of R2's May 2026 MAR identified R2 missed 27 doses from 5/1/26 at 8:00 a.m. through 5/14/26 at 8:00 a.m. due to no active order on the MAR. Review identified R2 missed a total of 49 doses of aspirin 81 milligrams.R2's medical doctor (MD) progress note dated 4/21/26, did not address R2's aspirin orders for deep vein thrombosis (DVT) prophylaxis.R2's nurse practitioner (NP) progress note dated 4/28/26, identified under assessment and plan: Arthroplasty Total Knee Replacement Status Post Right. The note further identified DVT prophylaxis with aspirin twice daily for 30 days post-operatively.R2's nurse practitioner (NP) discharge visit note dated 5/12/26 identified R2 was status post right total knee arthroplasty (right total knee replacement surgery) and continued on Aspirin for deep vein thrombosis (DVT) prophylaxis (prevention of blood clots). The note further identified concern for right lower extremity erythema (redness), mild heat, and drainage from the incision site compared to the left leg and identified an ultrasound would be ordered to rule out DVT (blood clot). Discharge orders further identified R2 was to continue aspirin twice daily through 5/14/26.During an interview on 5/19/26 at 4:12 p.m., nurse manager (NM)-A stated the facility initially believed R2 missed only three days of Aspirin doses; however, after review of the medication administration record (MAR), NM-A verified R2 received aspirin from 4/17/26 through 4/20/26 and then did not receive aspirin again from 4/20/26 through 5/14/26 when R2 discharged home. NM-A stated it appeared LPN-A discontinued the aspirin order on 4/20/26. NM-A further verified R2 developed redness and warmth to the right leg requiring an ultrasound to rule out a blood clot and stated the facility had not realized R2 missed that amount of aspirin until the interview and no prevention interventions had been implemented related to the medication error.During an interview on 5/19/26 at 4:23 p.m., DON stated R2's Aspirin 81 mg twice daily ordered for DVT prophylaxis to prevent blood clots following total knee replacement surgery was discontinued on 4/20/26, despite discharge orders identifying aspirin was to continue through 5/14/26. DON stated the root cause identified was LPN-A did not check RightFax and did not enter the restarted aspirin order into the EHR. DON further stated the physician faxed an order discontinuing aspirin on 4/20/26, followed shortly afterward by another order restarting aspirin; however, the restarted order was not entered into the EHR. DON-A verified R2 did not receive aspirin as ordered by the physician and stated this was the first awareness R2 had missed a significant number of aspirin doses and no prevention plan had been implemented because the facility was not aware what had occurred until just now.Further review identified although the facility investigation concluded R2 missed three doses of aspirin, the aspirin order had been discontinued on 4/20/26 and was not reactivated on the MAR for the remainder of the prescribed prophylactic period through 5/14/26. Review of the MAR identified R2 missed a total of 49 doses of aspirin 81 mg. The facility investigation did not identify the prolonged absence of an active aspirin order or the continued omission of physician-ordered DVT prophylaxis.R3:R3's face sheet printed 5/19/26, identified diagnoses including vascular dementia, hemiplegia following cerebral infarction (weakness/paralysis on one side of the body after stroke), and history of digestive system disease.R3's quarterly MDS dated [DATE], identified severely impaired cognition and was always incontinent of bowel.R3's care plan dated 12/26/25 identified altered elimination with constipation and bowel irregularity. The care plan identified R3 was to maintain a bowel movement at least every three days or per previous routine. Interventions revised 4/13/26, directed staff to administer an extra dose of Lactulose (bowel medication used to prevent and treat constipation) on day two without a bowel movement, administer a Dulcolax suppository on day three without a bowel movement, administer a tap water enema per standing order if no results from the suppository, and request an order for fecal impaction removal if still no results occurred. Additional interventions directed staff to encourage positioning on the left side to assist with bowel elimination and encourage fluids and meal intake.R3's physician assistant (PA) order dated 4/2/26, identified the previous lactulose order would be discontinued and replaced with lactulose 10 grams/15 ml solution three times daily for constipation.R3's April 2026 MAR identified Lactulose 10 grams/15 milliliters was administered two times daily from 4/2/26 through 4/7/26. Review identified the increased order for lactulose three times daily was not transcribed to the MAR until 4/8/26, resulting in R3 missing the additional ordered daily dose for six days.Review identified the increased lactulose frequency ordered on 4/2/26 was not implemented for six days despite the resident's care plan identifying ongoing constipation management interventions.R3's physician orders dated 4/8/26 identified an order for Lactulose oral solution 10 grams/15 milliliters to be administered by mouth three times daily for constipation.R3's Risk Watch form, incorrectly dated 4/2/26 and should have been dated 4/8/26, identified an order faxed on 4/2/26, to increase Lactulose to three times daily was not transcribed from RightFax and pharmacy did not receive the order. The document identified facility determined the medication error was a system failure. Interventions included staff education regarding checking RightFax and following transcription procedures. Immediate actions included transcription of the order and increasing lactulose to three times daily as ordered.An email sent from NM-A to all nurses dated 4/21/26, identified nurses were expected to check the RightFax inbox throughout evening and night shifts and weekends due to recent medication errors caused by orders not being checked in RightFax over the weekend. The email further identified staff were required to set up RightFax individually on each computer workstation used. Review identified the facility provided links to training videos regarding RightFax use; however, the facility was unable to provide evidence all nursing staff completed the education or evidence staff competency had been evaluated regarding use of the RightFax system.Although the facility reported education regarding RightFax review and medication transcription procedures had been completed with all nursing staff following the medication error, the facility was unable to provide documentation validating the education was completed with all staff or evidence staff competency had been evaluated regarding use of the RightFax system.During an interview on 5/19/26 at 4:29 p.m., NM-A stated R3 was prescribed Lactulose for constipation management and was bedbound. NM-A stated it had been three days since R3 had a bowel movement, R3 refused a suppository, and an increased lactulose dose was ordered on 4/2/26 to increase administration to three times daily; however, the order was not implemented until 4/8/26. NM-A stated the order came through RightFax on 4/2/26; however, she did not know which nurse was responsible for transcription and did not have documentation identifying the responsible nurse. NM-A further stated the facility later identified not all nurses had RightFax set up on their computers. NM-A stated health unit coordinators printed RightFax orders Monday through Friday and nursing staff were responsible for checking RightFax after hours and on weekends. NM-A stated links regarding RightFax setup were emailed to staff on 4/21/26; however, the facility did not have documentation staff completed the setup or training. NM-A further stated the facility's information technology staff ensured nursing staff had access to RightFax; however, she did not know when that occurred and did not have documentation verifying completion.R4R4's face sheet identified diagnoses including chronic embolism and thrombosis of the left internal jugular vein (long-term blood clot in a major neck vein), atrial fibrillation, history of DVT, history of transient ischemic attack/stroke, coronary artery disease, biventricular heart failure (heart failure affecting both sides of the heart), end stage renal disease requiring dialysis, and kidney transplant status.R4's 5-day prospective payment system (PPS) MDS, dated [DATE], identified R4 had moderate cognitive impairment and received anticoagulant medications.R4's care plan dated 4/13/26, identified R4 was at risk for bleeding and excessive bruising related to anticoagulant therapy. Interventions dated 4/13/26, directed staff to observe and report abnormal or unexplained bleeding, including gastrointestinal bleeding, nose bleeds, and bleeding gums, to the nurse practitioner or physician.R4's AVS dated 4/4/26 through 4/13/26 identified R4 was hospitalized for a closed left ankle fracture. The AVS further identified R4's (INR) was 3.2 with orders to administer Warfarin 1 mg on 4/13/26 and then continue daily as directed by the provider.R4's anticoagulant management provider note dated 4/14/26, identified R4's INR was 3.5, hold today and 2 mg Wednesday, recheck INR on 4/16/26.R4's April 2026, MAR identified on 4/13/26, warfarin 2 mg tablet; take 1/2 tablet (1 mg) on 4/13/26 then take daily as directed by prescriber. Review of the MAR identified no dose was administered on 4/15/26. The MAR further identified that warfarin 2 mg tablet was given on 4/17/26, as initials were documented in the space.Although staff initials were documented on the MAR indicating warfarin 2 mg was administered on 4/17/26, a clinical note dated 4/17/26 at 10:57 p.m. identified the medication was unavailable and not administered.R4's clinical note dated 4/16/26 at 5:17 a.m., identified the on-call physician directed staff to hold warfarin until a new INR was obtained. The note further identified R4 missed a 2 mg dose of warfarin on 4/15/26, the on-call physician was notified, an SBAR was sent to senior services with the updated INR result of 2.4, and nursing leadership was notified. A subsequent note dated 4/16/26 at 6:45 p.m. identified a new order for warfarin 3 mg on Thursday and Saturday and 2 mg on all other days with repeat INR testing ordered for 4/20/26.R4's clinical note dated 4/17/26 at 10:57 p.m., identified R4's warfarin 2 mg tablet was again not administered because the medication was unavailable. The note identified the on-call physician was notified and advised staff to document the missed dose with the next INR testing. An additional note dated 4/18/26 at 6:37 a.m. identified two nurses thoroughly checked the emergency medication kit and the medication was not found.R4's clinical note dated 4/18/26 at 5:44 p.m., identified R4's warfarin dose of 2 mg was taken from the e-kit and that the pharmacy was aware of the order. R4's Risk Watch incident report dated 4/15/26 identified R4 missed a dose of Warfarin 2 mg on 4/15/26 because the medication was not available from the pharmacy. The document identified the on-call physician was notified during the early morning hours of 4/16/26 and advised staff to hold warfarin and send an SBAR to senior services. The report identified R4's INR was 2.4 on 4/16/26. The facility investigation identified warfarin was available within the facility emergency medication kit and staff could have obtained the medication from the emergency kit. The report further identified the medication omission was determined to be an error of omission. Interventions included staff education regarding available options when medications were not received from the pharmacy, including use of the emergency medication kit or obtaining medication from Mayo Pharmacy.Although the Risk Watch incident report identified the 4/15/26 omission was related to medication availability, subsequent record review identified the missed dose on 4/15/26 was associated with transcription/order processing failures, while the missed dose on 4/17/26 occurred because the medication was unavailable from the pharmacy.During an interview on 5/19/26 at 5:00 p.m., nurse manager (NM)-A stated R4 missed two doses of Warfarin due to medication unavailability and staff should have obtained the medication from the emergency medication kit (e-kit). NM-A stated staff were educated following the medication error regarding use of the emergency medication kit. NM-A further stated she was unaware the missed warfarin dose on 4/15/26 was related to a transcription error rather than medication availability. NM-A additionally stated the facility had been experiencing ongoing issues obtaining medications from the pharmacy in a timely manner.During an interview on 5/18/26 at 2:19 p.m., Director of Nursing (DON) stated medication errors were identified by nursing staff, providers, and daily medication order reviews completed by nursing leadership. DON stated medication errors were reviewed weekly during Tuesday risk meetings with leadership and root cause analysis was completed verbally; however, findings were not formally documented. DON stated the facility identified increasing medication errors beginning in February 2026 and implemented nursing education in March 2026 regarding the medication management process from provider order through medication administration. DON further stated the facility identified transcription errors, omitted medications, and medication availability issues as ongoing concerns. DON verified the facility was not currently monitoring medication error trends and did not have data regarding medication error types. DON stated the facility did not currently document medication audits and the EHR did not have the capability to generate reports identifying missed medication doses without manually reviewing each resident's MAR/TAR. DON further stated medication errors continued after interventions were implemented and additional medication errors occurred during April 2026. DON stated more than 50 percent of registered nurses had turned over recently and medication transcription training was completed by preceptors. DON further stated competency validation was not formally completed for all education provided and March 2026 medication education consisted primarily of staff meetings and staff sign-off sheets.Further review identified the facility's corrective actions following medication errors primarily consisted of staff education and verbal reinforcement; however, the facility was unable to provide evidence of competency validation, sustained auditing, trend analysis, or effective monitoring systems to ensure physician orders were accurately transcribed, laboratory monitoring was completed, and medications were administered as orderedFacility policy, Adverse Consequences and Medication Errors Policy, revised 8/6/24, identified the interdisciplinary team would evaluate medication usage to prevent and detect medication-related problems and adverse consequences. The policy further identified residents receiving medications with potential adverse consequences would be monitored to ensure consequences were promptly identified and reported. The policy identified Charter House would minimize adverse consequences by following clinical guidelines for medication use, administration, and monitoring. The policy further identified medication orders would be evaluated for appropriate dose, administration, and monitoring and significant medication-related errors required immediate action to protect resident safety and welfare. The policy identified significant medication-related errors and adverse consequences were to be reviewed through the Quality Assurance and Performance Improvement (QAPI) process.Facility policy, Medication Holds Policy, revised 3/14/24, identified medication hold orders were required to include a restart date or time and hold orders without a restart date or time would be considered discontinued. The policy further identified nursing staff were required to document reasons medications were not administered within the medication administration record (MAR) and the health care provider was required to provide clear direction regarding when medications were to be restarted following a hold order

