Every finding on record at Chautauqua Springs Health Center

Based on interviews and record review, the facility failed to ensure wound care services were provided for 1 of 5 residents sampled for wound care (Resident #160).The findings included:An interview was conducted with Resident #160's daughter on 6/25/26 at 10:00 AM. She explained that her mother was receiving home hospice services and was admitted to the facility on [DATE] for a 5-day respite care stay. She further explained the plan was for the facility to provide comfort measures for Resident #160's pain and anxiety along with physician ordered wound care. She stated she spoke with a nurse and found out Resident #160 had not received wound care since her admission. As a result of this concerns, the daughter made the decision to take Resident #160 home that day instead of having her stay at the facility until 6/27/26 as planned.Review of Resident #160's medical record confirmed she was admitted to the facility on [DATE]. Resident #160 had a medical history significant for lung cancer, type 2 diabetes, pulmonary hypertension, Chronic Obstructive Pulmonary Disease, and anxiety.Review Resident #160's Physician's orders revealed there were active orders for wound care. These orders included the following: Right Hip-cleanse open area with normal saline, sure prep peri-wound, apply calcium alginate and cover with dry dressing every day shift, dated entered 6/22/26, start date 6/23/26; and Coccyx-cleanse open area with normal saline, sure prep peri-wound, apply calcium alginate and cover with dry dressing, every day shift, dated entered 6/22/26, start date 6/23/26.Review of Resident #160's Treatment Administration Record (TAR) revealed staff did not document that wound care was performed for Resident #160 on 6/23/26 or 6/24/26. Review of Resident #160's Plan of Care revealed there were no focus interventions related to Resident #160's wounds on the coccyx or hip. An interview was conducted with the facility's Director of Nursing (DON) on 6/25/26 at 11:34 AM. The DON stated Staff A, Licensed Practical Nurse (LPN) was assigned to care for Resident #160 on 6/23/26 and 6/24/26 and that she should have performed the resident's wound care on those days.An interview was conducted with Staff E, LPN and Wound Care Nurse on 6/25/26 at 12:17 PM. Staff E explained she normally performed wound care on Wednesdays at the facility. She stated she received a note in the morning on 6/25/26 that Resident #160 had something on her hip but further stated she did not perform wound care on Resident #160 because she was a new resident and she needed time to learn about the resident before she could perform the ordered wound care. Staff E confirmed she is not the only nurse who performs wound care but rather any nurse who is assigned to a resident requiring wound care if responsible for performing the task. She further stated she had Resident#160 on her list of residents to see that day. An interview was conducted with Staff A, LPN on 6/25/26 at 12:36 PM. Staff A stated she was assigned to care for Resident #160 on 6/23/26 and 6/24/26. She was aware that Resident #160 was admitted to the facility for respite care and that the plan was for the staff to provide medication for pain and anxiety and wound care according to the physician's orders. She stated she did not get around to do [Resident #160's] wound care on Tuesday and Wednesday. She further stated she did not perform the wound care because she was prioritizing safety and medication administration.An interview was conducted with Staff G, LPN on 6/25/26 at 2:56 PM. Staff G stated she received report on her residents from the night shift nurse, Staff H, LPN, at around 6:45 AM on 6/25/26. She stated she did not know Resident #160 had orders for wound care.An interview was conducted with Staff D, LPN and Unit Manager on 6/25/26 at 4:14 PM. Staff D confirmed Resident #160 was admitted to the facility on [DATE] and that her family had brought in the respite care medications from home. Staff D explained that she had previously assisted Resident #160 to the bed from wheelchair. Staff D recalled that Resident #160 was weak but was able to stand and pivot transfer to the bed. Staff D stated she had replaced Resident #160's wound care dressings on 6/22/26. Staff D, LPN stated Resident #160 had no concerns the last two days. Staff D stated, as a unit manager, I am not sure the reason wound care was not done the last two days, because if something was not done, the expectation was to communicate it to the next shift.

Based on observations, staff and resident interviews, and record reviews, the facility failed to ensure the resident environment remained free of accident hazards for 2 of 43 residents observed for accident hazards (Resident #103 & #129).The findings included:An observation was conducted of Residents #103 and #129 in their shared room on 6/23/26 at 2:50 PM. At this time, a roach-like insect was observed running under a case of bottled waters and other personal belongings on Resident #129's side of the room. Upon seeing this insect, Resident #129 propelled herself out of the room to speak to the Maintenance Assistant about the insect. The Maintenance Assistant entered the residents' room with a pump sprayer and began spraying an unknown substance around the edges of the room at the baseboards and where the insect was seen running near the resident's personal belongings and water bottles. When asked if the facility normally sprayed for insects with residents in their rooms, Resident #129 said, Yeah, they always do it when we are in the room. An interview was conducted with the facility Maintenance Assistant on 6/25/26 at 11:03 AM. When asked whether he sprays chemicals in resident's rooms while the residents are present in the rooms, he stated, I usually do not spray with people in the room. [The residents] sent a work order in and saw the bugs and wanted it taken care of, so I sprayed the room at that time. He went on to state that this is a chemical that is diluted with water and is immediately non-hazardous when it dries. He agreed he probably should have asked the residents to exit the room until the solution dried.An interview was conducted with the facility Maintenance Director on 6/25/26 at 11:20 AM. He provided the information for the spray used, which was Talstar Professional Insecticide, with an active ingredient of Bifenthrin (which is a synthetic form of Pyrethoid) (photographic evidence obtained). The Maintenance Director stated the residents should not be present in any room while spraying this chemical. He confirmed Resident #103 and #129 should have been escorted out of the room until the solution dried. According to the National Poison Control website (https://www.poison.org/articles/pyrethroids), this chemical should not come into contact with skin and, if spraying indoors, should be in a well-ventilated room to avoid inhalation of the spray. Inhalation, contact with skin, or swallowing pyrethroids are ways pyrethroids can enter the body . They can cause irritation and allergic reactions, while high levels can cause more serious symptoms. Some spray formulations contain volatile hydrocarbon solvents or pressurized propellants which can also cause toxicity, especially if inhaled.

Based on observations, record review, interviews, and facility policy review, facility staff failed to ensure proper protective measures were used for 1 of 1 resident sampled for contact isolation (Resident #158).The findings included:An observation was conducted on 6/24/26 at 8:40 AM of contact isolation signage present on Resident #158's room door. There was Personal Protective Equipment (PPE) in front of the room including isolation gowns, gloves and masks.Review of Resident #158's medical record revealed Resident #158 was admitted to the facility on [DATE] with medical diagnoses including Extended Spectrum Beta Lactamase (ESBL) resistance (a condition which makes a person resistant to antibiotic treatments). Physician orders included Contact Isolation for 10 days related to ESBL, dated 6/18/26. The care plan included diagnoses of Urinary Tract Infection (UTI) due to ESBL with antibiotic treatment through 6/29/26 with interventions including contact isolation precautions as ordered. An observation was conducted on 6/24/26 at 8:45 AM of Staff A, Licensed Practical Nurse (LPN) entering Resident #158's room with a medication cup. Staff B, Certified Nurse Assistant (CNA), was already inside the room assisting Resident #158. While donning gloves, Staff B asked Staff A to help assist with repositioning the resident. Staff A donned gloves without washing her hands. Neither staff member donned isolation gowns. Staff A and Staff B proceeded to assist Resident #158 with repositioning.An interview was conducted with Staff A, LPN on 6/24/26 at 8:55 AM, following the observation. She confirmed she was aware of Resident #158's Contact Isolation precautions but stated she did not have contact with Resident #158's urine. When asked to explain the facility's Contact Isolation protocol, Staff A stated Contact Isolation did not require wearing a mask but further stated staff should be donning an isolation gown before entering a room and should remove the gown before exiting. She acknowledged that she and Staff B did not wear isolation gowns when they were in Resident #158's room. When asked about hand washing, Staff A stated she only washed her hands after removing her gloves. An interview was conducted with Staff C, Registered Nurse (RN) on 6/24/26 at 3:35 PM. Staff C confirmed she was the facility's Infectious Preventionist. Staff C stated when a resident was on Contact Isolation, the facility would place the Contact Isolation signage on the resident's room door and would make PPE available to the staff. She further stated the staff should wear a gown upon entering the room and should wash their hands before donning and after removing their gloves. Review of the facility's policy titled Isolation Precautions (revised June 2025) was conducted. The policy stated, Contact precautions: must be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or patient-care items in the resident's environment. Wear gloves when entering room. Wear a gown when entering the room if you anticipate that your clothing will have substantial contact with the patient, environmental surfaces, or items in the patient's room, or if the resident is incontinent, has diarrhea, an ileostomy, a colostomy, or wound drainage not contained by a dressing.Review of the facility's policy titled Hand Hygiene (revised 3/1/25) was conducted. The policy stated, The use of gloves did not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.

Based upon observations, interviews, and record review, the facility failed to promote dignity by not having a privacy cover for a foley catheter bag for 1 of 1 residents observed for dignity (Resident #43). The findings include: On 03/10/25 at 12:00 PM, an observation Resident #43's room was made from the hallway since the room door was opened. A foley catheter bag was observed hanging from the bed railing on the side of the bed facing the doorway. The foley catheter bag did not have a privacy cover and was noted to have approximately 300 ml of urine in the bag. Resident #43 was observed lying in bed with eyes closed, respirations even and unlabored at this time. On 03/10/25 at 03:41 PM, the catheter bag was once again observed from the hallway since the room door was open. No privacy cover was in use. The foley catheter had approximately 700 ml of dark yellow urine present. On 03/11/25 at 09:09 AM, Resident #43's room door was again open and could be observed from the hallway. The foley catheter is observed hanging from the bed rail facing the doorway with no privacy cover noted. Approximately 150 ml of yellow urine observed in the bag. On 03/11/25 at 12:00 PM and 2:40 PM, Resident #43 was observed once again with a Foley catheter bag without a privacy cover hanging from the bed railing with yellow urine noted in the catheter bag. Resident 43 denies pain and discomfort at this time. On 03/12/25 at 09:00 AM, Resident #43 is observed out of bed in the hallway sitting in a wheelchair. His foley catheter is observed without a privacy cover and the catheter tubing dragging against the floor as he maneuvers his wheelchair in the hallway. On 03/13/25 at 08:15 AM, Resident #43 was observed with all his personal belongings with him and a foley catheter observed without a privacy cover hanging from bottom of wheelchair. A staff member assisted Resident #43 to the front lobby and then to being assisted on to a transportation vehicle to go home.

Based on observations, interviews and record review, the facility failed to provide specialized care needs for the provision of respiratory care in accordance with professional standards of practice, and the resident's care plan, goals and preferences for 1 of 1 resident sampled. (Resident #73) The findings include: On 3/10/2025, there was respiratory tubing, a mask, and a nebulizer observed on the floor beside Resident #73's bed. The tubing was attached to a machine nebulizer with a sticker dated 2/26/2025. On 3/10/2025 at approximately 1:00 pm, a second observation was made and the respiratory tubing, mask and nebulizer were still on the floor beside Resident #73's bed. On 3/11/2025 approximately 08:30 am, the tubing, mask and nebulizer were in a nightstand drawer beside resident #73 bed. The tubing attach to nebulizer machine still had a sticker with a date of 2/26/2025. On 3/11/2025 approximately 12:00 pm, an interview with Staff D, a Registered Nurse, was performed. He stated that Resident #73 has respiratory treatments as needed and tubing for oxygen and respiratory treatments are changed per orders every Wednesday. On 3/12/2025 a record review of orders for respiratory treatments on 2/12/2025 revealed an order for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 1 inhalation inhale orally every 4 hours as needed for SOB/WHEEZING related to CHRONIC RESPIRATORY FAILURE WITH HYPOXIA (J96.11), Check oxygen saturations every shift and as needed. Per administration records, this medication has not been administered to Resident #73 since the order given on 2/12/2025. The care plan included interventions as follows: Monitor lungs sound every shift and as needed. Document every shift. On 3/13/2025 approximately 8:00 am, interview was performed with Staff C, a Licensed Practical Nurse, about the Albuterol order. Staff C stated this is ordered for residents initially on admission for 10 days. On 2/19/2025, there is documentation that Resident #73 had abnormal breath sounds but no documentation of respiratory treatments were found on that day. On 3/13/2025 at approximately 8:30 am, an interview with the Director of Nursing (DON) was performed. She explained that oxygen tubing and respiratory treatment equipment is changed every Wednesday, but the tubing for Resident #73 has not been changed because he has not had any respiratory treatments since it was ordered. The DON was also made aware that Resident #73 did not receive the Albuterol order on 2/19/25. The DON acknowledged this order should have been given.