Based on observation, interview, and record review the facility failed to ensure transmission-based precautions (TBP) were initiated for 1 of 1 resident (R64) suspected of having clostridioides difficile (c-diff-a highly contagious bacteria that causes significant diarrhea, often attributed to antibiotic use). Findings include: R64's admission Minimum Data Set (MDS) dated [DATE], indicated mild cognitive impairment, no behaviors, substantial assist with activities of daily living (ADL's), transferring, and bed mobility. It also indicated incontinence. R64's diagnosis list includes incontinence and urinary tract infection's. R64's care plans included R64 required an assist of 1 for transfers, bed mobility, toileting, toilet hygiene, and ADLs. During interview and observation on 10/14/24 at 3:41 p.m., R64 stated diarrhea episodes started a couple days ago. No indication of transmission-based precaution noted on door. No personal protective equipment (PPE) noted outside room. During interview on 10/15/24 at 2:09 p.m., nursing assistant (NA)-A stated occupational therapy assists R64 with getting ready for the day and nursing staff assist R64 with cares and toileting the rest of the day. Nursing assistants also assist the nurses with positioning during dressing changes. NA-A stated R64 had loose stools for at least the past two days and received antibiotics for a urinary tract infection. NA-A stated loose stools are immediately reported to the nurse. During interview and observation on 10/15/24 at 2:12 p.m., R64 reported having loose stools for the past couple days that were loose enough to have occasional bowel incontinence. R64 was told by the facility medical provider the morning of 10/15/24 a stool sample was going to be collected. No indication of transmission-based precautions noted on resident's door. No PPE noted outside room. Progress notes indicated R64 was started on cefdinir (antibiotic) for UTI on 10/9/24. On 10/10/24, R64's antibiotics were changed from cefdinir to Augmentin. A large loose stool was noted on 10/11/24. R64 refused antibiotics due to having loose stools on 10/13/24. Two medium loose stools were documented on 10/14/24. October medication administration record (MAR) confirmed R64 received cefdinir on 10/9-10/11 and Augmentin 10/10/24-10/15/24. A provider order dated 10/14/24 indicated: -stool sample to rule out C-diff -hold Miralax, senna [stool softeners] if [R64] is having loose stools -given antimicrobial resistance on recent urine culture, would prefer to not change antibiotic at this time and would encourage [R64] to take Augmentin if [R64] is willing. Provider progress notes dated 10/15/24 indicated R64 had loose stools and C-diff/stool assessment was ordered 10/14/24 but not yet obtained. It also indicated R64 refusal to take prescribed antibiotic. During interview 10/15/24 at 2:48 p.m., registered nurse (RN)-A stated R64 has had several loose stools and was recently placed on Augmentin. RN-A stated the interdisciplinary team (IDT) met and discussed R64's loose stools, orders for stool sample, and placing R64 on C-Diff precautions. During interview on 10/15/24 at 4:41 p.m., the infection preventionist (IP) stated there is an IDT meeting every day however did not attend that morning due to a quality improvement meeting. The IP stated progress notes are reviewed every morning for documentation of any infection related issue. Residents are placed on TBP when suspected of having symptoms outside of their baseline and prior to when ordered labs are obtained. IP stated the provider did not want to adjust R64's antibiotics due to history of antibiotic resistance and wanted to rule out C-Diff. During observation on 10/15/24 at 4:29 p.m., no TBP or PPE were noted outside R64's room. During interview and observation on 10/15/24 at 4:49 p.m., the IP confirmed the facility received an order for C-diff testing on 10/14/24, was processed the afternoon on 10/14/24. IP confirmed R64 should be on TBP pending lab results. IP stated an email was sent to the care coordinator and nurse manager the morning of 10/15/24 indicated R64 is to be on precautions. IP confirmed there was no TBP or PPE located outside of R64's room. IP stated a clarification email was sent the morning of 10/15/24 confirming R64 should be on TBP while waiting for lab sample to be obtained. During interview on 10/16/24 at 12:25 p.m., the director of nursing (DON) stated if staff request orders from providers for testing for gastrointestinal illness, the expectation would be for resident's to immediately be placed on transmission-based precautions. This is necessary to prevent the spread of potential infections to other residents and staff. A policy titled Isolation Precautions: Modified Contact Procedure- Mayo clinic Health System, Rochester dated 7/8/24, indicated a purpose of provide personnel with the direction to safely care for a patient requiring Modified Contact Precautions to prevent the transmission of diseases spread by contact, specifically Clostridiodes difficile (C. Difficile), C. auris, or norovirus infections. Section titled Procedure indicated use Modified contact Precautions for suspected or confirmed Clostridiodes difficile (C. difficile), C. auris, or norovirus infections because these organisms require cleaning with bleach. A policy titled Clostriodioides Difficile (C-diff) guideline-Rochester dated 7/3/23 indicated Suspected infections of clostridium difficile will be verified by culture or by evidence of positive cytotoxin assay. Nursing should be alert to isolate residents with any symptoms when suspected and prior to obtaining confirmatory lab results.

Based on interview and document review, the facility failed to ensure 3 of 5 (R5, R114, R9) residents were appropriately vaccinated against pneumococcal disease upon admission and/or offered updated vaccination per Centers for Disease Control (CDC) vaccination recommendations. Findings include: R5 was [AGE] years old, admitted [DATE]. R5 received PCV-13 on 6/8/15 and PPSV-23 on 9/19/17. There was no documentation to support R5 had a discussion with a medical provider regarding the PCV-20 vaccine, according to current CDC guidance for vaccines. R9 was [AGE] years old, admitted on [DATE]. R9 received PCV-13 on 4/26/17 and PCV-23 on 12/3/18. There was no documentation to support R9 had a discussion with a medical provider regarding the PCV-20 vaccine, according to current CDC guidance for vaccines. R114 was [AGE] years old, admitted on [DATE]. R114 received PCV-13 on 1/29/16 and PPSV-23 on 10/1/99. There was no documentation to support R114 had a discussion with a medical provider regarding the PCV-20 vaccine, according to current CDC guidance for vaccines. During interview on 10/15/24 at 2:26 p.m., the IP stated immunizations are reviewed upon admission for COVID, pneumococcal, respiratory syncytial virus (RSV) and influenza. If residents have had PCV-13 and PPSV-23, they are deemed fully vaccinated and not triggered to receive PCV-20. IP stated she would ask facility providers if resident's were evaluated for eligibility of PCV-20. During interview on 10/16/24 at 9:30 a.m., the IP stated facility providers reported immunizations were generally deferred to the residents' outside primary care provider due to residents' stay being short term. IP reviewed medical records and confirmed R9, R114, and R5 were eligible to receive PCV-20 however, the records lack any documentation the vaccines were offered or evaluated for appropriateness. During interview on 10/16/24 at 12:25 p.m., the DON stated she would expect vaccines to be offered to residents who are eligible. A policy titled Vaccination of Resident's Policy-Rochester dated 7/2/24 indicated All residents will be assessed for current vaccination status prior to admission. Vaccinations will be offered annually or as indicated, unless medically contraindicated. Policy notes section of the policy states Vaccinations are offered to short Term Rehabilitation Center residents on admission, annually, and as needed. CDC pneumococcal guidelines located at https://www.cdc .gov/vaccines/vpd/pneumo/hcp/pneumo-vaccine-timing.html, identified for adults [AGE] years of age or older, staff were to offer and/or provide based off previous vaccination status as shown below: Received PCV-13 at Any Age AND PPSV-23 AFTER Age [AGE] years: aa) Use shared clinical decision-making to decide whether to administer PCV-20. If so, the dose of PCV-20 should be administered at least 5 years after the last pneumococcal vaccine.

Based on observation, interview and document review the facility failed to immediately report an allegation of abuse to the State Agency (SA) for 1 of 1 resident (R1) reviewed for allegations of abuse. Findings include: A Nursing Home Incident Report submitted to the state agency on 8/12/24 at 5:10 p.m. indicated R1 alleged rough care with nursing assistant (NA)-A on 8/12/24 at 1:50 a.m. and the resident outcome was fear and anger. R1's significant change Minimum Data Set (MDS) dated [DATE] indicated R1 had intact cognition and no noted behaviors. R1 had limitation in range of motion on one side of lower extremity and was dependent with toileting, transfers, and toileting hygiene. R1's progress note dated 8/12/24 at 3:48 a.m. indicated R1 had refused cares x 2 by certified nursing assistant (CNA) by approximately 1:50 a.m. R1 was educated of the risks and benefits of refusing cares, R1 then began breathing erratically, shouting, being verbally aggressive to writer becoming visibly overwhelmed. Writer allowed R1 to vent their feelings. R1 suddenly stopped speaking and asked writer why they were in their room pestering them. Writer then explained the risks and benefits of bed changes for incontinent patients. R1 then shouted at writer, Stop hurting me. Writer reminded R1 that they had not been involved with their cares this shift and R1's affect visibly relaxed and breathing slowed. Writer explained they have no intention of bringing any kind of harm to resident and stated in fact that is why I am here now to make sure you are safe and cared for. R1 stated, then make sure that girl doesn't come in here again, she's the one that hurts me, and I have the right to refuse. R1's respirations increased and became visibly overwhelmed again. During an observation and interview on 8/28/24 at 10:30 a.m. R1 was seated in a recliner in her room with the legs elevated. R1 stated she did have a complaint about a girl that worked the night shift a couple weeks ago, she was not listening to me and said she needed an answer to put in her report, it was very upseting and my preference would be for her to never work with me again. She did not watch where my foot went when rolling me and hurt my foot, my foot had a bruise on it, it's not there anymore, she was not careful, R1 pointed to her right foot. My preferencewould be to not have people taking care of me if they are going to hurt me. During a phone interview on 8/28/24 at 4:50 p.m. nursing assistant (NA)-A stated, she was responsible for R1's cares on 8/12/24 from 12:00 a.m. until 6:30 p.m. R1 had refused incontinence cares from me twice, she did not want me in there, she had said something about me bruising her, after the second refusal this was reported to my nurse between 1:30 a.m. and 2:00 a.m. and was no longer able to provide anymore cares to R1. NA-A denied the allegations. During a phone interview on 8/29/24 at 9:53 a.m., licensed practical nurse (LPN)-A stated, she was the nurse that worked the night shift on 8/12/24 when R1 alleged abuse from nursing assistant (NA)-A. R1 was very upset it took almost an hour to get R1 calmed down. R1 said NA-A hurt her, so NA-A was not allowed back into R1's room. This incident was reported to the charge nurse and documented in the progress note right after the situation was handled. During an interview on 8/28/24 at 9:48 a.m., registered nurse (RN)-A stated, she was working offsite that day and was reviewing the 24-hour progress notes and saw R1's progress note that identified R1 stated, then don't let that girl come in here again, she's the one who hurts me, and I have the right to refuse. R1 then became visibly overwhelmed. That was a red flag. (RN)-A stated the allegation of abuse that was alleged by R1 on 8/12/24 at 1:50 a.m., should have been reported immediately but no later than 2 hours to the state agency because she felt it was a potential allegation of physical abuse. During a phone interview on 8/28/24 at 5:16 p.m., RN-B stated, she had worked on 8/12/24, and was the charge nurse, the night nurse said something about R1 and the NA-A got into an argument or something, the nurse said she documented it. Due to an unawreness of abuse allegations it was not reported. We used to submit reports to the state agency ourselves, recently we were directed to report to the DON. The DON does all of the reporting to the state agency. RN-B was unsure of the timeline for reporting abuse. During a phone interview on 8/29/24 at 10:32 a.m., operations specialist (OS)-A stated, in other states she had worked in, abuse should be reported immediately to the state agency but no later than 2 hours, but because this facility's policy with abuse reporting was to report within 24 hours with no injury, we were trying to figure out if we were doing it right. During an interview on 8/29/24 at 10:55 a.m., interim director of nursing (IDON) stated any abuse allegation should be reported immediately but no later than 2 hours to the state agency. DON indicated the facility policy would be revised immediately to meet regulation and new education would be provided to staff. Review of the facility's Vulnerable Adult Reporting and Investigation Procedure dated 3/20/24 was not consistent with the requirements for reporting allegations of abuse. The procedure included: The nurse in charge, Nurse Manager, or designee must submit a report to Office of Health Facility Complaints (OHFC) through the Nursing Home Incident Reporting portal online within twenty-four hours of the incident's discovery, or within two hours when the alleged maltreatment involves serious bodily injury or death. State Operations Manual Appendix PP - (Rev. 211, 02-03-23) included S483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

Based on interview and document review the facility failed to ensure all residents were protected after R1 reported an allegation of abuse and was protected. This had the potential to affect all other residents residing in the facility at the time of the allegation. Findings include: A Nursing Home Incident Report submitted to the state agency on 8/12/24 at 5:10 p.m., indicated R1 alleged rough care with nursing assistant (NA)-A on 8/12/24 at 1:50 a.m., and the resident outcome was fear and anger. R1's significant change Minimum Data Set (MDS) dated [DATE] indicated R1 had intact cognition and no noted behaviors. R1's progress note dated 8/12/24 at 3:48 a.m. included R1 had refused cares x 2 by CNA by approximately 1:50 a.m. R1 was educated of the risks and benefits of refusing cares, R1 then began breathing erratically, shouting, being verbally aggressive to writer becoming visibly overwhelmed. Writer allowed R1 to vent their feelings R1 suddenly stopped speaking and asked writer why they were in their room pestering them. Writer then explained the risks and benefits of bed changes for incontinent patients. R1 then shouted at writer, Stop hurting me. Writer reminded R1 that they had not been involved with their cares this shift and R1's affect visibly relaxed and breathing slowed. Writer explained they have no intention of bringing any kind of harm to resident and stated in fact that is why I am here now to make sure you are safe and cared for. R1 stated, then make sure that girl doesn't come in here again, she's the one that hurts me, and I have the right to refuse. R1's respirations increased and became visibly overwhelmed again. During a phone interview on 8/28/24 at 4:50 p.m., nursing assistant (NA)-A stated, she was responsible for R1's cares on 8/12/24 from 12:00 a.m. until 6:30 p.m. R1 had refused incontinence cares from me twice, she did not want her in there, she had said something about me bruising her. After R1's second refusal it was reported to my nurse between 1:30 a.m. and 2:00 a.m. NA-a stated she was no longer able to provide cares to R1. NA-A further stated, she had no supervision while providing repositioning and incontinence care to other residents until 6:30 a.m. During a phone interview on 8/29/24 at 9:53 a.m., licensed practical nurse (LPN)-A stated, she was the nurse that worked the night shift on 8/12/24 when R1 alleged abuse from nursing assistant (NA)-A. R1 was very upset it took me almost an hour to get R1 calmed down. R1 said NA-A hurt her, so NA-A was not allowed back into R1's room. LPN-A stated NA-A did provide care to the other residents unsupervised until the end of her shift on 8/12/24 at 6:30 a.m. During an interview on 8/28/24 at 10:54 a.m., interim director of nursing (IDON) stated that NA-A was allowed to work with other residents after the allegation of abuse and should not have been working with other residents unsupervised. Review of facility policy, Vulnerable Adult Reporting and Investigation Procedure, dated 3/20/24, identified . Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents. Immediately remove the implicated personnel from further contact with the resident, and ensure the personnel is accompanied by other personnel during any direct contact with other residents. Implement one of the following: Partner the implicated personnel under continuous, direct observation with other personnel (i.e., implement paired care); or Re-assign the implicated personnel to an appropriate non-resident care role as available, or: Place the implicated personnel on temporary paid administrative leave.