Based upon observation, interview, and record review, the facility failed to practice infection control procedures concerning glucose monitoring for 1 of 1 residents reviewed for glucose monitoring (Resident #27) and for food handling procedures during 1 of 3 meals observed. The findings include: Glucose monitoring On 03/12/25 at approximately 1:28 PM, an observation was made of Staff D, a Registered Nurse (RN), checking Resident # 27's blood sugar using a glucometer and administering insulin. The RN did not perform hand hygiene before donning gloves to complete the blood glucose check or after doffing gloves, prior to exiting the resident's room and accessing the medication cart. The RN brought the communal tube of meter strips into the residents room but did not disinfect the communal container of meter strips prior to placing it back in the medication cart. The RN was asked if he had received training from the facility on infection control related to glucometer use. The RN replied, No training on infection control, just how to use the glucometer. A review of the facilities policy Obtaining a Fingerstick Glucose Level, dated January 2020, under Infection control protocol and safety, it reads, 2. Maintain clean technique and isolation precautions as indicated. Steps 17-19 of the procedure reads, 17. Remove gloves and discard into designated container. 18. Wash hands. 19. Clean glucose monitor with approved disinfectant before and after each resident. (photographic evidence obtained) 50783 Food handling On 3/12/25 at 11:30 am, during an observation of the dining room, Staff Member G and Staff Member I, both Certfied Nursing Assistants, were observed not sanitizing and/or washing hands in between serving residents seated in the dining room. Staff Member I was observed touching the counter top and drinking cup rims without washing her hands, then serving drinks to the residents. Staff Member G was observed entering the dining room without sanitizing or washing his hands, then proceeded to take clean cups sitting on the counter and dipping them into the pitcher of ice filling multiple cups and setting them on the counter. Staff Member I would take cups filled them with juice or tea and serve residents. When asked about hand hygiene, Staff Members G and I responded that it should take place when entering the dining room and in between each resident. Staff member G stated, I should have washed my hands when I came into the dining room prior to filling cups and assisting with the drinks. Staff member G stated that he should not have done dipped ice from the pitcher without hand hygiene. Staff Member I stated that we should have sanitized or washed our hands in between serving each resident their drinks. Both staff were aware of the sink used to wash hands and sanitizer on wall at entry door and on wall by counter where drinks were being provided.

Based on observations, interviews and record reviews, the facility failed to maintain a sanitary environment shower room environment in 1 of 4 shower rooms observed and in the laundry area. The findings include: Shower room On 3/10/25 at approximately 4:51 PM, Shower room [ROOM NUMBER] was observed with the trash can overflowing. There was a variety of opened hygiene products cluttered on the vanity next to a biohazard container. A stack of folded towels was sitting on an over bed table exposed. Observed on 3/13/25 at approximately 1:00 PM, a second observation of Shower room [ROOM NUMBER] was made with the following unsanitary conditions were noted: a dirty towel was laying on the shower bed and another towel was on the floor near the shower chair, a stack of clean towels were placed on top of an over the bed table beside an open pack of briefs, and a variety of used hygiene products were on the vanity. A biohazard container that was a third full was sitting next to the variety of hygiene products. A closet that is in the shower room was open exposing an opened cabinet that contained a variety of hygiene products, cleaning chemicals and roll of toilet paper. A small sink with 3 fingernail clippers were laying by faucet. A pair of rain boots and used gloves were underneath a black mat that was propped up against the wall had fallen over. The trash can was full. On 3/10/25 at approximately 11:45 AM during an interview with Staff J, a Licensed Practical Nurse (LPN), verified that the shower room is used all day for showers and incontinence care for residents. 50783 Laundry area On 3/13/2025 at 11:00 AM, an observation of the laundry area was made. The area behind the washing machine and dryer had a dark color on the tiles. The sink was observed with dirt and debris and an orange stain in the sink with a dark green and blackish film around the inside of the sink. (photos obtained) The laundry area for facility linens had a blackish color film on the sink. (photo obtained) The area behind the dryers and washing machines had dust and lint observed on the floor and pipes where the detergent was sitting. The handwashing sink was observed with multiple clear plastic bags hanging next to it and a tube of caulk laying on the sink.

Based on observations, record review, resident interview, staff interviews, and policy review, the facility failed to obtain physician orders to administer oxygen in accordance with the resident care plan for 1 of 1 sampled residents receiving oxygen therapy. (Resident #479) The findings include: Observations of Resident #479 were conducted on 12/4/23 at 11:30 AM, 12/5/23 at 2:42 PM, 12/5/23 at 4:26 PM, and 12/6/23 at 8:48 AM. During every observation, the resident was observed in bed and wearing oxygen at 3 liters per minute via nasal cannula from a concentrator. An interview was conducted with Resident #479 on 12/5/23 at 2:42 PM. At this time, the resident stated she had been wearing the oxygen since she was admitted to the facility. A review of the resident's medical record revealed an admitted [DATE] and a current care plan dated 12/4/23 related to risk for complications related to Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure with a nursing intervention to administer oxygen per orders. The medical record contained no physician orders for oxygen. An interview was conducted with Employee A, a Registered Nurse, on 12/6/23 at 12:01 PM. Employee A stated the resident had been using oxygen since he first saw her on 12/2/23. An interview was conducted with the Assistant Director of Nursing (ADON) on 12/6/23 at 12:03 PM. The ADON stated the resident did not have oxygen orders and the admitting nurse should have put the order in upon admission. She stated the nurse who places the oxygen on the resident should place the order for the oxygen. A review of the policy Medication Orders (dated October 2019) reveals, .a current list of orders must be maintained in the clinical record of each resident. Oxygen orders: When recording orders for oxygen, specify: The rate of flow, route and rationale.