Based on interview and document review the facility failed to have a policy consistent with federal requirement for reporting allegations of abuse to the state agency immediately but no later than two (2) hours. This deficient practice had the potential to affect all residents in the facility. Findings include: Review of the facility's Vulnerable Adult Reporting and Investigation Procedure dated 3/20/24 included: The nurse in charge, Nurse Manager, or designee must submit a report to Office of Health Facility Complaints (OHFC) through the Nursing Home Incident Reporting portal online within twenty-four hours of the incident's discovery, or within two hours when the alleged maltreatment involves serious bodily injury or death. During a phone interview on 8/29/24 at 10:32 a.m., operations specialist (OS)-A stated, in other states she had worked in, abuse should be reported immediately to the state agency but no later than 2 hours, but because this facility's policy with abuse reporting was to report within 24 hours with no injury, we were trying to figure out if we were doing it right. During an interview on 8/29/24 at 10:55 a.m., interim director of nursing (IDON) stated any abuse allegation should be reported immediately but no later than 2 hours to the state agency. IDON indicated the facility policy would be revised immediately to meet regulation and new education would be provided to staff. State Operations Manual Appendix PP - (Rev. 211, 02-03-23) included S483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

Based on interview and document review the facility failed to ensure manufacturers recommendations were followed for full body mechanical lift transfers for 1 of 1 resident (R1) who sustained serious injury with hospitalization . This deficient practice was issued at past non-compliance related to corrective action taken to ensure proper use of mechanical body lift prior to the survey. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment with diagoses that included stroke, seizure disorder, dementia, and hemiparesis or hemiplegia both sides of body. R1's MDS further indicated R1 was dependent for all activities of daily living (ADL)'s except for eating which required supervision or touch assist from staff. R1's care plan (CP) dated 8/27/17, indicated R1 was at risk for falls and injury related to right-side weakness following stroke, decreased peripheral vision on her right side, weakness, and debility. R1's ADL care plan identified R1 required extensive assistance from two staff for transfers usisng a Hoyer (full body mechanical lift). Facility incident report dated 2/06/24 at 12:15 p.m., indicated R1 had a fall during transfer to her wheelchair with the Hoyer lift. R1 was being transferred with the lift when straps malfunctioned causing R1 to flip out of the sling onto the floor. The report also indicated a black rubber piece was noted off the Hoyer where the sling attaches. Two nursing assistances were present during the transfer and reported they had checked the sling prior to lifting the resident. Director of nursing (DON) concluded while transferring R1 from bed to wheelchair, one of the loops on the sling came off the transfer bar, potentially caused by R1 body weight shift during the transition from bed to wheelchair. R1 fell with the impact to the right side of her body and head. Bar end guard found on the floor which aide stated was in place at the time of connecting the sling to the transfer bar. R1's progress note dated 2/6/24 at 1:38 p.m., indicated, at 12:15 p.m. two staff were transferring R1 with the Hoyer lift from her bed to her wheelchair, the strap closest to R1's left shoulder came off the Hoyer, causing R1 to fall to the floor. Staff reported R1 hit her head on the floor causing a large hematoma on her left forehead and blood was noted on her tongue. CNP was immediately at bedside and family, hospice and emergency medical services (EMS), notified. R1 was transported to hospital at 1:00 p.m. R1's emergency department (ED) to hospital admission summary dated 2/6/24, indicated she was found to have a right intertrochanteric femur fracture on radiographs. Plan was made to proceed with inpatient hospitalization under palliative care medicine with comfort cares and no plan for surgical interventions. During interview on 2/12/24 at 4:51 p.m., nursing assistant (NA)-A stated on 2/6/24 she was assisting NA-B to get R1 transferred out of her bed to the wheelchair for lunch. NA-A stated she attached the upper two loops to the lift and the left leg side and NA-B attached the right leg loop to the lift. R1 was raised up off the bed. NA-B was moving the machine and NA-B pushed the button on the machine for R1's weight when the right shoulder loop came off the machine. The loop of the sling came off the hook of the lift along with the black rubber piece that was supposed to prevent the sling loops from coming detached from the hook. NA-A stated R1 was safely lifted above the bed for 30 seconds or more before they had moved her when the fall happened. NA-A was still unsure why the fall had happened but thought maybe the weight was not distributed causing a slack in the on loop resulting in the loop coming off. NA-A reported she felt the machine had functioned correctly during the transfer. NA-A identified she was provided education via computer training and one on one education with the DON before she was able to return to work. During interview on 2/13/24, at 9:16 a.m., NA-B stated on 2/6/24 she was assisting NA-A with R1's transfer from her bed to wheelchiar with the Hoyer. NA-B stated she and NA-A had attached R1's sling to the lift as they always had done. R1 was raised up over the bed for a few minutes when NA-A moved the lift away from the bed. NA-B stated she had supported R1's legs for comfort during the transfer while she was in the air. When NA-B pushed the button for R1's weight she heard a pop sound and the sling loop had come off the hook. NA-B stated her and NA-B had made sure the sling was attached correctly and R1 was where she was supposed to be in the sling before they moved R1. NA-B stated the incident happened so fast and was unable to articulate what had gone wrong. NA-B stated she was off one day during the investigation. She was provided education and had to demonstrate how to safely use the lift to the nurse manager before she was able to return to the floor and provide care to the residents. During interview on 2/12/24 at 3:08 p.m., director of nursing (DON) stated she had investigated the incident and found, it had to be operator error which caused R1's fall. One of the NA's stated they had multiple loops on one of the hooks of the lift versus only one per hook, making it hard to identify the amount of slack on the loop. DON indicated the weight of R1 must have shifted and caused the loop to slip off the hook, resulting in R1's fall. DON stated during the transfer the correct sling size was used. After interviewing NA-A and NA-B they were put on administrative leave pending investigation and re-educated on safe lift practices before they were able to return to work. DON stated all nursing staff on the unit were required to complete the online lift and transfer education and to complete teach back to nurse managers before they were allowed to work on the unit; the education was completed on 2/8/24 and 2/9/24. DON reported the lift and the sling were removed (tagged out) pending investigation from service immediately and fully inspected by maintenance before returned to service. DON reported the staff were all trained on which sling to use and are arranged by size and type in the sling closet on the unit. Therapy decides and assessess for appropriate lift and sling for each resident and this is identified in the residents closet and on the care lists in the chart. Facility document titled, Portable Lift Equipment, Safe Patient Handling, undated, directs staff to Use 2 staff when lifting patients. Ensure the loops are secure on the hooks. Failure to do so, may result in injury to the patient. Work within the weight capacity limits of the lift. Check to ensure the battery has enough charge time. If unsure replace with fully charged battery. Check the slings to ensure there are no tears, torn stitching, or other issues. EZ Way Smart Lift (Trademark) 500, 600 & 1,000 lb. CapacitiesForm 2-174 REV. 06/14/2023, directions for attaching the slings Attach the straps located near the patient ' s shoulders to the lift hanger bar hooks using the same length and color of loop strap on each side. Example: If you choose the shortest loop on the strap for the right shoulder, you must use the shortest loop on the strap for the left shoulder.Make a final check of all four loop attachment points to ensure each loop is sufficiently attached to the respective hook of the hanger bars. To lift Push the UP button on the hand control to initiate the upward motion of the lift. Continue the upward motion until there is tension on the legs of the sling, making sure all the loops on the sling are securely hooked on the hanger bars.

Based on observation, interview and document review, the facility failed to ensure a self-administration of medication (SAM) assessment was completed for 1 of 1 resident (R1), reviewed for medication administration . Findings Include: R1's significant change minimum data set (MDS) assessment dated [DATE], indicated R1 was cognitively impaired and totally dependent on staff for bed mobility, dressing and toilet use. R1 diagnosis included aphasia (language disorder caused by damage in a specific area of the brain that controls language expression and comprehension; it leaves a person unable to communicate effectively with others), and respiratory failure. R1's face sheet included diagnosis of cerebral vascular accident (CVA, or a brain attack, is an interruption in the flow of blood to cells in the brain), non-Alzheimer's dementia (a variety of disorders characterized by pathological changes involving various cortical and subcortical circuits), hemiplegia (paralysis of one side of the body), seizure disorder, asthma, chronic obstructive pulmonary disease (a condition involving constriction of the airways and difficulty or discomfort in breathing). R1's care plan updated 10/6/23, indicated pulmonary/oxygen use with pneumonia history and interventions included nursing to provide medications and oxygen supplements per orders and to encourage cough and deep breathing exercises especially after each pair of nebulizer's. R1's physician orders dated 9/5/23, included ipratropium 0.5 milligram(mg)-albuterol 3 mg (2.5 mg base)/3 milliliters (ml) nebulization solution (3ml) ampule for nebulization; ipratropium-albuterol (duoneb) 0.5-2.5 mg/3 mL nebulizer solution. Inhale 3 ml by nebulization four times a day. During observation on 11/14/23 at 12:41 p.m., registered nurse (RN)-A emptied a vial/ampule of duoneb into nebulizer container and placed face mask onto R1's face. After set up, with duoneb being administered via inhalation, RN-A stated R1 had a self-administration of nebulizer and could be left alone while nebulizer treatments were ongoing. RN-A left R1's room. During observation on 11/14/23 at 1:01 p.m., R1 was in room alone while nebulizer treatment was being administered via face mask. R1's medical record lacked a self-administration of medication (SAM) assessment. During interview on 11/14/23 at 3:00 p.m., RN-A stated her understanding was R1 had a SAM assessment and could be left alone since there was also a camera monitor in R1's room. Care coordinator, RN-C, mentioned during interview with RN-A, R1 did not have a SAM assessment and should not be left alone during nebulizer treatment. During interview on 11/14/23 at 3:05 p.m., nurse manager, RN-B verified R1 did not have a SAM assessment and should not be left alone during nebulizer treatment administration. During interview on 11/16/23 at 12:06 p.m., with director of nursing and quality assurance nurse (RN)-D stated residents should have a SAM assessment completed to ensure resident could be left alone based on the assessment findings. The facility policy for self administration of medication was requested and was not received.

Based on observation, interview and document review the facility failed to ensure gloves were changed during dressing change for 1 of 1 resident (R109) reviewed for skin tear. Findings Include: R109's face sheet included diagnosis of unspecified dementia, and history of falling. R109's physician orders dated 11/14/23, indicated check wound for drainage. Cleanse with normal saline, pat dry leave steristrips in place for seven days or until falls off. During observation on 11/14/23 at 1:53 p.m., registered nurse (RN)-C entered R109's room. RN-C donned gloves and removed old transparent dressing from skin tear to R109's right thigh. RN-C did not change gloves. RN-C then took saline and placed onto 4x4 gauze and cleaned the skin tear to R109's right thigh. RN-C did not change gloves and then placed steristrips onto R109's skin tear. RN-C assisted R109 to pull up pants and then removed gloves and sanitized hands. During interview on 11/14/23 at 2:03 p.m., RN-C verified had not changed gloves after removing R109's old dressing, cleaning the skin tear with saline and gauze and then applying steristrips to R109's right thigh skin tear. RN-C stated she normally would have changed gloves but had not done so during R109's observed dressing change to right thigh skin tear. During interview on 11/16/23 at 12:06 p.m., with director of nursing and quality assurance nurse, RN-D stated it was the expectation hands should be sanitized before cares, gloves donned and when soiled dressings were removed, glove were to be changed and hand sanitized. The facility Hand Hygiene policy updated 10/4/21, indicated hand hygiene must be performed in patient care settings: after contact with blood or body fluids and after glove removal; when moving from contaminated body sit or activity to another body site during patient care (e.g., after changing a wound dressing and then brushing the patient's teeth).

Based upon observation, interview and document review, the facility failed to ensure residents were free from physical restraints for 1 of 1 resident (R1) reviewed. Findings include: R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R1 was dependent on almost all activities of daily living (ADLs) and did not use restraints. R1's Medical Diagnosis Form (undated) indicated the following diagnosis: diabetes, Aphasia from stroke, hemiparesis, hemiplegia, muscle weakness, morbid obesity, abnormal posture, debility, unspecified dementia. During an observation on 11/13/23 at 6:46 p.m., R1 was in the dining room, right arm was secured to right arm rest of wheelchair with two Velcro straps. Under same right arm was a wedge shaped cushion that elevated R1's elbow. No visible skin abrasions, tears, or issues observed on right arm. R1's clinical physician orders were reviewed and lacked orders for a restraint. R1's most recent care plan dated 9/8/23 indicated assistance with positioning and risk of falls due related to weakness, hemiparesis, hemiplegia, but had no indication of restraint or durable medical equipment use. During interview on 11/14/23 at 2:37 p.m., R1 stated they don't remember who ordered the Velcro straps for her arm and wheelchair, or how long they had been used. During interview on 11/14/23 at 3:03 p.m., Registered Nurse (RN)-E, stated only been employed at facility for around three months, no training given regarding R1's Velcro straps, only that they're present for safety and protection. RN-E further stated no mention by facility that the straps were used as a restraint. During interview on 11/14/23 at 3:32 p.m., Registered Nurse (RN)-B, stated not sure how long ago the Velcro straps were ordered or implemented. During interview on 11/15/23 at 7:20 a.m., RN-B acknowledged R1's current care plan does not mention reason for use, an assessment, or have a record of a physical device evaluation, or how to evaluate use of straps for R1, and mentioned the straps are not a restraint. RN-B indicated they are being used as a safety device due to R1's lack of use of her right side. RN-B also stated no record of staff training for Velcro straps. RN-B further stated the facility found a durable medical equipment (DME) order, dated 5/31/19, which was only for a swing away lateral pad. No other documentation was provided by facility. RN-B stated facility expectations are every resident is receiving the appropriate care and devices as needed and each staff member is aware, educated, and trained on use of DME and competencies are evaluated. RN-B also stated a resident using any DME would receive ongoing evaluation of DME usage to ensure safe and appropriate use. RN-B further stated an expectation is care plans are properly followed, and evaluated. During an interview on 11/15/23 at 8:02 a.m., Nursing Assistant (NA)-B, stated received training around two and half years ago regarding how to use the Velcro straps for R1, but believed it was an informal, on-the-job type of instruction and training. NA-B further stated does not remember receiving training or instruction on charting and assessment of the straps and has not been charting these areas. Facility restraint policy requested. Director of Nursing (DON) stated they don't have one because they don't use restraints, documentation provided was a copy of the [NAME] of Rights.

Based on interview and document review, the facility failed to provide ongoing assessments and monitoring after a respiratory change of condition was identified for 1 of 1 residents (R1) who sustained a medical emergency requiring administration of oxygen. R1 was found without a pulse or respirations, and subsequently died . This resulted in an Immediate Jeopardy (IJ) for R1. The IJ began on [DATE], when the facility failed to provide ongoing assessment of R1 who was having shortness of breath and low oxygen saturation levels. R1 was found deceased on [DATE]. The administrator and nurse manager were notified of the IJ on [DATE], at 2:45 p.m. The IJ was removed, and the deficient practice was corrected on [DATE], prior to the start of the survey and was therefore Past Noncompliance. Findings include: R1's Face Sheet dated [DATE], indicated R1 was admitted to the facility for short term care rehabilitation, with diagnosis's of cardiovascular disease, heart failure, hypertensive heart, stage 4 chronic kidney disease, leakage of heart valve prosthesis, and aortic valve insufficiency. R1's health history and physical exam dated [DATE], by R1's primary care physician, documented R1 was being admitted to the facility with acute on chronic diastolic (congestive) heart failure. R1's 5-day Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact, exhibited no signs of [CONDITION(S)] (temporary mental state characterized by confusion and anxiety), R1's MDS indentified R1 did not use oxygen. R1's care plan printed on [DATE], directed R1 anticipates discharging and returning to his independent living venue and resuming home health care, at risk for fluid imbalance related to diuretic medication, has cardiac and renal disease and placed on a fluid restriction, activities of daily living decreased functional abilities related to recent hospital stay and weakness, nursing staff to provide assistance to reposition and off load at least every two-three hours and as needed in bed and chair and monitor oxygen saturation. R1's admission physician medication order dated [DATE], included [MEDICATION(S)] ([MEDICATION(S)] nebulizer) inhalation nebulization solution as needed for wheezing or shortness of breath. R1's Cardiology Hospital Discharge Summary dated [DATE], indicated on [DATE], R1 underwent a transcutaneous aortic valve replacement for severe calcific aortic valve stenosis (replacement of calcific heart valve). A Progress Note dated [DATE], at 4:00 p.m. by registered nurse (RN)-H documented R1 continues to have a persistent productive cough with whitish sputum. R1 had one dose of [MEDICATION(S)] nebulizer with some relief and lung sounds are diminished. A Progress Note dated [DATE], at 9:36 p.m. licensed practical nurse (LPN)-A documented R1's oxygen saturation was 79% (normal saturations are considered to be 95%-100%; 79% reflects severe [CONDITION(S)] and a medical emergency) on room air and he has shortness of breath while resting. Oxygen (O2) standing orders activated and R1 was placed on 2 liters (lpm) of oxygen per nasal cannula. O2 saturation level improved to 94% on 2 lpm. In-basket notification was faxed to certified nurse practitioner (CNP). LPN-A indicated During non-business hours, the providers In-Basket is monitored by the on-call provider. It is the responsibility of the on-call provider to monitor faxes from the In-Basket and to respond to the facility. It is unknown why the on-call provider did not respond to the facility fax. A Progress Note dated [DATE], at 7:24 a.m. RN-A documented R1 was observed at 5:03 a.m. on [DATE], and that he passed away peacefully in his sleep. There were no signs of life. House supervisor RN-B was paged, and she confirmed no signs of life (no vital signs, no blood pressure, and not breathing). R1's medical record was reviewed between [DATE] to [DATE], and no respiratory documentation of R1's level of consciousness, breathing rate, pattern and effort, skin color, chest configuration, or symmetry of chest expansion was documented. During an interview on [DATE], at 4:45 p.m. nurse manager (NM)-A stated from her chart review, she did not find documentation by RN-A that she provided any care, assessments and monitoring for R1 during her overnight shift from [DATE] - [DATE]. During an interview on [DATE], at 8:06 a.m. primary care physician (PCP) stated R1 has a lot of comorbidities from his hospitalization and additionally his advanced age. PCP stated his expectations if the facility would follow their protocol for care of residents. PCP further stated if there is no documentation in the chart, it is hard to verify what care was provided. During an interview on [DATE], at 8:45 a.m. nursing assistant (NA)-D stated she received an end of shift report from NA-A at approximately 10:00 p.m. but there was no mention of R1 having oxygen on. When NA-A rounded on R1 at approximately midnight, R1 was noted to not have oxygen or his C-PAP on. NA-D stated nursing assistants are supposed to check and change R1 every two hours, but he was not observed until approximately 3 a.m. by NA-E. NA-D explained at 3:00 a.m. NA-E had observed R1 was moving so she did not check or change or reposition him. At approximately 4:58 a.m. NA-D went to R1's room and found out that he had passed away. During an interview on [DATE], at 8:57 a.m. LPN-A stated on [DATE] she worked the 6 a.m. to 10 p.m. shift and handed off care to RN-A at the end of her shift. LPN-A informed RN-A that NA-A obtained R1's O2 saturation of 84% on [DATE], at 7:35 p.m. and placed the Dynmap Vital Signs Machine print out slip on the nurses' desk instead of notifying her. LPN-A stated by the time she assessed R1 on [DATE], at approximately 9:30 p.m. R1's O2 saturation had decreased to 79%. Further, R1 was experiencing shortness of breath and a high respiratory rate. LPN-A informed RN-A that she started R1 on oxygen at 2 lpm., per the Standing Order, and sent an in-basket message to CNP. During an interview on [DATE], at 9:45 a.m. NA-C stated if an abnormal vital sign is obtained, the nursing assistant (NA) is required to immediately take it to the nurse in charge of the resident. The NA must stop all other activities and report to the nurse. During an interview on [DATE], at 1:00 p.m. RN-A stated she had not been assigned to the hallway that R1 resided, usually worked the other hallway, so she had limited experience in providing care for R1. RN-A acknowledged that LPN-A provided an end of shift report on R1's oxygen status. RN-A stated the end of shift report from LPN-A, indicated that R1 appeared to have improved with the 2 lpm oxygen via the nasal cannula. RN-A indicated she checked on all the residents at the beginning of her shift and when she observed R1, he appeared to be sleeping and did not seem in distress. RN-A stated she did not wake R1 or complete an assessment. RN-A stated she did not document her observation and does not chart every interaction she had with a resident. RN-A stated she did not have enough time to chart every observation or interaction she had with a resident. RN-A stated it is the nursing assistants job to check and change and reposition R1 every two hours, but they did not complete that task so they didn't see how R1 was doing and if his condition had further detiorated. RN-A acknowledged she did perform assessments or chart any interaction with R1 until approximately 4:45 a.m. on [DATE], when R1 was found deceased . RN-A stated R1 was cold, and his hands and arms were getting stiff. On [DATE], at 8:37 a.m. attempts to contact NA-A were unsuccessful due to NA-A being out of the country. During an interview on [DATE], at 10:45 a.m. nurse manager (NM)-A summarized from her investigation that NA-A obtained an oxygen level of 84% but did not immediately notify the nurse in charge of the resident. Further, NA-A continued to obtain other residents vital assigns before she placed the vital sign slip on the nurse desk, again did not notify the nurse. NM-A stated NA-A indicated she did not understand that she should have notified the nurse immediately if an abnormal vital sign is obtained. During an interview on [DATE], at 9:06 a.m. director of nursing (DON) stated it appeared that nursing did not document any overnight contact with R1 on [DATE], until approximately 5:00 a.m. on [DATE], when R1 was found expired. DON stated all residents should be assessed after any change in condition and it should be documented in the residents chart. DON further stated there is a nurse assigned to every resident and the vital signs sheet for R1 should have gone directly to that nurse. During an interview on [DATE], 2:30 p.m. RN-B stated on [DATE], at approximately 4:45 a.m. she was notified that R1 had passed away. RN-B stated she confirmed that R1 did not have an apical pulse and was not breathing. RN-B indicated she did not inquire about R1's overnight care or code status. The Standing Orders for Post-Acute and Long-Term Care (Adapted for Charter House) policy revised date ,d+[DATE], directed that in a Change of Condition, if the oxygen saturation level is less than 88% from baseline room air, notify the clinician. No documentation could be found in R1's chart that a clinician responded to R1's low oxygen saturation. The past noncompliance IJ began on [DATE]. The immediate jeopardy was removed, and the deficient practice corrected on [DATE] after the facility implemented one-on-one coaching for RN-A and NA-A, and all staff were required to complete the watch-and-notify reeducation on resident assessment, documentation, oxygen delivery, and reporting of abnormal vital signs.

Based on interview and document review, the facility failed to follow the Provider Orders for Life Sustaining Treatment (POLST), did not initiate cardiopulmonary resuscitation (CPR) as per the residents wishes or follow the American Heart Association guidelines for CPR for 1 of 1 residents (R1). R1 was found without a pulse or respirations and staff did not initiate CPR and expired. This resulted in an Immediate Jeopardy (IJ) for R1. The IJ began on [DATE], at approximately 4:45 a.m. when R1 had no respirations or pulse, and CPR was not initiated. The administrator and nurse manager (NM)-A were notified of the immediate jeopardy on [DATE], at 2:45 p.m. The facility implemented corrective action and the IJ was removed on [DATE], at 2:45 p.m. However, non-compliance remained at the lower scope and severity of a D, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's Face Sheet dated [DATE], indicated R1 was admitted to the facility for short term care rehabilitation, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's 5-day Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact. R1's care plan printed on [DATE], directed R1 anticipates discharging and returning to his independent living venue and resuming home health care. On admission R1 confirmed and provided a copy of his POLST dated [DATE], directing that in the event of cardiopulmonary arrest, staff would attempt resuscitation and begin CPR. R1's POLST was confirmed by his primary care physician (PCP) on [DATE], indicating R1 confirms his wishes to be full code (perform chest compressions and rescue breathing) today and CPR components and outcomes discussed. A Progress Note dated [DATE], at 7:24 a.m. registered nurse (RN)-A documented R1 was observed on [DATE], at 5:03 a.m. and that he passed away peacefully in his sleep. There were no signs of life. House supervisor RN-B was paged, and she confirmed no signs of life (no vital signs, no blood pressure, and not breathing). The progress note does not document that CPR was attempted. During an interview on [DATE], at 4:45 p.m. NM-A stated R1 was a full code and CPR should have been started, but it was not. NM-A interviewed RN-A and asked her why she did not start CPR and RN-A shared it was the first time she had encountered a resident death and did not know what to do. NM-A provided the Emergency Medical Response (Code Blue and Rapid Response Teams) Policy - Rochester, unknown date, that directed on how to provide a coordinated response to a medical emergency but did not contain components from American Heart Association (AHA) recommendations that directed staff when to initiate basic life support or address how to ensure staff were familiar with facility policies related to CPR. NM-A stated she is unaware of what components of the AHA guidelines should be included in a policy or what assessments indicators would indicate if CPR should be initiated or not. NM-A stated there were no other policies for CPR. During an interview on [DATE], at 8:06 a.m. primary care provider (PCP) stated R1 has a lot of comorbidities from his hospitalization and additionally his advanced age. PCP stated his expectations if the facility would follow their protocol for care of residents. PCP further stated if there is no documentation in the chart it is hard to verify what care was provided. During an interview on [DATE], at 8:45 a.m. nursing assistant (NA)-D stated she received an end of shift report from NA-A at approximately 10:00 p.m. but there was no mention of R1 having oxygen on. When NA-A rounded on R1 at approximately midnight, R1 was noted to not have oxygen or his C-PAP on. NA-D stated nursing assistants are supposed to check and change R1 every two hours, but he was not observed until approximately 3:00 a.m. by NA-E. NA-D indicated NA-E observed R1 was moving at 3:00 a.m. so she did not check, change, or reposition him. At approximately 4:58 a.m. NA-D went to R1's room and found out that he had passed away. During an interview on [DATE], at 1:00 p.m. RN-A stated she had not been assigned to the hallway that R1 resides, usually works the other hallway, so she has limited experience in providing care for R1. RN-A indicated she checked on all the residents at the beginning of her shift and when she observed R1, he appeared to be sleeping and did not seem in distress. RN-A stated she did not wake R1 or complete an assessment. RN-A stated she did not document her observation and does not chart every interaction she has with a resident. RN-A acknowledged she did not assess or chart any interaction with R1 until approximately 4:45 a.m. on [DATE], when R1 was found deceased . RN-A stated R1 was cold, and his hands and arms were getting stiff. RN-A stated she knew R1 was a full code and should have started CPR but has not experienced a death of a resident and was not sure of what she should do. RN-A stated she is not familiar if the facility has a code blue policy. RN-A stated she thought the overnight nursing supervisor would tell her what to do but she did not inform RN-B that R1 was a full code. During an interview on [DATE], at 9:06 a.m. director of nursing (DON) stated it appeared that nursing did not document any overnight contact with R1 on [DATE], until approximately 5:00 a.m. on [DATE]. DON stated all residents should be assessing after any change in condition and it should be documented in the residents chart. DON further stated there is a nurse assigned to every resident and the vital signs sheet for R1 should have gone directly to that nurse. DON confirmed that Mayo Clinic Health System has their own CPR policy, they follow Lippincott Nursing Procedures and indicated she was unaware of the AHA guidelines. The IJ began on [DATE], was removed on [DATE], at 2:45 p.m. when the facility implemented one-on-one coaching for RN-A, all staff were required to complete the watch-and-notify reeducation on resident assessment, documentation, oxygen delivery, reporting of abnormal vital signs, attend Mock Code in-service training, and review the Emergency Medical Response Code Blue Procedure - Charter House revision and implementation dated [DATE], and Emergency Medical Response Code Blue Policy - Charter House [DATE] revision and implementation.

Based on observation, interview, and document the facility failed to ensure a medication brought from home was appropriately labeled and secured for 1 of 1 residents (R122), failed to ensure 2 of 2 medication carts were appropriately secured, and failed to ensure eye drops and insulin were labeled/refrigerated/and discarded in accordance with manufacturer's guidelines for 2 of 2 residents (R3, R13). Findings include: R122's admission Minimum Data Set (MDS) dated [DATE], included cognitively intact with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R122's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During observation on 4/4/22, at 2:56 p.m. an unlabeled, undated, home medication silver tube of [MEDICATION(S)] 1% topical gel was on R122's bedside table in room. During observation on 4/4/22, at 3:04 p.m. registered nurse (RN)-D applied [MEDICATION(S)] 1% topical gel that was on R122's bedside table to R122's right hip. During observation on 4/4/22, at 3:42 p.m. RN-D removed [MEDICATION(S)] 1% topical gel from R122's room and proceeded out to hallway. R122 stated the facility leaves her [MEDICATION(S)] gel at her bedside at all times, R122 stated she was not aware why it was now removed from her bedside table. Shortly after R122 put on call light to ask staff where it went as she was concerned that it was her tube of medication from home. When interviewed on 4/4/22, at 5:15 p.m. R122 stated RN-D had notified her the medication was removed from her room and placed in the East medication cart in hallway. When interviewed on 4/5/22, at 10:38 a.m. R122 stated she thought the [MEDICATION(S)] 1% topical gel was accidentally left on her bedside table and has noticed this happen previously. When interviewed on 4/5/22, at 3:05 p.m. R122 stated RN-D thought the [MEDICATION(S)] 1% topical gel had been left out accidentally prior to her shift During observation and interview on 4/5/22, at 3:53 p.m. surveyor requested to see inside medication cart for R122's medication slot and observed an unlabeled silver tube of [MEDICATION(S)] 1% topical gel was inside cart licensed practical nurse (LPN)-A confirmed the silver tube of [MEDICATION(S)] did not come from facility's pharmacy and was uncertain how it got in the medication cart. LPN-A confirmed facility should not leave medications at bedside LPN-A stated medications brought from home should be sent home with family or have facility pharmacy identify the medication and staff nurses would apply a proper label. When interviewed on 4/5/22, at 3:58 p.m. director of nursing (DON) stated expectation for medication reconciliation to be completed by nurse and physician for any home medications brought into facility. DON stated expectation for medications be in a locked box inside resident room as her concern is there would always be an opportunity for other staff or resident's to come in and take someone else's medications. DON stated the facility staff should be verifying any unlabeled medication with the pharmacy and obtain an identifying label for each medication. DON stated medication should be dated on the day it was opened, marked for expiration after 30 days, and expect if a medication was dated that it should be opened. On 4/5/22, at 4:02 p.m. Surveyor returned to East medication cart to complete the medication storage review, although no further concerns with labeling and storage were identified, LPN-A left his medication cart unlocked and walked away with RN-B while surveyor was still going through medication storage of cart. During observation and interview on 4/5/22, at 4:05 p.m. surveyor requested RN-G to secure the East medication cart. RN-G stated medications should never be left at the bedside as facility would want to ensure safety of all residents and staff. RN-G stated facility policy requires family to take medications from home back out of the facility. RN-G stated that medications should be dated with the date they were opened and to discard of any medication in cart if found unlabeled. During an observation of West wing medication cart on 4/5/22, at 4:15 p.m. RN-I proceeded to leave unlocked and opened medication cart with surveyor despite knowing surveyor was doing medication storage and handling of cart as she had to do medication pass with a resident. Survey team requested RN-A come out of her office to assist with medication storage. R3 had an opened but not dated bottle of [MEDICATION(S)] 0.005% eye drops. The box identified it was opened 2/14/22, and according to manufacturer's guidelines it should be discarded and not used after 28 days. Medication received by facility on 3/10/22. A second bottle of R3's [MEDICATION(S)] 0.005% eye drops were found in cart opened but not dated. The box identified it should be refrigerated per Thrifty White Pharmacy and was found in medication cart. R13's [MEDICATION(S)] 0.005% eye drops were opened on 2/14/22, but not discarded at 28 days and facility was administering these daily. Medication was received by facility on 1/27/22. When interviewed on 4/5/22, at 4:50 p.m. RN-A confirmed medication carts should be locked by facility staff before walking away. RN-A stated unlabeled and expired medications could potentially affect resident safety as medications can increase or decrease in strength beyond their expiration dates. RN-A confirmed medications from home should not be in the medication carts and pharmacy should verify home medications with medication reconciliation prior to use. During an observation of medication administration on 4/6/22, at 9:21 a.m. R3's [MEDICATION(S)] U-100 Insulin 100 unit/ml (3 mL) subcutaneous pen observed opened on 3/6/22 and should have been discarded per pharmaceutical guidelines after 28 days. RN-F called pharmacy for renewal of medication as new pen was not located on unit. When interviewed on 4/6/22, at 2:29 p.m. RN-E stated facility does not usually accept home medications and they do not use them if not provided from our pharmacy. Facility will encourage a family member to bring them back home or should be stored in a locked box and placed inside the secure medication storage room. RN-E stated that insulin and eye drops are discarded after 28 days from being opened. RN-E voiced concern that medications would no longer be safe to use past their expiration date. When interviewed on 4/7/22, at 9:29 a.m. RN-D stated medications should not be kept in resident's room at the bedside. Home medications would be labeled with resident identifiers and kept in the locked medication storage room. RN-D stated she just started on duty on 4/4/22 when R122's [MEDICATION(S)] gel was noted to be at resident's bedside. RN-D confirmed she removed it from resident room and placed it in east med cart on 4/4/22, however, the medication had since been removed. RN-D was unable to confirm when the date of the silver tube with [MEDICATION(S)] had been opened prior to administering on 4/4/22. RN-D confirmed she was not aware it was a home medication. RN-D stated facility policy for home medications would consist of locking them into a secure medication storage area on the unit, labeling them with correct resident identifiers, informing both the resident and family, telling facility staff, and informing her nurse manager. When interviewed on 4/07/22, at 12:06 p.m. DON stated expectation that home medications should be sent home with family or stored in a lock box in a secured medication storage room. Medication should include resident name, mayo clinic number, and date of birth using at least two resident identifiers. DON confirmed home medications should not be stored in medication cart and the only time would be in a special situation if facility is unable to obtain from pharmacy. DON expressed her expectation for staff to not leave medication at the bedside and it is ideal for staff to watch medication is taken by resident. DON stated most medications expire at 30 days but not sure which medications expire prior to that. Medications should be dated upon opening and discarded upon expiration. DON's concern would be that expired medication would not be as effective in treating medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . DON stated expectation to keep medication carts on unit at all times as her concern would include resident safety and medication diversion. Medications from home should be verified online and with facility pharmacist. The facility policy Medications Brought to the Facility by the Resident/Family Guideline - Charter House - Rochester revised 9/28/2020 indicated, the facility shall ordinarily not permit residents and families to bring medications into the facility. -Medications brought into the facility that are not approved for the resident's use shall be returned to the family. -Medication(s) awaiting return to family will be recorded on the Drug Inventory record, which shall include the date, medication name/strength, by two licensed staff and noted on resident inventory record and shall be stored in the medication room until returned to resident and/or family. The facility policy Administering Medications Charter House Procedure - Rochester reviewed 4/7/2020 specified medications shall be administered in a safe and timely manner, and as prescribed. -Medications must be administered in accordance with the orders, including any required time frame. -If a dosage is believed to be inappropriate or excessive for the resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's attending physician or the facility's medical director to discuss the concerns. -The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. -The expiration date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be written on the container. -During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. -The individual administering the medication must utilize the Pulled function when preparing medications for administration. Initial verification of the 5 Rights occurs during the Pulled process, second verification occurs when medication is placed in medication cup and third verification occurs when reviewing medications against the MAR prior to administration of medications.