Based on observation, interview, and record review, the facility failed to ensure provision of safe and timely Activities of Daily Living (ADL) care for 2 of 2 resident hallways reviewed (100 Hall and 200 Hall). The findings include: 100 Hallway On 12/12/22 at approximately 10:52 AM, during the initial tour of the 100 hallway a strong odor similar to urine was noted. Several residents were noted sitting in wheelchairs in the hallway, but the majority of the residents remained in their beds in their rooms. A second tour of the hallway was completed on 12/12/22 at approximately 2:30 PM. The hallway continued to have a urine like odor, which was strongest outside rooms [ROOM NUMBERS]. On 12/12/22 at approximately 10:52 AM, an interview was conducted with Resident #11 who stated the staff work hard, they are busy, but they do not have enough staff. During the interview, a urine odor was noted while standing next to the resident. On 12/12/22 at approximately 3:10 PM, an interview was conducted with Resident #10 who revealed the residents are lucky they will get 2 showers a week, but it is usually just one time per week, and on the weekends, they do not get much help at all. A review of the Point of Care Activities of Daily Living (ADL) report for the date range of 8/15/22 to 9/6/22 for resident #1 revealed 20 days were coded as 8 under bathing, which indicates activity did not occur. There were 2 days noting bathing occurred. A review of the Point of Care ADL report for the date range of 11/1/22-12/14/22 for Resident #5 revealed 19 days were coded as an 8 under bathing which means activity did not occur. There were 3 days noting bathing occurred. A review of the Point of Care ADL report for the date range of 11/1/22-12/14/22 for Resident #9 revealed 22 days were coded as an 8 under bathing which means activity did not occur. There were 4 days noting bathing occurred. A review of the Point of Care ADL report for the date range of 11/1/22-12/14/22 for Resident #10 revealed 23 days were coded as an 8 under bathing which means activity did not occur. There were 2 days noting bathing occurred. A review of the Point of Care ADL report for the date range of 11/3/22-12/14/22 for Resident #11 revealed 22 days were coded as an 8 under bathing which means activity did not occur. There were 3 days noting bathing occurred. 200 Hallway On 12/12/22 at approximately 10:20 AM, a strong foul odor similar to urine and stool was noted in the 200 halls at the initiation of the initial facility tour. The door to room [ROOM NUMBER] was closed. The surveyor went into the room and met Resident #4. She was seated in a chair and appeared tired and exasperated. The odor in the room was overpowering. It smelled like urine and stool. A pair of brown and yellow stained wet soiled clothes laid on the floor close to the resident's feet. There was a yellow stained wet towel that was on the floor near the bed. A yellow stained towel laid on the bed. The bed had no sheet on it. The mattress was stained and soiled as well. The used breakfast tray was in the room from breakfast and there were no cups for water anywhere in the room (photographic evidence was obtained). The resident said: I called for help to change my brief this morning and no one came. Needed help to pull off and put pants on. I changed my own brief. I called last night for water and haven't gotten any yet. The surveyor asked Resident #4 if she ate breakfast. She replied: They did not tell me that breakfast was here this morning but I did get breakfast this morning. They still have not come to get the breakfast tray yet. The surveyor pushed the call button in the room at approximately 10:30 AM. At approximately 10:59 AM Staff Member A, Certified Nursing Assistant (CNA) entered the room. Resident #4 asked for water. Staff Member A, CNA left the room to go get water for Resident #4. A few minutes later Staff Member A, CNA returned with a cup of water. The CNA gave the resident the water and left immediately without picking up the soiled clothes, the breakfast tray or offering information about when someone would be back to assist. On 2/12/22 at approximately 1:10 PM, the soiled clothes remained on the floor of Resident #4's floor. The room still had a strong odor and the bed had not been made. An interview was conducted with Staff Member A, CNA she was asked why she did not pick up the clothes or make the bed earlier when she brought the resident water. Staff Member A, CNA explained that she was not assigned to care for the resident. She said she would get the CNA who was assigned to care for her. A review of the care plan revealed that the resident had an ADL self-care deficit and is at risk of not having needs met. The care plan indicated that Resident #4 had an end-of-life prognosis and that she should be allowed frequent rest periods during assistance with care. Additionally, it was listed that ADL needs should be anticipated and met as indicated. The care plan also listed that, Resident #4 was at risk of skin breakdown related to occasional incontinence and other diagnosis. It was recommended that staff provide incontinence care after incontinent episodes and apply barrier cream as needed. The care plan also recommended that staff assist the resident with repositioning and provide the amount of assistance or supervision necessary for toileting. Resident #4 was determined to be at risk for falls. Implementation steps related to falls prevention included keep call light within reach and keep room free from clutter. A review of Resident #4's record was conducted. Section G (Bathing) of the Minimum Data Set (MDS) revealed that the resident was scored to be totally dependent upon staff for assistance with bathing. The resident utilized a walker and a wheelchair for mobility. Section H revealed that Resident #4 was known to be frequently incontinent of bowel and bladder. Section J listed that Resident #4 had a condition that may result in a life expectancy of less than 6 months. A review of the Point of Care ADL report for the date range of 11/1/22 to 12/14/22 for Resident #4 revealed 27 days were coded as an 8 under bathing which means activity did not occur. There were 4 days noting bathing occurred. On 12/12/22 at approximately 3:08 PM, Resident #4's room continued to have a strong odor. The soiled clothes were still on the floor. The wet towel was on the floor. The bed had not been made. An interview was conducted with Staff Member B, CNA. Staff Member B, CNA and the surveyor walked to the resident's room. Staff Member B, CNA immediately began picking up soiled clothes from the floor and cleaning up the room. She said: I should have already taken care of this. She also explained that she would have to look for sheets for the bed because the mattress was larger and required special sheets. On 12/13/22 at approximately 1:30 PM, an interview was conducted with Nurse D, Licensed Practical Nurse (LPN) the nurse assigned to Resident #4 on 12/12/22. She was shown images of the unmade bed, wet soiled clothes, and towels on the floor in the room. The nurse explained that Resident #4 often urinates on the floor in the room. The flooring has been replaced in the past and that housekeeping usually goes in the room twice a day. She indicated that the room should have been more attended too. Nurse D, LPN was asked about the unmade bed, wet soiled clothes, and towels that laid on the floor all day. The nurse explained that this was a new assigned resident for Staff Member B, CNA. She explained that she expects the CNA's to do their jobs. Nurse D, LPN said: I asked her to attend to Resident#4's needs. I did not realize it needed to be itemized. The surveyor asked the Nurse D, if she had enough time to check to and see if the CNA's are completing their assignments. Nurse D responded by saying: Not 100 percent but I check on them as much as I can. 41718 Received a portion of the paper shower sheets that were requested. Many of the documents have the resident name written on them but does not indicate if a bath or shower was completed, and most of the forms did not indicate the nurse was notified if the resident refused the offer of a shower. A review of the facility Resident Census and Conditions of Residents Report (CMS form 672) revealed the facility had a census of 119 residents. The report revealed 61 of the residents required one or two person assist with bathing and 43 were dependent on staff for bathing. The report further noted 50 residents required assistance of one to two staff for toilet use, and 41 were dependent on staff. On 12/14/22 at approximately 9:21 AM, an interview was conducted with the Director of Nurses, (DON) who stated she has a CNA scheduled to perform showers, but if that CNA is pulled to the floor to work, the staff assigned to the resident will try to shower the resident or the person on the next shift would shower the resident. The DON stated the restorative CNA would be pulled to assist. The DON stated if the resident wants to shower daily, they would shower the resident daily, or baths /showers are usually given on Monday, Wednesday and Friday, or Tuesday, Thursday and Saturday. The DON stated the facility has had multiple staff call ins and stated the facility has started using CNAs from the agency in November and nurses from the agency since September. The DON revealed if a resident refuses a shower, the CNA should let the nurse know, and the nurse would talk with the resident or the family and should offer another day or time. A follow-up interview was conducted with the DON on 12/14/22 at approximately 9:21 AM, who revealed not all of the CNAs are able to document in the ADL function of the computer and stated the facility has shower sheets that are used if documentation cannot be done electronically. The DON stated the shower sheets are in boxes, and it will be cumbersome to get the shower sheets. On 12/12/22 at approximately 12:50 PM, an interview was conducted with Staff Member A, CAN, who stated, We are short staffed; We do not have time to give everyone showers when the residents are supposed to get them. We have all these lights going off but often the nurses do not help. She indicated that this has been going on for the past year but recently staffing had gotten worse. She also explained that staffing is short a few days a week when someone calls in. On 12/12/22 at approximately 2:00 PM, an interview was conducted with Staff Member C, CNA who stated, The residents complain that they are not getting showers and that staff is not answering call buttons. I am burned out on this job because we do not have enough help. On 12/12/22 at approximately 2:50 PM, an interview was conducted with Staff Member B, CNA, who stated that that they try to get everyone bathed and showered, but sometimes residents do miss their showers because there is not enough staff. She explained that they have not had the extra CNA assigned to shower duties often in the last three weeks.