Based on observation, interview, and document review, the facility failed to ensure 1 of 3 residents (R16) who were dependent of staff for nail care, received assistance for long and jagged nails. Findings include: R16's admission Minimum Data Set (MDS) dated [DATE], indicated R16 was cognitively intact and required extensive assist with most activities of daily living (ADLs) due to a recent fall that required surgical repair of right hip. MDS indicated R16 had moderate difficulty with vision and hearing and R16 did not wear glasses. R16's care plan indicated R16 had moderate impairment of vision and hearing. During observation on 4/4/4/22, at 5:43 p.m. R16 was lying in bed and noted to have fingernails which were brittle, long, and had jagged, chipped edges. R16 stated she scratched something open on her leg today and a nurse had told her to stop scratching it. During observation on 4/5/22, at 10:08 a.m. R16's nails continued to be long and jagged. R16 stated staff had not assisted her with nail car, I need help to have this done, as I cannot see clearly. When interviewed on 4/5/22, at 3:27 p.m. nursing assistant (NA)-B stated R16 needed one person assistance with ADL's which included nail care and bathing. NA-B stated NAs do not complete nail care as nurses were required to perform that ADL. NA-B stated he would only clean under the nail bed during baths. NA-B stated R16 had very poor vision. During an observation on 4/6/22, at 11:19 a.m. R16's fingernails observed to be long and jagged. Registered nurse (RN)-B removed R16's ACE wraps on lower extremities. R16's toenails were observed to be long, jagged, and thick with yellow discoloring. R16 was observed to have a new right calf abrasion with a skin flap hanging off of the area. When interviewed on 4/6/22, at 11:51 a.m. RN-B stated NAs should be doing nail care on bath days for non-diabetic residents. RN-B stated nail care consisted of cutting, filing, and kept clean. RN-B confirmed R16's fingernails were long and appeared to not have been cut since admission. R16 stated, I had previously asked for a fingernail clipper as they are too long, so now I just rip them off with my teeth. RN-B asked R16 to perform nail care after lunch and R16 got teary eyed. When interviewed on 4/6/22, at 12:11 p.m. RN-H stated nail care should be performed for non-diabetic residents on bath days by a NAs. RN-H confirmed R16's bath days were twice a week on Monday mornings and Thursday evenings. RN-H confirmed NAs should complete a pink bath sheet twice a week on bath days and the form is handed to a nurse to document skin changes and resident refusals. RN-H confirmed R16 had no refusals documented since admission. RN-B and RN-H found one pink bath sheet since admission. When interviewed on 4/6/22, at 2:29 p.m. RN-E stated nail care should be performed for non-diabetic residents on bath days by a NA. RN-E stated NA should fill out pink bath sheet with each bath and the nurse would document in electronic record as an assessment or progress note. When interviewed on 4/7/22, at 10:02 a.m. RN-D stated nail care should be completed for non-diabetic residents by facility NA's. RN-D stated she was unaware of when this should be completed. When interviewed on 4/07/22, at 11:14 a.m. R16 stated her nails were cut and filed down yesterday by RN-B. R16 stated, They are perfect now and my toenails are getting checked by a provider soon. R16 stated her daughter cut them at home prior to admission. When interviewed on 4/7/22, at 12:06 p.m. director of nursing (DON) stated NAs should be completing nail care on non-diabetic residents. DON stated expectation for nurses and NAs to be monitoring this on bath days at least weekly if not more often. DON stated NAs should complete pink bath sheet and identify any conditions and give this sheet to nurse to follow-up on any identified concerns. DON stated expectation is for the nurse to document and chart in electronic health record any identified concerns. DON expressed concern for staff not completing a thorough head to toe assessment, lack of hygiene, potential contamination, and possible skin integrity including skin tears. The facility policy titled, Nail Care Procedure - Rochester revised on 9/28/21, indicated to ensure the needs of residents who are unable to complete nail care or trim their nails, staff are to provide assistance with fingernail or toenail care and trimming as indicated, and are to follow safe nail care practices including infection control procedures. -Licensed nurses are to be notified by CNAs of the need for assistance for nail trimming and care for residents who are diabetic, immune suppressed, and/or on anticoagulants, so the licensed nurse may complete trimming of resident fingernails and toenails.

Based on observation, interview, and document review, the facility failed to provide meaningful and ongoing activities for 1 of 1 residents (R16) reviewed for activities. Findings include: R16's admission Minimum Data Set (MDS) dated [DATE], indicated R16 was cognitively intact and required an extensive assist with most activities of daily living (ADLs). The MDS indicated R16 had moderate difficulty with vision and hearing and R16 did not wear glasses. The MDS interview for activity programs dated 3/23/22, identified it was, important but can't do or no choice, for the following activities: have books, newspapers, and magazines to read, doing favorite activities, and participate in religious services or practices. The interview also identified it was very important to R16 to listen to her favorite music, be around animals and pets, and go outside to get fresh air when weather is good. R16's Activities assessment dated [DATE], indicated, resident had a lot of expressed activity interests however due to vision, hearing and hand deficit it makes it very hard for her to engage in them at this time. R16 was provided a voice amplification device during assessment and was noted to make a huge difference in communication with resident. The assessment indicated R16 grew up growing her own food on the farm. R16 stated she enjoyed listening to the news and watching television but no longer could due to vision and hearing deficits. Due to vision problems R16 needed large print reading material. Goal for R16 included activity and socialization daily over the next 15 days. R16's greatest strength was her ability to socialize and tell different stories from her childhood. R16's care plan dated 3/16/22, indicated R16 was at risk for alteration in socialization related to recent hospitalization and Group activities may be limited or restricted during [COVID-19] outbreak status or when unit is on quarantine. R16 would eat meals in room the first 14 days following admission if not fully vaccinated. R16 has moderate impairment of vision and hearing. Staff were directed to allow time for R16 to process information, encourage repetition to ensure R16 can hear you including an intervention to encourage use of amplification device for quality of life. R16's activity care plan indicated she would have activity and or socialization daily. The activity care plan directed staff of the following: -During room visits, provide choices for in-room recreational activities from the activity care such as (large print reading materials such as books on history, Z Gray novels, or magazines with recipes or patterns), musical supplies (likes WCCO on radio and used to love to dance) and sewing supplies as desired. -Encourage participation in activities that provide enjoyment (listening to music, reading, and sewing) as R16 is able to tolerate due to vision, hearing, and hand deficits. -Due to hearing impairment, before beginning a conversation with R16 help her put on her pocket talker but respect resident right if she chooses to refuse it. -Provide a copy of activity schedule and allow R16 to choose activities. -Assist R16 to attend/participate as needed such as musical programs, reading groups, and special events while keeping in mind residents right to refuse. -R16 to eat all meals in the dining room as tolerated. Review of electronic medical record, R16 was on isolation precautions until 3/31/22, due to vaccination status. R16's activities note dated 4/1/22, indicated, [R16] observed to be sleeping more and refusing some meals. The note indicated checks were done daily, and staff engaged her in conversation as well as brought her daily schedules and reading packets from the group activities. During an observation and interview on 4/4/22, at 5:54 p.m. there was an isolation cart outside of R16's room. Licensed practical nurse (LPN)-A stated R16 had been on quarantine related to COVID-19 precautions, however, R16 was no longer on precautions. R16 stated she had not participated in any activities since admission. R16 stated she had all kinds of hobbies in the past such as sewing, crocheting, knitting, farming, gardening, [NAME] fresh fruits and vegetables, and reading the local newspaper. R16 stated she had carpel tunnel in both of her wrists and had very poor vision which made it difficult to enjoy her past hobbies. R16 was animated and smiling when she spoke about farm life and crocheting activities. R16 indicated prior to admission she still lived on her farm. During an observation on 4/4/22, at 6:10 p.m. R16 was observed eating alone in the dining room with no other residents seated at table. Other residents were observed seated together in small groups amongst the other tables in dining room. When interviewed on 4/5/22, at 10:08 a.m. R16 was seated in recliner in room next to window. R16 stated yesterday was the first time she ate in the dining room. R16 stated she was allowed to go to breakfast the day of 4/4/22, but then a nurse stated she had to return to her room to eat alone as she was still on isolation precautions. R16 stated she was supposed to be off isolation precautions last week. R16 stated she was allowed to come out for lunch and dinner on 4/4/22, but facility staff sat her at a dining table alone. An activities schedule and Daily Chronicle newsletter was observed lying on R16's bed not within reach. When asked if R16 could read the print, R16 replied, no and got teary eyed. R16 stated the facility staff did not read the activity schedule or newspaper to her. Multiple newspapers and a big print search-a-word puzzle book was located in R16's window sill. R16 stated daughter-in-law buys the newspaper every Christmas, but she is unable to read the fine print anymore. Activities schedule for 4/5/22 included: -10:30 a.m. Bible Study - Church -11:00 a.m. 27 Dandelion Facts that will blow you away (In Honor of Dandelion Day) -1:00 p.m. Severe weather awareness presentation in [NAME] Hall -2:30 p.m. Social Hour and Snack -3:00 p.m. Mind Binders Puzzle. During an observation on 4/5/22, at 10:23 a.m. R16 sat in a recliner next to the window in her room. RN-B applied pain relieving gel to R16's joints. Staff did not attempt or offer to take R16 to bible study that started at 10:30 a.m. R16 was observed not to be in attendance in bible study. During an observation on 4/5/22, at 12:48 p.m. R16 was eating lunch in dining room at a table alone with no other residents located at table. A laminated activity cue card was located in the middle of each table. Activity included, Would you rather dance or sing? Why? What would you name your boat if you had one? What's the most ridiculous fact you know? Fun fact: There is only one fish that blinks with two eyes. A [NAME]. Staff were not observed to read or converse with her about the card. After lunch R16 returned to her room and it was not observed staff approached her to offer the 1:00 p.m. activity nor was it observed R16 was in attendance. During an observation on 4/5/22, at 1:47 p.m. R16 was asleep in the recliner in her room. During an observation on 4/5/22, at 2:05 p.m. R16 was asleep in a darkened room in bed. An activities sheet titled, 27 Dandelion Facts that will blow you away was observed lying on bedside table next to activities schedule and Daily Chronicle. Multiple paged pamphlet observed in regular sized print given to all residents on unit. Pamphlet had not been opened as a staple was located in left hand corner and pages were not bent over. The pages were unwrinkled and remained untouched. During an observation on 4/5/22, at 3:17 p.m. a social worker sitting on edge of bedside discussing discharge plans for R16. When interviewed on 4/5/22, at 3:27 p.m. a nursing assistant (NA)-B stated R16 only walks with staff outside of room. NA-B was unsure if R16 participated with activities. NA-B stated R16 was on quarantine for two weeks but came off of quarantine on 3/31/22. During an observation on 4/5/22, at 3:42 p.m. R16 was sitting on edge of bed with bedside table not within reach. R16 stated she was not aware of the Dandelion activity, nor did staff offer to take her to the activity. During an observation on 4/6/22, at 7:12 a.m. R16 was lying in bed awake on right side. During an observation on 4/6/22, at 9:20 a.m. R16 was observed sitting at far dining room table by television with no other residents at table. Four other tables of at least two to three residents sitting together socializing after breakfast were observed. During an observation and interview on 4/6/22, at 11:19 a.m. surveyor asked R16 if facility is utilizing the pocket talker microphone to communicate. R16 shrugged shoulders, got teary eyed, and stated not really. Activity schedule for 4/6/22, located on bedside table and appeared untouched. R16 stated facility did not offer bingo activity at 11:00 a.m. During an observation on 4/6/22, at 11:49 a.m. RN-B walked R16 to dining room and sat R16 at a table alone. RN-B stated that activities (ACT)-A does activities schedule for unit. RN-B stated most of the resident's do not come out to group activities and one-to-one activities are provided individually. During an observation on 4/6/22, at 2:23 p.m. R16 was sleeping in bed on her back in darkened room. ACT-A completing a one-to one in commons area in front of health unit coordinator (HUC) desk with another resident. When interviewed on 4/7/22, at 8:36 a.m. ACT-A stated he was doing a lot of social visits with R16. ACT-A stated he had a difficult time interacting with R16 as she seems more isolated after coming out of quarantine and more withdrawn. ACT-A stated R16 was quarantined for an extended period due to no current COVID-19 vaccination and now seems to be set in her ways. ACT-A offered large print reading material, music, and sewing supplies upon admission, but R16 refused as one of her hands no longer works to knit. ACT-A stated he brings in activity schedule and group packet information daily to R16. ACT-A confirmed he did not read it out loud or provide information in larger font. ACT-A stated one-to-one social visits are one to two times weekly and he completes weekly notes for all residents on every Friday. ACT-A stated R16 does not engage with him other than enjoying having someone to speak to about her daily life. ACT-A confirmed R16 came out to dining room on 4/4/22, for first time since admission. ACT-A stated he was uncertain why R16 was kept in her room beyond the discontinuation of quarantine precautions. ACT-A stated a nurse brought R16 out to breakfast on 4/4/22, but then shortly thereafter R16 was brought back to eat in her room alone. ACT-A stated will not wake R16 when sleeping but does not go back to room to reevaluate at a later time. ACT-A confirmed he did not know R16 lived on a farm previously but then retracted statement stating a majority of his activities do not include farm, gardening, or knitting related activities. ACT-A stated he felt it was hard to replicate farm life to R16. When interviewed on 4/7/22, at 9:49 a.m. ACT-A stated he uses activity connection and cater activities to look at special days of the week such as dandelion day. ACT-A stated he provided lots of activity packets so residents can complete and read at their leisure. ACT-A completes two group activities per day, but R16 was not included since 3/31/22. ACT-A stated R16 was very sleepy lately and seemed to be withdrawn since COVID-19 quarantine precautions. ACT-A confirmed he charts refusals of all group activities. When interviewed on 4/7/22, at 10:02 a.m. RN-D confirmed R16 was seen listening to music or reading a newspaper in the activities area approximately one week ago with ACT-A on only two occasions. RN-D stated R16 enjoyed sewing, being a home-maker, farming, and speaking about her life and great grandchildren who also learned to sew. RN-D stated she will read R16 the memo and agenda for day, but only works three days per week. RN-D stated she did not think other staff completed this with R16. During an observation and interview on 4/7/22, at 11:14 a.m. daily activity schedule was observed sitting in cupboard space located between bathroom and resident bed. R16 stated facility staff did not notify her of schedule or read it aloud to her that day. At 11:29 a.m. occupational therapist arrived to R16's room and going to walk R16 down to therapy room. When interviewed on 4/7/22, at 11:37 a.m. RN-A stated expectation for activities to be completed daily by staff and if a resident was on isolation the activity would be completed with resident in room. RN-A expected ACT-A to encourage R16 to come out of room as much as possible. RN-A stated ACT-A charting should be completed daily and marking refusals appropriately. RN-A stated it was not observed if R16 had come out of room this week for activities. R16 was only observed out of room for meals and not aware R16 was placed at table alone. RN-A confirmed she was not certain if staff was reading activities schedule and education pamphlets to R16 due to vision deficits. RN-A was unaware of staff bringing R16 out to dining room for breakfast on 4/4/22, and then bringing her back to room to eat alone. RN-A stated she only observed staff speaking to resident and never observed R16 participating in activities. When interviewed on 4/7/22, at 12:06 p.m. director of nursing (DON) stated expectation is for staff to provide meaningful and individualized activities for each resident based on initial activities assessment upon admission. DON stated she would expect staff to read information out loud to a resident with visual deficits. DON stated she would expect staff to ensure each resident could read material and not just assume a resident could read. She would expect staff to engage with resident to come out of room for activities and to encourage socialization. DON stated if a resident is on isolation/quarantine she would expect staff to bring activities into a residents room. DON expressed concern stating a resident could become depressed due to lack of activities and social isolation. DON stated she would encourage staff to adapt to resident wishes and hobbies they enjoy such as providing an I-pad device to do a zoom visit with family members. When interviewed on 4/7/22, at 12:48 p.m. RN-A stated R16 refuses voice amplification device sometimes. RN-A stated that ACT-A completes daily notes, offered a sewing kit upon admission, but did not use activities that R16 was interested in. RN-A confirmed ACT-A did not know R16 enjoyed farming. During an observation on 4/7/22, at 2:01 p.m. activities pamphlet titled 100 Facts about [NAME] Holiday's Life and Legacy was found lying on R16 bed between two pillows unopened. R16 was asleep in recliner next to window. Pamphlet was not provided in large font and same material used on all residents residing in the facility without visual deficits. When interviewed on 4/7/22, at 2:11 p.m. R16 stated today was first time ACT-A spent any significant time speaking to her and discussed her previous farm life and hobbies. R16 appeared happy and content with a smile on her face for the first time all week. R16 stated she didn't understand why facility could not have completed activities or socialization with her prior to today. A facility policy and procedure regarding activities including individualized care was requested but was not provided.

Based on observations, interviews, and record reviews, the facility failed to ensure physician orders were transcribed correctly for 1 of 1 residents (R3) reviewed for medication administration. Findings include: R3's face sheet indicated resident had medical diagnoses which included: type 2 diabetes mellitus with [CONDITION(S)] and long term (current) use of insulin. R3's physician orders dated 3/22/22, indicated R3 was to receive insulin [MEDICATION(S)] 100 unit/ml (3 mL) subcutaneous pen and to inject 4 units under the skin 3 (three) times a day with meals. Hold if skipping a meal. Monitor blood glucose four times a day, before meals and at bedtime. R3's electronic medication administration record (EMAR) dated April 2022, R3 received [MEDICATION(S)] FlexTouch 100 unit/ml (3 mL) subcutaneous four units three times a day starting 3/22/22 Inject four units under skin three times a day with meals. Hold if skipping a meal. Also known as [MEDICATION(S)]. [MEDICATION(S)] insulin documented as received by R3 from 4/1/22-4/6/22. ([MEDICATION(S)] is a modified form of Insulin [MEDICATION(S)]. The addition of vitamin B3 to the structure of Insulin [MEDICATION(S)] results in its rapid onset of action and rapid absorption via the skin when administered into the skin). [MEDICATION(S)] insulin order re-transcribed by registered nurse (RN)-F on 4/6/22 at 10:07 a.m. to corrected order received by physician on 3/22/22. Incorrect insulin charted by numerous facility staff from 3/22/22 until 4/6/22 when surveyor was monitoring medication administration at 9:21 a.m. with RN-F. During an observation and interview of medication administration on 4/6/22, at 9:21 a.m. RN-F observed to check insulin pen orders against EMAR and noted R3's insulin pen from pharmacy did not match R3's orders in record. RN-F looked up [MEDICATION(S)] insulin on Google website and noted it was not the same medication as insulin [MEDICATION(S)]. [MEDICATION(S)] is insulin [MEDICATION(S)] plus vitamin b3 which has the potential to work more rapidly against elevated high blood sugars. RN-F brought insulin [MEDICATION(S)] pen over to hard paper chart and checked pen against last physician orders dated 3/22/22 and noticed the wrong medication was transcribed into EMAR on 3/22/22. When interviewed on 4/6/22, at 9:45 a.m. RN-H confirmed insulin order in EMAR, stated R3 should receive [MEDICATION(S)]. RN-H printed off original physician order from 3/22/22 and confirmed R3 should receive insulin [MEDICATION(S)]. RN-H stated RN-B transcribed the order incorrectly into EMAR. RN-H confirmed order was entered on 3/22/22 for R3 to receive 4 units of insulin [MEDICATION(S)] with meals and at bedtime. RN-H confirmed correct insulin had been administered by facility staff and EMAR was incorrectly transcribed from the physician order in the electronic chart. When interviewed on 4/6/22, at 10:25 a.m. RN-F expressed concern of R3 could have received the wrong type of insulin. RN-F confirmed staff should be performing five rights of medication administration with every medication pass. RN-F stated staff should be checking residents name, date of birth, right dose, right time, right route, and right medication against physician orders. RN-F stated the health unit coordinator (HUC) transcribed all medication orders into EMAR when they are working or the nurses will enter them if the HUC is off duty. A second person will double check orders for accuracy. RN-F stated facility had been trying to enforce second and third medication transcription checks for some time now. RN-F stated the facility had sent out emails regarding this enforcement recently for staff to complete second and third (24 hour) checks. RN-F stated she thought the nurses were responsible for entering orders, checking the fax machine regularly for new orders, and notifying the nurse assigned to the resident if a new order came through for the day. When interviewed on 4/6/22, at 12:30 a.m. RN-B stated new medication orders are entered by the HUC if they are on-duty, enter it into a draft mode and flag the medication, flag gives alert to nurse so they can complete the second check, and night shift nurse would complete the 24 hour check against the hard copy orders to EMAR transcription order. RN-B stated she specifically remembered R3's [MEDICATION(S)] insulin order as she had never heard of that type of insulin before. RN-B admitted to looking up insulin [MEDICATION(S)] and discovering on a random medication website that [MEDICATION(S)] was also known as insulin [MEDICATION(S)]. RN-B stated she did not look further into medication discrepancy prior to performing the second check on R3's orders. RN-B admitted to now knowing that [MEDICATION(S)] insulin also contained vitamin B3 which could have had the potential for adverse reactions for R3. RN-B stated the insulin pen that facility received from Thrifty White pharmacy was a regular insulin [MEDICATION(S)] pen so facility felt comfortable administering medication to R3. RN-B confirmed she did not consult with a pharmacist that day and she was part of entering R3's orders. RN-B confirmed licensed practical nurse (LPN)-A entered R3's initial orders from physician on 3/22/22 at 12:22 p.m. RN-B stated she edited the order transcribed at 7:07 p.m. to include a notation on the [MEDICATION(S)] order Also known as insulin [MEDICATION(S)]. RN-B admitted to not understanding why R3's insulin pen was labeled as insulin [MEDICATION(S)] and the transcribed orders stated insulin [MEDICATION(S)]. RN-B stated she received training from facility on how to edit/discontinue medication orders into EMAR and just started entering orders on 4/5/22 on her own without having RN-H walking her through the process step by step. RN-B stated agency pool staff receive formal facility training of two days which included: outlook email, Educare modules, MyUnity charting system, EPIC charting system, a brief overview on how to find things in the system, order entry, and practice on a simulated fake dummy resident record. RN-B stated, I should have looked it up better and questioned it better, but I felt comfortable as it said insulin [MEDICATION(S)] as it was the same number of units per ml and that's why I only entered an additional comment into the order saying also known as insulin [MEDICATION(S)]. When interviewed on 4/6/22, at 12:51 p.m. LPN-A stated staff transcribed physician orders into EMAR, then double to verify by placing the medication with a flag, medication sits in draft mode until a second nurse can verify the original order entered. LPN-A confirmed staff should be signing off original hard copy physician orders with both checks and then the night shift nurse will complete what is known as the third check or 24 hour check and that's completed in red ink. LPN-A confirmed he did not sign or place black checks next to original physician orders nor question himself upon entering insulin [MEDICATION(S)] into EMAR as insulin [MEDICATION(S)]. LPN-A admitted to not knowing what insulin [MEDICATION(S)] was and he would have to get back to surveyor on that question. LPN-A confirmed insulin [MEDICATION(S)] was originally ordered for R3 on 3/22/22 and insulin [MEDICATION(S)] was entered into EMAR. LPN-A indicated the two insulins are not the same and could not remember who he requested to complete his second check. LPN-A stated he was unable to look at MAR prior to the seven day lock back period. LPN-A confirmed R3 did not receive insulin ordered at lunch time on 3/22/22 and there was not a note stating why it wasn't given. LPN-A stated medication was administered late at 9:04 p.m. LPN-A stated insulin [MEDICATION(S)] should be administered with meals and uncertain why no dinner dose was given. LPN-A confirmed R3's blood glucose was 196 at dinner time. LPN-A expressed concern that medication orders transcribed did not match for R3 and concern noted R3's blood sugars could have been off due to her not receiving correct insulin ordered. LPN-A stated his concerns for R3 included: possible allergy to [MEDICATION(S)] insulin, possible [MEDICATION(S)] as different insulin types work differently on each resident and control blood sugars differently. LPN-A indicated he did not complete five rights of medication administration correctly for R3 and not triple checking verification prior to administering R3's medications. LPN-A stated he received two days of orientation to facility which included: going through physician orders, care plans, MyUnity charting system, and received three shifts of being precepted by a Charter House experienced nurse. LPN-A stated if he has a question that he would ask a peer, RN-H, a nurse manager on duty or the Charter House nurse supervisor that covers the entire building on evenings and night shift. When interviewed on 4/7/22, at 10:51 a.m. Thrifty White pharmacist consultant confirmed the local Thrifty White store receives original physician orders from provider verses receiving transcription orders from facility. Pharmacist consultant confirmed there is not an interface between facility system and Thrifty White system. Pharmacist consultant stated [MEDICATION(S)] insulin would work faster than regular insulin Apsart as it contains vitamin D. He stated it could have potentially been a big medication error which could have resulted in R3 receiving adverse reactions and low blood sugars. When interviewed on 4/7/22, at 12:06 p.m. director of nursing (DON) stated expectation of nurses to check physician orders and have a second and third nurse check order for accuracy. DON stated nurses should be initialing and dating the original order with who checks the transcription into their EMAR. DON expressed concern regarding staff not completing the five rights of medication administration and following the correct facility process for resident safety. DON confirmed facility needed more steps in place to mitigate medication errors. DON stated facility has two different groups of pool agency nurses hired; one hired by Charter House and the other hired by Mayo Clinic. Charter House pool agency nurses get four weeks of training; while Mayo Clinic pool agency nurses only get three days of orientation which included Educare online modules, only 3 shifts on the floor prior to being alone. Training included physician order entry and introduction to facility electronic charting system. DON reinforced that good training is based off of a good preceptor and that can make or break how a nurse's training outcome will be. Pool agency staff are precepted by an experienced Charter House nurse. The facility policy titled Administering Medications Charter House Procedure - Rochester reviewed on 4/7/20, indicated medications shall be administered in a safe and timely manner, and as prescribed. -If a dosage is believe to be inappropriate or excessive for the resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's attending physician or the facility's medical director to discuss concerns. -The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. -If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall document reason medication not administered at the scheduled time.