Based on observations, staff interview and review of facility policies the facility failed to ensure medications were not left unattended at the resident's bedside for 1 of 5 residents sampled for unnecessary medications (Resident #20) and failed to ensure that medications were stored in locked compartments accessible only to authorized personnel for 1 of 5 medication carts observed. The findings include: Resident #20 On 6/13/22 at approximately 11:37 AM, during an interview with Resident #20, it was noted that there were two cups of pills sitting on her bedside table. A few minutes into the interview she stated, Oh, let me take my medicine, and then picked up both cups and took the medications. (Photographic evidence obtained) A review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #20's care plan failed to reveal care planning for self-administration of medications. On 6/16/22 at approximately 11:38 AM, an interview was conducted with the Administrator. At that time she stated that the nurses should not be leaving medications unattended with residents at the bedside. A review was conducted of the facility policy, Medication Administration: 7.3 Self-Administration by Resident, dated 11/2017. Under the procedures section it stated, item number 1, If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical and visual ability to carry out this responsibility, during the care planning process. Under item number 3 it stated, The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment, which is placed in the resident's medical record. Unlocked Medication Cart On 6/16/22 at approximately 8:44 AM, an observation of medication pass was conducted with Licensed Practical Nurse Z. After pulling all of the medications for Resident #520, she asked another nurse to get for her Vitamin B12 500 micrograms because it was not available on the cart. On 6/16/22 at 8:46 AM staff Z, proceeded to take Resident #520's other medications to him while she waited for the other nurse to return with the Vitamin B12, and left the medication cart unlocked. Resident #520's room was located down the hall and around a corner from where the medication cart was left unattended. She returned to the cart on 6/16/22 at 8:48 AM, and she acknowledged that she should have locked the cart and that it was a mistake. On 6/16/22 at 8:52 AM, she went to take the missing B12 medication to Resident #520. She again left the medication cart unlocked and unattended while she went to the resident's room, out of the sight of the cart (Photographic evidence obtained). A review was conducted of the facility policy, Medication Administration: 7.1 General Guidelines, dated 1/2021. Under the, Procedures Section, subsection, Medication Administration, item number 17, it stated, During Administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse .The cart must be clearly visible to the personnel administering medications when unlocked.

Based on observations, staff interviews, posted menu review and policy review, the facility failed to follow the preapproved menu during 2 of 5 meal observations, failed to ensure approval was received prior to making meal substitutions, failed to keep record of those substitutions, and failed to post the daily menu in accordance with facility policy. The findings include: On 6/13/22 at approximately 12:10 PM, the posted menu outside of the facility's dining room was observed. The menu was dated for the previous Wednesday (6/8/22) and indicated lunch would consist of hamburger on bun, cucumber onion salad, [NAME] tots and oranges. An observation of the facility's lunch service revealed the residents were served ham, sweet potatoes, and collard greens. (Photographic evidence obtained) On 6/15/22 at approximately 9:11 AM, the posted menu outside of the facility's dining area room was observed. The posted menu for Wednesday (6/15/22) indicated dinner would consist of turkey pot pie, biscuit, peas and carrots. A review of the weekly menu indicated dinner on Wednesday (6/15/22) would consist of breaded fish on bun, peas and carrots, and [NAME] tots. (Photographic evidence obtained) On 6/15/22 at approximately 1:29 PM, an interview was conducted with the Registered Dietician (RD) who stated that the Manager in Training (MIT) will substitute preapproved menu items without approval. The RD stated the MIT requested she authorize a menu substitution two weeks after the substitution was made. On 6/15/22 at approximately 3:08 PM, an interview was conducted with the MIT, who stated she does not post the menu anywhere in the facility and that there are too many changes to the menu. When asked to review the facility's documentation of meal substitutions, the MIT stated, she had no record, and was not aware she needed to keep track of menu changes. A review of the facility's Dining Services Policy and Procedure dated 5/2014 revised 9/2017, Menus Policy 004 revealed: menus will be posted in the Dining Service department, dining rooms and resident/patient care areas, and menu substitutions log will be maintained on file.

Based on record reviews, policy reviews and interviews, the facility failed to complete and transmit the Minimum Data Set (MDS) assessments for 2 of 2 residents sampled for Resident Assessments. (Residents #1 and #2) The findings include: On [DATE] a review of the MDS assessment history was conducted for residents #1 and #2. Resident #1 was admitted to the facility on [DATE] and expired at the facility on [DATE]. Per the review of the MDS assessments, the last quarterly review was conducted on [DATE]. No death in facility MDS was completed at the time of this survey. Resident #2 was admitted to the facility on [DATE]. On [DATE] the resident was sent to hospital and did not return to the facility. Per the review of the MDS assessments, the last annual review was conducted on [DATE]. A discharge MDS was not completed at the time of this survey. On [DATE] at approximately 12:33 PM, an interview was conducted with the MDS assistant who stated the day a resident discharges to the hospital or expires at the facility the associated MDS is done. If these events happen on a weekend, it is done the next business day. She confirmed that there should have been a discharge completed on resident #2. The MDS assistant stated, We must have missed one. We missed that discharge, it was not done. For resident #1, she confirmed there was no death in the facility MDS done and verified that it was put on the log but not put in the computer. On [DATE] a review of the policy Resident Assessment revised [DATE] page 4 state Discharge Assessment-return not anticipated will have the MDS completion date is discharge date + 14 calendar days. Death in Facility Tracking Record MDS completion date is Discharge (death) Date + 7 calendar days.

Based on interview and record review the facility failed to promote and facilitate resident self-determination through support of resident choice for 1 of 4 residents (#77) sampled for Activities of Daily Living. The findings include: On 8/26/19 at 1:19 PM, an interview was conducted with Resident #77. At that time she asked the surveyor, Why can't I have a shower when it is my shower day? She stated that staff complain that they do not have enough people. She also stated that her niece had been down to speak to administration regarding the issue of her not receiving her showers and did not get any results. A review of grievances for the last three months was conducted which revealed a grievance dated 7/2/2019 filed by the niece of Resident #77. The grievance stated that the niece was concerned about whether the resident was receiving baths on her bath days. The niece expressed this concern to the social worker, the Director of Social Services and the Assistant Director of Nursing. Under the resolution section it was stated that staff received education regarding bathing. A review was conducted of nursing assistant documentation for bathing which revealed that for the month of (MONTH) the resident had received baths twice on 8/16/19 and 8/19/19, for all other scheduled bath days the documentation stated Activity did not occur. There were no documented baths after 8/19/19. On 8/28/19 at 12:22 PM an interview was conducted with Certified Nursing Assistant (CNA) G. She stated that there was a book that they used to know when a resident was scheduled to have a bath. She showed this book to the surveyor. All residents in A beds (beds that are closest to the door to the hallway) are bathed on Monday, Wednesday and Friday and all B beds (beds near the window) are bathed on Tuesday, Thursday and Saturday. She stated that after the bath is given she would go into the electronic system and document that it was completed. She went on to state that if she had previously documented that it did not occur, she could go back into the system and document again if the resident did end up getting a bath. When asked what she would do if the resident refused a bath she stated that she would go back again later and try and if the resident still refused the bath she would tell the nurse for her to try to convince the resident to take their bath. On 8/28/19 at 12:37 PM an interview was conducted with Nurse F. At that time she reiterated what CNA G had stated about schedules and the process for ensuring residents received their baths and how to approach residents that refuse to bathe. She was asked if she was able to access the documentation that CNA's completed and she said she could. She was then asked to show the surveyor the last time Resident #77 was documented to have received a bath. She agreed that there were no documented baths after 8/19/2019. On 8/28/19 at 1:00 PM and interview was conducted with the Director of Nursing. She stated that staff should be documenting baths in the, Matrixcare, computer system. She was asked to locate the last documented bath for resident #77. The last time she was able to see that a bath was given in the, Matrixcare, computer system was on 8/19/2019.

Based on observations, policy review, and interviews, the facility failed to provide a clean, safe, homelike environment in 4 resident rooms (123, 125, 129, and 201) and one exterior wall adjacent to resident rooms on the 100 hallway. The findings include: During an initial facility tour on 8/26/2019 at approximately 10:15AM, environmental concerns were noted for resident rooms #123, 125, 129, and 201. The concerns included peeling paint, patched, unpainted sections of walls in rooms [ROOM NUMBER], and a hole in the wall near the bed in room [ROOM NUMBER]. rooms [ROOM NUMBERS] had brown/black colored spots covering the vent grates on the air conditioning units. room [ROOM NUMBER] had an over bed light over bed B which was hanging down, pulled away from the wall over a bedbound resident (resident #126). On 8/27/19 at 4:23 PM, during an interview and observation, staff A, the facility maintenance director, confirmed the overbed light was pulled away from the wall over bed B in room [ROOM NUMBER] where a bedbound resident was located (resident #126). Staff A confirmed the presence of a dark rust colored substance behind and beneath the middle of the light and stated he didn't know what it was. An observation of room [ROOM NUMBER] on 8/28/2019 at 11:00am revealed the light had been replaced and the wall painted. On 8/28/2019 at approximately 1:55PM, during observations in the 100 hall, staff A confirmed the sinks in rooms [ROOM NUMBERS] were leaking and he was unaware of the problem. Staff A stated staff members are expected to submit work orders to alert maintenance staff, but during interviews with staff A and the administrator, they confirmed there is no formal training for staff members to know how to submit work orders, it is expected to be passed on during orientation. Staff A also confirmed the presence of multiple patched areas on walls in rooms [ROOM NUMBER]. In room [ROOM NUMBER], staff A was asked about spots on the vent grates of the air conditioning unit. Staff A said it was dirt build up and attempted to remove by wiping with finger but multiple brown-rust colored spots remained. Staff A confirmed during the tour the air conditioning unit in room [ROOM NUMBER] also had multiple spots on the vent grates. Staff A explained there is a plan to work on 3 rooms every month and do the worst rooms first. Staff A was unable to produce documentation of a dated, room by room list to demonstrate that the repairs were scheduled. Staff A provided handwritten notes with identified areas in rooms, but there was no date on the documents and staff A could not verbally provide a time frame when the maintenance staff performed rounds or completed the documentation. No definitive date when the damage to rooms was first noted could be provided either verbally or in writing. On 8/29/19 at 10:48 AM, in a follow up interview, staff A confirmed there was no documentation of specific areas in need of repair, but jots down notes when he makes rounds. Staff A was asked again to provide documentation of scheduled maintenance and was unable to provide this prior to the end of the survey. Staff A confirmed the presence of a hole in the wall in room [ROOM NUMBER]. On 8/29/19 at 11:20 AM, staff A provided a document he referred to as a renovation schedule which consisted of a one sheet document which did not include a date. A title at the top of the page identified the document as Room renovation schedule and stated: Maintenance will tentatively be renovating three rooms a month. The renovations will consist of painting, changing baseboards as needed, new light fixtures, wall guards at head of beds and new trim around windows. These renovations will start the end of July, 2019. On 8/29/19 at 11:55 AM staff A and the administrator were asked to provide facility policies related to maintenance of the building and a policy/procedure for submitting work orders. At 12:04pm, the administrator brought a copy of a one page long policy titled Work Orders with a date of (MONTH) 2005 which described the process for submitting work orders to maintenance. Asked if there were any other policies or procedures related to maintenance, the administrator replied, that was all we found. (Photographic evidence obtained)

Based on interview and record review, the facility failed to ensure residents who are unable to carry out activities of daily living receive the necessary services to maintain good personal hygiene for 1 of 4 residents (#77) sampled for activities of daily living. The findings include: On 8/26/19 at 1:19 PM, an interview was conducted with Resident #77. At that time she asked the surveyor, Why can't I have a shower when it is my shower day? She stated that staff complain that they do not have enough people. She also stated that her niece had been down to speak to administration regarding the issue of her not receiving her showers and did not get any results. A review of grievances for the last three months was conducted which revealed a grievance dated 7/2/2019 filed by the niece of Resident #77. The grievance stated that the niece was concerned about whether the resident was receiving baths on her bath days. The niece expressed this concern to the social worker, the Director of Social Services and the Assistant Director of Nursing. Under the resolution section it was stated that staff received education regarding bathing. A review was conducted of nursing assistant documentation for bathing which revealed that for the month of (MONTH) the resident had received baths twice on 8/16/19 and 8/19/19, for all other scheduled bath days the documentation stated Activity did not occur. There were no documented baths after 8/19/19. On 8/28/19 at 12:22 PM, an interview was conducted with Certified Nursing Assistant (CNA) G. She stated that there was a book that they used to know when a resident was scheduled to have a bath. She showed this book to the surveyor. All residents in A beds (beds that are closest to the door to the hallway) are bathed on Monday, Wednesday and Friday and all B beds (beds near the window) are bathed on Tuesday, Thursday and Saturday. She stated that after the bath is given she would go into the electronic system and document that it was completed. She went on to state that if she had previously documented that it did not occur, she could go back into the system and document again if the resident did end up getting a bath. When asked what she would do if the resident refused a bath she stated that she would go back again later and try and if the resident still refused the bath she would tell the nurse for her to try to convince the resident to take their bath. On 8/28/19 at 12:37 PM an interview was conducted with Nurse F. At that time she reiterated what CNA G had stated about schedules and the process for ensuring residents received their baths and how to approach residents that refuse to bathe. She was asked if she was able to access the documentation that CNA's completed and she said she could. She was then asked to show the surveyor the last time Resident #77 was documented to have received a bath. She agreed that there were no documented baths after 8/19/2019. On 8/28/19 at 1:00 PM and interview was conducted with the Director of Nursing. She stated that staff should be documenting baths in the, Matrixcare, computer system. She was asked to locate the last documented bath for resident #77. The last time she was able to see that a bath was given in the, Matrixcare, computer system was on 8/19/2019.