Based on observations, interview and document review, facility failed to follow orders, assessment and treatment protocol for 1 of 1 residents (R119) reviewed for non-pressure related skin problems. In addition, the facility failed to identify/evaluate and monitor [CONDITION(S)] and failed to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: R119's progress note in the medical record dated 3/22/22, indicated R119 was admitted to the facility for rehabilitation and cardiac monitoring. The note indicated R119 was alert and oriented to person, place and time. The note further indicated R119, had several skin issues related to graft bypass surgery-see skin assessment. R119's progress note dated 3/22/22, indicated R119 was admitted with skin issues to his lower abdomen, bilateral groin and inner thighs were extremely dry. R119's progress note dated 3/26/22, indicated, Several skin issues related to graft bypass surgery-see skin assessment. Slight excoriation noted coccyx. Barrier cream applied. [MEDICATION(S)] (an adherent, occlusive foam dressing) to be applied. A review of R119's electronic Treatment Administration Record (TAR) did not identify a treatment order had been obtained or transcribed for the excoriated coccyx area. R119's record did not include a comprehensive wound assessment after the area of excoriation had been identified. R119's progress note dated 3/30/22, written by registered nurse (RN)-C indicated R119's coccyx open area 4.5 cm's [centimeters] length, width 1 cm, also another area next to that is 0.5 cm's. Appearance is friction and moisture, TX [treatment] xeroform [a medicated dressing] to wound bed and covered with [MEDICATION(S)] border dressing was applied and to be changed every other day. This note indicated the medical provider was notified, but did not indicate an order had been received; however, the TAR indicated that RN-C had written in the recommendations as a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R119's corresponding Wound Assessment Detail report dated 3/30/22, identified the area as moisture associated skin damage. Progress note dated 4/3/22, indicated, coccyx has 2 open areas 4.5 cm's by 1 cm and an area of 0.4 cm's TX Xeroform covered with [MEDICATION(S)] border dressing. R119's record did not include an assessment of the newly identified open area that measured 0.4 cm. During an observation on 4/5/22, at 10:31 a.m. R119 had two bright red areas about the size of a nickel, one under each of the ischium of buttocks (the bony prominence at the bottom of the pelvis) with peeling skin surrounding each of them. Small scattered sacral open areas were also noted. Licensed practical nurse (LPN)-A said they had just noted these areas but was not sure there was a treatment order, however, a [MEDICATION(S)] dressing had been covering the sacrum, so that is what LPN-A planned to do for a treatment. LPN-A asked a nursing assistant (NA)-A if they used anything else, and NA-A pointed to a container labeled Z-guard (an over the counter barrier cream containing petroleum and zinc that protects against moisture). LPN-A put a large amount of Z-guard in palm and spread over entire buttocks and sacrum and then placed the [MEDICATION(S)] over the wet ointment. R119's progress note dated 4/5/22, 12:23 p.m. included, coccyx has multiple small open areas. NP [nurse practitioner] was there to assess all skin concerns. R119's record did not identify or address the skin breakdown on the ischium. R119's provider note dated 4/5/22, a nurse practitioner (NP)-A wrote that two SBAR's [a notification of change in condition] had been received from the facility however, indicated the SBAR's were unrelated to R119's impaired skin integrity to his coccyx, sacrum, or ischium. NP-A did note a non-pressure related pin point open area of the left gluteal cleft was found during assessment, however, the assessment did not identify or address the observed red and peeling areas of the ischium. NP-A wrote an order to apply a prophylactic [MEDICATION(S)] to sacrum and coccyx, ensure it is in direct contact with skin to prevent moisture related breakdown, lift twice daily to check skin and change every three days and as needed. The provider note did not include a treatment plan to areas on the ischium. When interviewed on 4/5/22, at 3:57 p.m. LPN-A stated a nurse finding a new area of skin concern should first check the resident's chart to see if that problem had previously been noted and documented. If not, LPN-A stated the nurse should notify the medical provider to get an order, and then follow that order. LPN-A also stated the wound should be assessed and findings documented. This assessment should include a description of the wound, any pain or any sign of infection. LPN-A stated, I wasn't 100% sure if wound care had been done [before she applied application of Z-guard and dressing], the provider came today and looked at it. She just gave us an order now. I was just helping out. I don't necessarily do a treatment without looking at an order, but I just knew we were covering it in the meantime. LPN-A stated a nurse could use facility standing orders if there was not an order in the TAR, but then should enter that order into the TAR. LPN-A was unable to find a list of standing orders in R119's chart. LPN-A was not sure if Z-guard was a standing order or if it could be used on open areas. LPN-A reviewed standing orders in another resident's chart and noted lubricating barrier cream could be used on reddened skin, but LPN-A did not know if Z-guard was considered lubricating, and confirmed R119's skin was open on some areas of buttocks and sacrum. During an interview 4/5/22, at 4:18 p.m. RN-A stated a superficially open area may be described as excoriation, but would still require an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . If no treatment order was found, the nurse should assess the wound and enter the information into a computer app they called the Risk Watch system. RN-A stated a nurse must have an order to provide a treatment; could use standing orders, but should notify the provider. RN-A said Z-guard is a barrier cream but is generally used for incontinence as it helps to dry the skin. RN-A stated it did not match facility standing orders that say to use a lubricating barrier for red areas. R119's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Clean and dry areas 2. Apply prophylactic [MEDICATION(S)] boarder sacrum dressing. Lift twice daily to asses skin and ensure dressing is changed every 3 days and as needed. During an interview on 4/6/22, at 8:55 a.m. RN-A stated when a new area of concern, such as a wound, was noted the nurse should assess the wound and enter information into a computer app they called the Risk Watch system so staff and providers would be aware of the problem. RN-A stated she was unable to find that R119's skin problems were listed in the app. RN-A stated the facility does have standing orders, but they must be reviewed and signed each time a person is admitted . If they are not in the chart, they should not be used, and an order from the medical provider must be sought out. RN-A stated the physician and family should be notified of any new wounds, and this should be documented in the chart. If standing orders are utilized they must be transcribed from the hard copy into the electronic record so they flow to the TAR. During an observation on 4/6/22, at 9:49 a.m. RN-B stated R119 did have superficial, upper layers of skin peeling off the ischium on the right side extending up in an oblong path for about 3 inches, and also, a less noticeable area on the left ischium. RN-B also stated there were several tiny open areas to the left and right sides of the coccyx, inside the crack of the buttocks, and wondered if this was due to friction from using a lift sheet during transfers. R119's progress note dated 4/6/22, included, coccyx has multiple small open areas. There are areas that are healing from what might be friction. These areas are blanchable, slightly pink in color and not open. When interviewed on 4/6/22, at 9:59 a.m. RN-H reviewed R119's chart and stated R119 did not have a signed current standing order sheet. RN-H reviewed standing orders in another residents' charts and stated xeroform dressings were not listed on the standing orders and to use the product an order from a physician would need to be obtained. RN-H also stated Z-guard does not meet the criteria of a lubricating barrier cream and should not be applied to open areas without an order. When interviewed on 4/6/22, at 10:25 a.m. the director of nursing (DON) stated any new area of concern on the skin should be followed by a, good clinical assessment and obviously notification to the provider, and then documentation is the Unity Wound Assessment [facility electronic assessment form]. DON stated if a wound was superficial, I don't know if would notify family but should be documentation and monitor so does not get infected. If very superficial we might notify physician but assess for worsening and then notify MD as needed. DON stated she was in charge of over site of all nursing in the facility and the associated assisted living facility, so did not stay closely in-tune to all orders, but said nursing staff should use standing orders, and any policy or wound care protocol. DON did not know if Xeroform was on standing orders or if Z-guard was a lubricating ointment that would match standing orders. DON stated a nurse cannot write orders, but can transcribe what is given by a provider. A facility policy titled, Skin and Wound Management undated indicated, aid staff will perform routine skin inspections daily with cares, nurses are to be notified to inspect the skin if any skin conditions and/or pressure ulcers are identified. Document on any pressure, stasis skin ulcer, skin tear or open wound with treatment will include: location and size, type, stage of wound, drainage, signs symptoms of infection, treatment, date and time of dressing change. Additionally, policy indicated skin care alert form is to be used if there is noted disruption in skin integrity and the physician/NP and family will be notified upon discovery of a skin concern. The policy did not include reference to the facility standing orders. Charter House Standing orders 10/19/21 signed by medical director, indicated: Facility lubricating/barrier cream or ointment three times daily PRN (as needed) for dry skin and/or for prevention of skin breakdown secondary to incontinence (E.g. Lubriderm®). For Stage I OR Reddened area: If affected by friction & shear: For prevention, may apply a film dressing and change every 5 days prn soiling. For Stage II Pressure OR Partial Skin Loss Area: Intact serum filled blister: apply hydrogel impregnated dressing, attempting to avoid rupturing blister and change every five days prn soiling, secure with secondary dressing. Shallow crater: apply hydrogel impregnated dressing/[MEDICATION(S)] (if minimal drainage) or foam dressing (if moderate drainage) and change every 5 days prn soiling, secure with secondary dressing.) R16's admission MDS dated [DATE], indicated R16 was cognitively intact and required an extensive one assist. R16's medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R16's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Notify certified nurse practitioner (CNP) if three pound weight gain overnight or five pound weight gain in one week. Also notify CNP of 5 pound weight loss in one week. On 4/5/22, apply compression wraps in the morning and take off at bedtime was ordered. R16's physician notes dated 3/22/22, indicated, R16 had trace [CONDITION(S)] in bilateral lower extremities and compression wraps to bilateral knees. Daily weights were requested but these had not been completed by facility. Daily weights reordered with notification of CNP. R16's care plan dated 3/16/22, indicated to obtain weight per orders by nurse or nursing assistant, float heels on pillow in bed, and encourage elevation of legs as able to reduce swelling. Weekly head to toe skin monitoring. R16 is at risk for fluid imbalance related to cardiac issues. R16's treatment administration record (TAR), compression wraps were initiated on 4/5/22. Weight monitoring daily starting 3/23/22. Skin assessment and weight completed two times weekly starting 4/6/22. Requested March 2022 TAR on 4/7/22, but facility did not provide. During an observation and interview on 4/4/22, at 5:43 p.m. R16 was observed lying in bed with no compression or ACE wraps applied to legs. R16's legs were observed to have [CONDITION(S)] present in both bilateral lower extremities and feet. R16's left leg was more swollen than right leg and was wearing white cotton socks. R16's legs were not elevated on a pillows in bed. R16 stated she is supposed to wear compression stockings on legs at all times due to past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . R16 was observed to have purplish discoloration of skin to bilateral lower extremities. R16 stated a nurse previously applied ACE wraps to her leg one day, but then looked at her white paper sheet located in her pocket and immediately removed the wraps stating R16 did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 4/4/22, at 6:10 p.m. registered nurse (RN)-B was observed walking R16 to dining room table. R16 was wearing white cotton socks and black crocks on feet with notable [CONDITION(S)] present in both lower extremities and feet. During an observation on 4/4/22, at 9:52 a.m. R16 was observed sitting in recliner next to window in room with lower extremities on floor. RN-B present in room with resident taking her vital signs. During an observation and interview on 4/5/22, at 10:08 a.m. R16 was observed sitting in recliner in room next to window with bilateral extremities on floor. R16 stated her legs were wrapped by RN-B earlier this morning . R16 observed wearing bilateral ACE wrap compressions from feet to knees. At 10:23 a.m. RN-B came into R16's room to apply pain relieving gel. R16 stated legs felt better now that they were wrapped this morning. During an observation on 4/5/22, at 12:47 p.m. R16 was observed asleep in recliner with ACE wraps to bilateral lower extremities, but legs were not elevated. During an observation on 4/5/22, at 2:05 p.m. R16 was asleep in bed with ACE wraps on bilateral legs with pillows located under both legs. During an observation on 4/5/22, at 3:42 p.m. R16 was sitting on edge of bed with ACE wrapped legs dangling to the floor. During an observation on 4/6/22, at 7:12 a.m. R16 was asleep in bed with legs elevated on pillows, but no ACE wraps on. During an observation on 4/6/22, at 9:20 a.m. R16 was observed sitting at dining room table with ACE wraps on. During an observation on 4/6/22, at 10:30 a.m. R16 was observed sleeping in recliner in room with ACE wraps on, but legs not elevated. During an observation and interview on 4/6/22, at 11:19 a.m. R16 notably upset after physical therapy and nursing staff as facility placed white cotton skin protection wraps underneath ACE wraps today. R16 was observed with ACE wraps on bilateral lower extremities, but legs were not elevated. RN-B came to R16's room after physical therapist voiced to her that R16 was very upset in room. R16 requested wraps be removed immediately as it was causing her extreme pain. RN-B took wraps off and educated R16 that the cotton wraps located underneath ACE wraps were for skin protection. R16 stated staff did not inform her why those were added this morning. R16 observed with considerable [CONDITION(S)] in bilateral feet as wraps were placed from ankle to knee and fluid built up in feet as a result. When interviewed on 4/6/22, at 11:36 a.m. RN-B stated R16's ACE wraps were not ordered until 4/5/22. RN-B confirmed R16 wore compression wraps at home prior to admission. RN-B stated R16 preferred leg wraps to be applied after she gets back from the bathroom in the morning. RN-B confirmed she placed wraps on R16 today while resident was in bed prior to going to the bathroom. RN-B stated R16 had not had swelling in her legs until she noticed it in R16's feet today due to the wraps not being placed correctly. RN-B stated R16 wore compression wraps for comfort verses [CONDITION(S)]. RN-B stated R16 did not have [CONDITION(S)] in legs yesterday. RN-B stated R16's physician confirmed she did not have [CONDITION(S)] in legs since admission to facility. RN-B confirmed R16 asked for compression wraps. RN-B stated R16 normally does not sit in her recliner and only lies in bed or walks with physical therapy. RN-B stated R16 should have pillows underneath legs at all times while in bed with heels floating off the edge. When interviewed on 4/6/22, at 12:11 p.m. RN-H stated he would not know if R16 wanted compression leg wraps nor if she would have [CONDITION(S)]. RN-H confirmed nursing staff should be completing a head-to-toe assessment daily. RN-H stated assessment should be documented daily in skilled nursing Medicare progress notes. When interviewed on 4/6/22, at 2:29 p.m. RN-E confirmed nurses should be completing an [CONDITION(S)] assessments and if a resident had [CONDITION(S)] staff would elevate extremities right away and send a note to physician for further intervention and treatment plan. RN-E stated R16 should have legs elevated on pillow in bed or elevated while sitting in recliner to reduce fluid in legs. When interviewed on 4/7/22, at 10:02 a.m. RN-D stated she heard that R16 requested compression wraps this week. RN-D stated she completed R16's admission assessment and noted [CONDITION(S)] in bilateral legs. RN-D confirmed R16 was wearing compression hosiery and elevated her legs on pillows while in bed and while sitting in recliner in room. RN-D indicated wraps should have been on R16 since admission to present. RN-D stated nursing assistants (NA's) applied these daily in the mornings and were removed at bedtime. RN-D stated R16's legs were +1 [CONDITION(S)] (when compressed with digit, would leave an impression of 2 millimeters) upon admission and not as swollen as they were this week. When interviewed on 4/7/22, at 11:14 a.m. R16 stated her legs were wrapped this week on 4/5/22 mid-morning suddenly. R16 stated, I don't know why facility did not listen to me requesting leg wraps prior to this. R16's room was observed to have no compression hosiery socks located in room other than current ACE wraps which were applied to her legs. When interviewed on 4/7/22, at 11:37 a.m. RN-A stated expectation for nurses to assess for [CONDITION(S)] daily and ensure physician is notified for treatment and intervention orders. RN-A confirmed if a resident requested leg wraps, facility staff should notify physician immediately. RN-A stated nursing interventions of elevating legs on recliner foot rest, encouraging ambulation to shift fluid build-up, and use of pillows to elevate extremities should have been completed for R16. RN-A stated facility had standing orders for compression wraps and was unsure if facility completed an [CONDITION(S)] assessment upon admission. RN-A was uncertain if [CONDITION(S)] was monitored daily. When interviewed on 4/7/22, at 12:06 p.m. director of nursing (DON) stated expectation for [CONDITION(S)] assessment to be completed upon admission with a skilled nursing note to be completed daily on each resident; especially for residents with known heart failure or known [CONDITION(S)]. DON expected nursing staff to complete interventions such as weight monitoring, assessing skin integrity and pressure spots, listening to lung sounds, elevating legs so swelling did not become dependent, care planning, monitoring, measurements of swelling, and ensuring physician was aware of condition. DON stated concern for static [CONDITION(S)] to worsen medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The facility provided a lower extremity [CONDITION(S)] algorithm to follow for patients with lower leg = to or > than +2 peripheral [CONDITION(S)] not dated which indicated, elevate and provide medical management x 24 hrs. If patient meets at least 1 exclusion criteria of (pitting [CONDITION(S)] +1 or less), that lower leg wraps NOT recommended and to discuss with provider and consider vascular studies. If patient is ambulatory, apply short stretch & padding for 24 hrs. If [CONDITION(S)] decreases within 24 hrs, continue to elevate and apply previous compression wraps only if patient continues to have >+1 [CONDITION(S)]. Discontinue if [CONDITION(S)] resolves. If [CONDITION(S)] does not decrease in 24 hrs, discuss with primary provider for ongoing independent [CONDITION(S)] management. A facility policy related to lower extremity [CONDITION(S)] was requested on 4/7/22, but facility did not provide. A care plan on R16 related to [CONDITION(S)] was not provided.