Based on observations and interviews, the facility failed to meet requirements for staff posting in 1 of 3 resident hallways (200 hallway). The findings include: On 8/27/2019 at approximately 8:57AM, the 200-hallway staff list whiteboard listed the date 8/25/2019 and contained only the first names of Certified Nursing Assistants (CNAs) assigned. Areas marked for nurses' names was blank and the posted information did not contain the facility name, current date, total number and actual hours worked by category of registered nurses, licensed practical nurses, or the resident census. On 8/28/19 at 3:59 PM, staff B, the Assistant Director of Nursing, confirmed during an observation the staff posting on 200 hall included only the names and room numbers for CNAs assigned. The staffing hours were on a clipboard lying on the counter, not visible to residents in a wheelchair (w/c). Staff B noted that the nurse names were not on the board and made no attempt to fix it, but said normally the nurse names are included, but it apparently wasn't posted today. At the time of this observation, the staff posting did not include the facility name, total number and actual hours worked by category of registered nurses, licensed practical nurses, or the resident census. On 8/29/19 at 11:16 AM, the Director of Nursing (DON) confirmed during an observation of the staff posting on the 200 hall the date was not posted and that the hours were sitting on the counter on a clipboard and not visible to residents in w/c. The DON used the whiteboard marker to add the date to the whiteboard and used a piece of tape to post the staffing on the white board at a level visible to residents in wheelchairs. There was a resident present in a wheelchair at the time of observation who stated it was nice that she could read it after the DON taped it to the whiteboard.

Based on record review, facility policy review and staff interview, the facility failed to implement the plan of care for 2 of 3 residents reviewed for diabetes management related to insulin (#1 & #2). Findings include - Resident #1 On 1/3/2019 a closed record review was conducted for resident #1. The review revealed that the resident had returned to the facility on [DATE] after a 4 day hospital admission for heavy vaginal bleeding. Upon return to the facility on [DATE] the physician wrote an order to Continue all previous nursing home orders. Review of physician orders [REDACTED]. of 477. At this time a new order was written for [MEDICATION NAME] 15 units subcutaneously every morning, which is 5 units less that the resident was previously receiving and was noted on the MAR indicated [REDACTED]. Further review of the record found the resident returned to the facility on [DATE] at which time an order was written to continue all previous nursing home orders however the resident was not ordered [MEDICATION NAME] upon her return. On 12/10/18 the resident was transferred to the emergency room for evaluation and treatment after her blood sugar was noted to be 600. It is noted that at the family's request the resident did not return to the facility. Review of the resident plan of care (P[NAME]) date 9/13/18 found an identified problem of Risk for complications associated with hyper or [DIAGNOSES REDACTED] [DIAGNOSES REDACTED]. Resident #2 On 1/3/19 a record review was conducted for resident #2 which revealed the resident had a physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. On all occasions the MAR indicated [REDACTED]. Further review of the record found there to be no documentation within the nursing notes indicating why the medication had been held. Continued review of the record found there to be a lack of a physician's orders [REDACTED]. Review of the resident's plan of care dated 2/14/18 found the resident was at risk for complications associated with hyper/[DIAGNOSES REDACTED] which included interventions to report to physician any unstable blood sugar and administer oral and/or insulin as ordered.

Based on record review, facility policy review and staff interview the facility failed to ensure residents receive insulin therapy in accordance with the comprehensive person-centered care plan. The facility failed to administer insulin as ordered and failed to notify the physician when insulin was held for 2 of 3 residents reviewed for diabetes management related to insulin (#1 & #2). Findings include: Resident #1 On 1/3/2019 a closed record review was conducted for resident #1. The review revealed that the resident had returned to the facility on [DATE] after a 4 day hospital admission for heavy vaginal bleeding. Upon return to the facility on [DATE] the physician wrote an order to Continue all previous nursing home orders. Review of physician orders [REDACTED]. of 477. At this time a new order was written for [MEDICATION NAME] 15 units subcutaneously every morning, which is 5 units less that the resident was previously receiving and was noted on the MAR indicated [REDACTED]. Continued review of the record found the resident returned to the facility on [DATE] at which time an order was written to continue all previous nursing home orders however the resident was not ordered [MEDICATION NAME] upon her return. Further review of the record revealed an Adult-Gerontology Nurse Practitioner (AGNP) assessment dated [DATE] in which the AGNP documented writer had in depth discussion with pt's (patient's) daughter regarding pts overall health condition and generalized decline she further documented that the residents daughter stated that she just wanted the pt to be comfortable and that education was provided to the family on urinary tract infections and diabetes in the elderly. She then went on to document Writer verbalized that at this point in pt's life, quality is what is more focused on and that strict glycemic control would not be done. Writer did agree to start patient on po (by mouth) medication for her diabetes to see if this would bring blood sugar down and at this point, sticking pt more than necessary, ie insulin coverage and more than 2 finger sticks per day would not benefit patient. At this time the AGNP ordered an oral Diabetes medication Pioglitaone HCL 15 mg daily. It is noted the AGNP ordered on [DATE] twice daily accuchecks but withheld the morning dose of [MEDICATION NAME]. Blood sugar readings in the evenings were noted to be 12/7/18 500, 12/8/18 586 and 12/9/18 600. On 12/10/18 the resident was transferred to the emergency room for evaluation and treatment after her blood sugar was noted to be 600. At the family's request the resident did not return to the facility. On 1/4/19 at approximately 2:30 PM an interview was conducted with the Director of Nursing (DON) in which she stated that the family was struggling with the residents declining health. She revealed the family had rescinded the residents Do Not Resuscitate (DNR) order when she was readmitted to the facility in (MONTH) and had stated they did not want hospice or palliative care. She stated that the AGNP discussed with the family that the resident was not benefiting from receiving so many insulin injections and that it would be to the residents benefit to stop the subcutaneous injections. When asked if the resident had been receiving insulin or blood glucose monitoring between her readmission on 12/3/18 and 12/6/18 when the AGNP met with the family she stated no. She was also asked when the resident had returned to the facility on [DATE] if the insulin orders had been placed on the Medication Administration Record [REDACTED]. When shown the order written by the physician continue all previous nursing home orders she stated that had been a mistake and that it should have been written to reflect the hospital's discharge instructions. When shown that the same order had been written on 12/3/18 she again stated it was a mistake and should have been written differently. When asked who reviewed the orders when a patient is admitted she stated either her or the assistant DON reviewed them 100% of the time but the continue pervious nursing home orders were missed on both 11/17/18 and 12/3/18. Review of the resident plan of care (P[NAME]) date 9/13/18 found an identified problem of Risk for complications associated with hyper or [DIAGNOSES REDACTED] [DIAGNOSES REDACTED]. Resident #2 On 1/3/19 a record review was conducted for resident #2 which was revealed the resident had a physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. On all occasions the MAR indicated [REDACTED]. Further review of the record found there to be no documentation within the nursing notes indicating why the medication had been held. Continued review of the record found there to be a lack of a physician's orders [REDACTED]. On 1/4/18 at approximately 2:30 PM an interview was conducted with the pharmacist at Pharm America in which he stated that there were no parameters within the record that indicated the insulin was to be held below a set blood sugar. He stated that Basaglar is a long acting insulin that peaks after 12 hours he stated that with the blood sugar being low in the morning he would have recommended it being held at the evening dosage. He stated he was not aware that the medication was being held and that the facility had been ordering refills that indicated that it was being given. Interview with the DON on 1/4/19 at 12:00 PM revealed that she was unable to find documentation to support that the doctor was notified of the holding of the insulin in the morning. She stated standard is to notify the physician after 3 days however was unable to find where this was done. Review of the resident's plan of care dated 2/14/18 found the resident was at risk for complications associated with hyper/[DIAGNOSES REDACTED] which included interventions to report to physician any unstable blood sugar and administer oral and/or insulin as ordered. Review of facility policy Medication Administration General Guidelines revised (MONTH) (YEAR), under titled section documentation item 2 states if a dose of regularly scheduled medication is withheld, refused or given at other than the scheduled time the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN documentation. If two consecutive does of a vital medications are withheld or refused the physician is notified. Review of the Pharm American Educational information related to Basaglar revealed it lasts longer than regular insulin provides a low steady level of insulin and instructs to Use exactly as prescribed by your doctor. Even small changes in the amount of insulin may have a large effect on your blood sugar. The literature further advises Missed Dose: It is very important to follow your insulin regimen exactly. Ask your doctor ahead of time what you should do if you miss a dose of insulin.