Based on interview and document review, the facility failed to develop an antibiotic stewardship program, which included the development of protocols and a system to monitor antibiotic use, to include how the program will be implemented and antibiotic use will be monitored. This deficient practice had the potential to affect all 14 residents who resided in the facility. Findings include: A review of the facility's infection control surveillance program was conducted on 12/3/19, at 2:01 p.m., with registered nurse (RN)-B. The facility lacked development of protocols for a facility-wide system to monitor the use of antibiotics which includes (but not limited to) appropriate prescribing of antibiotics, criteria before antibiotic use and periodic review of antibiotic use by physicians. The program also lacked protocols for review of signs and symptoms, labs, determination of appropriate antibiotic use and reporting of any patterns identified. During interview on 12/3/19, at 2:01 p.m., RN-B stated we (facility) do not have an antibiotic stewardship policy. During interview on 12/3/19, at 2:53 p.m., the director of nursing (DON) stated the facility had not developed antibiotic stewardship policy. The DON stated, It is in the works.

Based on observation, interview and record review, the facility failed to ensure one multi-use [MEDICATION NAME] solutions (solution to test for [MEDICAL CONDITION]) had been dated when opened. This had the potential to affect 5 of 5 recently admitted residents (R115, R375, R366, R358 and R352) who were administered the [MEDICATION NAME] solution, and any other new admissions or newly hired staff. Findings include: On 12/2/19 at 5:28 p.m., a tour was completed of the facility medication room with registered nurse (RN)-[NAME] A white refrigerator was inspected which contained one open vial [MEDICATION NAME] ([MEDICATION NAME] derivative). The box identified Lot # 1 contained enough product for 10 Tests, and the opened vial had visible solution remaining inside. A pharmacy label was affixed to the boxes, which identified the solution name, along with a 'fill' date on the label printed as 10/21/19. However, neither the box nor the vial of the opened solution had been dated to demonstrate when the vial had been opened. RN-A verified the vial had no open date. This surveyor asked for a list of residents who had received [MEDICATION NAME] solution from the above mentioned vial. The following residents had received the [MEDICATION NAME] beyond the 30 days of the above fill date: R115 had received on 11/25/19. R375 had received on 11/22/19. R366 had received on 11/23/19. R358 had received on 11/12/19 and 11/28/19. R352 had received on 11/27/19. During interview on 12/2/19, at 6:04 p.m., RN-B stated staff were not aware the [MEDICATION NAME] vial needed to have a date open. RN-B stated the should have had a date open written when the vial had been opened to be used and the [MEDICATION NAME] was good for only 30 days after being opened. The Pharmaceutical [MEDICATION NAME] manufacturer insert dated 3/16, indicated the solution was used for intradermal injection(s) to help determine the presence of [MEDICAL CONDITION] (an infectious agent). The insert provided storage instructions for the medication including bold lettering describing, Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. A policy for dating medications was requested. The facility provided [MEDICATION NAME] skin testing, revised 8/16/19, which included check the expiration date on the vial. If the vial has been open for more than 30 days or the expiration date has passed, discard the vial and obtain a new vial.

During observation, interview and document review the facility failed to ensure standard precautions for the use of gloves during cleansing of a multiuse glucometer for 1 of 1 residents (R64), observed to have a blood sugar checked. Findings include: During observation on 12/3/19, at 11:17 a.m., registered nurse (RN)-C checked R64 blood sugar using a multiuse glucometer. After checking R64's blood sugar RN-C removed gloves and washed hands. RN-C carried the glucometer in a white basket to the nurses station. RN-C with no gloves on used a Super-sani wipe to clean the glucometer. During interview on 12/3/19, at 11:26 a.m., RN-C verified she had no gloves on when cleansing the glucometer. During interview on 12/4/19, at 1:52 p.m., the director of nursing stated it seems universal precautions should be implemented when cleansing the glucometer. The facility policy Glucose Point of Care Testing, review date 2/18, indicated Procedure: Glucose P[NAME] Testing: 19. Wipe meter and supply case with Oxivir wipe after every patient. The meter must remain wet for one minute to assure disinfection. Avoid getting [MEDICATION NAME] wet on bottom of meter. The policy did not address the use of gloves when cleansing the meter. CDC (Centers for Disease Control) indicates, wear gloves during blood glucose monitoring and during any other procedure that involves potential exposure to blood or body fluids.

Based on interview and document review, the facility failed to provide a safe transfer for 1 of 3 residents (R2) reviewed by not ensuring the attachment straps on the mechanical ceiling lift were secure during the transfer. One strap became loose and the resident fell from the lift. Harm occured when the R2 sustained a clavicle and rib fracture because of the fall. Findings include: R2's progress note dated 8/7/17 at 11:22 a.m., indicates the resident has a history of stroke with residual right sided weakness and aphasia; communication ability was impaired. R2 required a full body lift for all transfers. R2 was able to use the call light to alert staff for needs. Progress note dated 8/27/17 at 3:47 p.m., Registered Nurse (RN)-D indicated R2 fell from the lift and was on the floor on her right side and right arm, but able to follow commands. R2 stated that her right arm hurt. Per the aides report, R2 had fallen out of the ceiling lift. Hospital radiology note dated 8/27/17 at 5:33 p.m., indicated R2 had moderately displaced right-sided rib fractures and right associated pulmonary contusions, and a right clavicle fracture. R2 was hospitalized for [REDACTED]. After the hospitalization and returning to the facility, a slider sheet/board transfer from bed to special wheelchair was implemented and the mechanical ceiling lift was no longer used eliminating any fear or anxiety it could cause R2. When interviewed on 11/7/17 at 12:40 p.m., Nursing Assistant (NA)-A stated that when the lift in R2's room was on the curved part of the track, it 'sticks.' After the curve, the transfer resumed, and the loop popped out by R2's head, and R2 fell out. NA-A stated she did not know what caused the loop to 'pop.' NA-A stated that repositioning of R2's arm occurred at one point during the transfer. NA-A was focused on R2's position in the sling and not the loop placement. On 11/7/17 at 1:20 p.m., NA-C was interviewed and stated that when R2 was being moved around the curve in the ceiling track, R2 said ouch and the transfer was stopped. R2 told staff they needed to move her right arm. Getting past the curve point in the track required more force and a little harder push. The transfer resumed and NA-C noted a 'jerk' in the lift, so they moved the lift backward a foot and then forward again. As they moved forward, R2 started to fall with the right side of the sling falling first. NA-C stated the lift loops were secure after repositioning R2's arm because R2 remained in an upright position. On 11/7/17 at 3:10 p.m., NA-B stated that during the transfer activity, staff were talking about non-transfer related things. She witnessed staff adjusting R2's arm in the bathroom, right over the toilet. She did not see any loops loose at that time but could not verify if she looked at them during the entire transfer. NA-B remembers thinking the gap in the track at the bathroom door was big and had never seen a gap that big in a track before. NA-B believed the lift got hooked in between the gap at the bathroom door making the transfer difficult and does not remember seeing anyone checking the loops and hooks to be secure. Interview with Safety Coordinator (SC)-E team member on 11/9/17 at 1:05 p.m., SC-E verified that there were no mechanical or defective issues with the sling or lift; observed the sling was in good working order; no frays or cuts in the sling making it inappropriate to use. Interview with RN-D on 11/9/17 at 3:07 p.m., went to R2's room after hearing screams. RN-D saw R2 on the floor and 3 of the 4 loops were still attached to the lift. On 11/7/17 at 2:23 p.m., interview with FM-F stated that he was told the lift was in good working order and the fall had to be related to not being properly hooked up. He has observed staff transfer R2 before and feels they could have performed more supervision during the transfers. On 12/4/17 at 9:35 a.m., interview with FM-G indicated that full lift transfers were observed before and staff many times lifted R2 too high above the ground, lifting R2 as high as the lift would go. FM-G also observed staff being inattentive and conversing about non-transfer related things during transfers and had to remind staff to pay attention to the transfer. In the policy titled Safe Lifting and Movement of Residents, dated 8/22/16, it indicates: In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents.

Based on interview and record review, the facility failed to ensure the use of a therapy recommended assistive device for safe ambulation for 1 of 3 residents (resident #1) reviewed. Resident #1 fell on [DATE] while ambulating and sustained a fracture and bilateral ankle sprains. A gait belt was not used by the nursing assistant (NA) as recommended and instructed by the physical therapist. Findings include: Record review for resident #1 revealed a hospital Dismissal Summary dated 02/04/2011 that showed resident #1 was hospitalized with progressive weakness, had a [DIAGNOSES REDACTED]. Review of the physical therapy notes for the time period of 02/04/2011 through 02/07/2011 indicated resident #1 required nursing staff assistance to ambulate to and from meals. Further review of the physical therapy notes for the time period of 02/08/2011 through 02/14/2011 stated resident #1's right lower extremity can mildly give out during ambulation and contact guard assistance is needed during ambulation due to "occasional buckling of the right lower extremity." Contact guard assistance was also provided by therapy during ambulation for this same reason during the time period of 02/15/2011 through 02/21/2011. Review of resident #1's temporary care plan for risk of injury and falls dated 02/04/2011 included interventions of "Use White-out board to communicate reminders, as needed" and "Additional interventions: (physical therapy)." A Care Plan Conference Summary for resident #1 dated 02/16/2011 contained documentation that "(right) knee goes out on (resident #1)" and also indicated that physical therapy planned to discharge resident #1 the first week in March. This report also showed various facility staff attended the care conference, which included a registered nurse and physical therapist. A nursing progress note entered on 02/23/2011 contained documentation that resident #1 fell on [DATE] when resident #1's "right knee buckled causing (resident #1) to lose balance." Review of the Interdisciplinary Post-Fall Assessment form for the 02/22/2011 fall incident indicated "no gait belt" as a probable cause for the fall, based on facility review and investigation. Resident #1 was interviewed on 3/15/2011 at 12:26 p.m. Resident #1 stated resident #1's right knee had a tendency to give out during physical therapy sessions and this was the reason the physical therapist wrote a reminder on the white board in resident #1's room to use a gait belt. Resident #1's white board contained an entry by the physical therapist dated 02/08/2011 that directed staff to "use gait belt and hold on to it." Resident #1 verified the right knee buckled during the fall of 02/22/2011 and a gait belt was not being used at the time of the fall. Resident #1 also stated the use of the gait belt (with staff's hold on it) during therapy sessions provided stabalization when resident #1's right knee buckled. Employee (A)/NA was interviewed on 03/15/2011 at 1:13 p.m. Employee (A) stated resident #1 had no memory problems and is compliant with all cares. Employee (A) acknowledged being familiar with resident #1's need for assistance with ambulation and stated she always used a gait belt with resident #1 prior to the 02/22/2011 fall incident. Employee (A) stated gait belts are readily available in the facility. Employee (A) recalled the fall incident of 2/22/2011 and stated resident #1 was in the dining room and requested assistance to ambulate to resident #1's room. Employee (A) carried resident #1's seat cushion and beverage at the request of resident #1 and walked next to resident #1. Employee (A) indicated she did not physically assist resident #1, resident #1 was not wearing a gait belt and Employee (A)'s hands were full when she remembered and realized resident #1 needed a gait belt (Employee (A) stated this was about five feet into the process of ambulation). Employee (A) stated as they entered resident #1's room, resident #1's right knee buckled and resident #1 fell towards the floor. Employee (A) "tossed everything" she was holding and grabbed resident #1 from behind at the time resident #1 "was just getting down to the ground." Employee (A) stated resident #1's right leg "was already twisted" at this time. Employee (F)/Physical Therapist was interviewed on 03/23/2011 at 7:47 a.m. and stated contact guard assist means to hold on to the gait belt. Employee (F) stated prior to resident #1's fall of 02/22/2011, resident #1's right knee would occasionally, slightly give out. During these times, Employee (F) held on to the gait belt while resident #1 supported herself with a walker and "was able to hold herself up." Employee (F) verified that the recommendation in place for ambulation assistance with resident #1 at the time of the 02/22/2011 incident included the use contact guard assist with a gait belt. Review of the facility education provided to staff in March 2011 and titled "Gait Belts (and) Safe Resident Handling" included documentation that "gait belts are used to provide safe resident transfers and ambulation" and to "inform the resident that the belt is used to prevent falls." During the interview with resident #1 on 3/15/2011, resident #1 reported "having tremendous amount of pain until last week" and difficulty sleeping. Review of the Primary Care Internal Med Nursing Home Limited Exam note dated 02/22/2011 for resident #1 indicated "(resident #1) is having quite a bit of pain in (resident #1's) legs" and physical examination showed bilateral ankle swelling, left ankle bruising and fluid noted laterally in the right knee. The clinician ordered an increase in Ultram (a synthetic centrally active analgesic used for moderate to moderately severe pain). Continued review of clinician notes and orders for February 2011 and March 2011 showed ultram was not effective for pain control and resident #1 required the use of oxycodone (an opioid analgesic and controlled substance used for moderate to severe pain) with zofran (a medication used to prevent nausea and vomiting from the use of oxycodone) and flexeril (medication used to relieve muscle spasms). Review of the Orthopedic Trauma Service Consult dated 02/24/2011 contained documentation that the imaging studies of the right knee showed a nondisplaced fracture. This consult note also included a [DIAGNOSES REDACTED]. Review of the Care Plan Conference Summary dated 03/08/2011 contained documentation that there were no plans "at this time" to discharge resident #1.