Based on observation, record review and staff interview, the facility failed to implement the plan of care for 1 of 4 residents (#41) in regards to repositioning and provision of dietary supplements and for 1 of 1 resident sampled for tube feeding (#76). The findings are: Resident #41 had a Minimum Data Set (MDS) assessment, with an assessment reference date of 7/24/18, that showed the resident required extensive, two person assistance with bed mobility and supervision with eating. Review of the most current plan of care for resident #41, dated 7/26/18, indicated that the resident was to be turned and repositioned at least every 2 hours and more often as needed, and the head of the resident's bed was to stay flat, as tolerated, to reduce shearing. Resident #41 was observed on the following dates and times positioned on her back with the head of the bed elevated to approximately 30-45 degrees, indicating the plan of care was not being followed: 9/24/18 at 10:20 am, 11:30 am, 1:20 pm, 2:40 pm, 3:45 pm, & 3:55 pm 9/25/18 at 1:15 pm, 1:30 pm, 2:06 pm, & 2:45 pm 9/26/18 at 10:40 am, 12:00, 1:20 pm, 2:00 pm, & 2:30 pm 9/27/18 at 9:00 am, 10:10 am, 12:53 am, 1:00 pm, 2:30 pm, 3:00 pm and 3:30 pm. On 9/26/18 at 12:00 pm, an interview with staff H, a certified nursing assistant (CNA) who cared for the resident, indicated the resident was incontinent and was to be checked, changed, and repositioned every two hours. Further review of the resident's plan of care revealed resident #41 was to be assisted with meals and provided diet as ordered, including a dietary supplement (Magic Cup) for extra calories. Observation on 9/25/18 at 1:15 pm found no magic cup on the resident's tray. On 9/26/18 at 1:20 pm, observation again revealed there to be no magic cup on the resident's tray. Review of physician orders [REDACTED]. Review of the resident's diet card did not indicate she was to receive this supplement. Resident #76 On 9/26/2018 at approximately 6:15 AM, an observation of resident #76 was made. During this observation, Certified Nursing Assistant (CNA) staff Q and CNA staff R where assisting the resident with incontinent care. At the time of the observation, the resident was noted to be lying in supine position with the head of the bed down level with the foot of the bed. The pump that housed the resident's tube feeding was noted to be illuminated and indicated the tube feeding was infusing at 50cc/hr as evidenced by a drop symbol blinking off and on next to the infusion rate. During the incontinent care, the resident was turned side to side to allow for the linen under the resident to be removed and the soiled brief to be changed while the resident remained in bed. After the staff had completed the process of changing the resident they lowered the head of the bed further placing the resident into a Trendelenburg position and pulled the resident up toward the top of the bed and then elevated the head of the bed with the resident in a reclined sitting positon. At no point was the tube feeding observed to be stopped. On 9/26/2018 at approximately 6:30 AM an interview was conducted with staff members Q & R in which they were asked about the care of a resident with a tube feeding. They stated that when a resident had a tube feeding, they were required to keep the head of the bed elevated at all times to avoid the feeding getting into the residents lungs. When asked why they had not ensured the feeding was turned off or had kept the residents head elevated during care they stated that they were busy. When asked if placing a resident in the Trendelenburg position was a safe practice while a tube feeding was infusing they stated probably not. Review of the resident's care plan showed a problem identified as potential for complications related to using/having a feeding tube with an intervention to keep HOB (head of bed) elevated 30 degrees while administering feeding.

Based on observations, interviews and record review, the facility failed to provide appropriate care, in accordance with current standards of care, to prevent complications of tube feeding for 1 of 1 resident sampled (#76). Findings Include: On 9/26/2018 at approximately 6:15 AM, an observation of resident #76 was made. During this observation, Certified Nursing Assistant (CNA) staff Q and CNA staff R where assisting the resident with incontinent care. At the time of the observation, the resident was noted to be lying in supine position with the head of the bed down level with the foot of the bed. The pump that housed the resident's tube feeding was noted to be illuminated and indicated the tube feeding was infusing at 50cc/hr as evidenced by a drop symbol blinking off and on next to the infusion rate. During the incontinent care, the resident was turned side to side to allow for the linen under the resident to be removed and the soiled brief to be changed while the resident remained in bed. After the staff had completed the process of changing the resident they lowered the head of the bed further placing the resident into a Trendelenburg position and pulled the resident up toward the top of the bed and then elevated the head of the bed with the resident in a reclined sitting positon. At no point was the tube feeding observed to be stopped. On 9/26/2018 at approximately 6:30 AM an interview was conducted with staff members Q & R in which they were asked about the care of a resident with a tube feeding. They stated that when a resident had a tube feeding, they were required to keep the head of the bed elevated at all times to avoid the feeding getting into the residents lungs. When asked why they had not ensured the feeding was turned off or had kept the residents head elevated during care they stated that they were busy. When asked if placing a resident in the Trendelenburg position was a safe practice while a tube feeding was infusing they stated probably not. ` On 9/29/2018 at 10:42 AM, a professional nursing article, entitled Heads up to Prevent Aspiration during Enteral Feedings, was reviewed and stated, unless medically contraindicated, elevate the head of bed to 30-45 degrees to reduce the risk of aspiration. If the resident must be placed supine for a procedure, turn off the feeding 30 to 60 minutes before the procedure to prevent aspiration.