Every finding on record at Cherry Hill Rehabilitation & Healthcare Center

Based on observation, interview, the facility's policy for Menus, the facility's Meal Guide Report for Week 3, the facility's Recipe Report for Pudding Parfait, and the facility's chart for scoop size and capacity; the facility failed to ensure Pureed Lasagna and Chocolate Pudding Parfait were served in the portion sizes as indicated on the menu for Tuesday, 12/13/2022. This had the potential to affect 67 of 97 residents receiving meals from the kitchen. Findings Include: The facility's policy for Menus, dated 6/2017, included the following: Policy: Menus are planned to meet the nutritional needs of the residents in accordance with the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences. The facility shall provide residents with a nourishing, palatable, well balanced diet that meets daily nutritional needs . Procedure: 1. Menus for regular and therapeutic diets are preplanned. Preplanned menus are developed to meet the nutritional needs of the majority of the residents . 3. The correct portion size for each menu item is listed for each diet included in the menu modifications. 5. Foods will be served as planned on the menu . 7. Menus are planned and modified by a registered dietitian and the DM (Dietary Manager) in accordance with the Recommended Dietary Allowances to include: . c. Portion sizes for each item are noted on the menu. 9. The current day's menu is posted in the kitchen near the serving line. 12. Standardized recipes are available for all items included on the cycle menu. 14. The current week's menu is posted in one or more accessible places for easy use by the food service staff during the preparation and service of food. The facility's Recipe Report for Parfait, Pudding w/ (with) Topping, copyright 1999-2022, included the following: . Yield: 99 . Portion: 1/2 cup . Ingredients . Pudding, Vanilla Pudding from Mix . Chocolate Pudding from Mix . Topping, Whipped . The facility's Menu Guide Report for Fall/Winter 2022/2023, Tuesday, Week 3, Day 3 included the following for lunch: . Pureed Lasagna 1 #6 dipper . for the Puree diet and . 1/2 cup Pudding Parfait . for the Regular, Mechanical Soft, Puree, Limited Fat, and Soft/Bland diets. The facility's chart for scoop size and capacity, undated, identified a blue-handle scoop as a #16 size scoop that yielded two fluid ounces or 1/4 cup. On 12/13/2022 at 10:30 AM, the AM Cook, Employee Identifier (EI) #6 was observed pureeing Lasagna. At 11:20 AM, the tray line was being set up for lunch. At 11:38 AM, the temperatures of the food items on the tray line were taken, including Pureed Lasagna. At 11:52 AM, EI #6, who was serving the hot food on tray line, said a #8 scoop/dipper was being used for portioning the Pureed Lasagna. The number eight was observed on the scoop/dipper. During the lunch tray line on 12/13/2022 at 12:21 PM, a Regular diet test tray was requested for the Two West cart. At 12:39 PM, the test tray was observed with EI #4, the Dietary Manager (DM). The Chocolate Pudding Parfait serving size looked small. It filled less than half the 4-ounce insulated bowl. EI #4 said it looked like two ounces. Later in the kitchen at 12:46 PM, EI #4 spooned the Pudding Parfait from the bowl into a #8 scoop/dipper (four ounces, 1/2 cup), but it did not fill the scoop/dipper. EI #4 agreed the Pudding Parfait serving was probably between two and three ounces. During an interview on 12/13/2022 at 12:50 PM, EI #4, the DM, observed that a #8 scoop/dipper was being used in the Pureed Lasagna. The Week 3, Meal Guide Report for Fall/Winter 2022/2023, Tuesday, Day 3, lunch menu was reviewed with EI #4. The Puree diet specified one #6 dipper (#6 scoop/dipper, six ounces, 2/3 cup) of Pureed Lasagna as a serving. The Pudding Parfait serving size was specified as 1/2 cup. When asked if a scoop/dipper chart with corresponding ounces and cup sizes was posted anywhere for staff to use, EI #4 said, No. On 12/14/2022 at 9:30 AM, EI #7, the Dietary Aide who prepared the Pudding Parfaits for lunch on 12/13/2022, was interviewed. EI #7 said he followed a recipe to make the pudding parfaits. EI #7 further said he didn't think he had enough chocolate pudding yesterday. When asked how did he know how much to use for a regular serving, EI #7 said normally he asked the Dietary Manager (EI #4) or the Assistant Dietary Manager (EI #5) what scoop/dipper to use, but yesterday he just grabbed one. EI #7 said the scoop/dipper he used was a three ounce, with a blue handle. EI #7 also said he thought he saw a three in a circle on the handle of the scoop/dipper. EI #7 said normally he just filled to the top of the bowl, but yesterday he just did not have enough pudding made. EI #7 further said EI #6, the AM Cook, made the pudding and he helped her by making the topping. When asked if there was a conversion sheet available to show how many ounces or what was the cup measurement in the different size scoops/dippers, EI #7 said EI #4, the DM, just put one on the wall. EI #7 then said there should be something in the recipe book. EI #7 showed the recipe used for Pudding Parfait and pointed to 1/2 cup as the serving size. EI #4, the DM, was interviewed on 12/14/2022 at 9:58 AM. When asked how staff knew how much to serve for a regular size portion for any menu item, EI #4 said it was on the menu. EI #4 said she used to have a conversion sheet posted to show how many ounces and the cup measurement for the different size scoops before the kitchen wall was painted. EI #4 then said she put up a new conversion sheet last night. Upon being asked what the portion size should have been for the Pureed Lasagna served yesterday (12/13/2022), EI #4 said six ounces. EI #4 further said the menu actually specified a #6 scoop/dipper for Pureed Lasagna on the Tuesday, Day 3, Week 3 menu. EI #4 said the portion size for the Pudding Parfait should have been four ounces and then said the menu actually specified 1/2 cup. When asked what was the problem if residents got served portions smaller than that specified on the menu, EI #4 said they could lose weight. On 12/14/2022 at 10:12 AM, EI #3, the Corporate Registered Dietitian, was interviewed. According to EI #3, the staff can refer to the menu spreadsheet or menu guide to know how much to serve for a regular size portion for any menu item. EI #3 said there should be a conversion sheet posted to show the number of ounces or the cup measurement for the different size scoops/dippers. EI #3 further said standardized measures were used to make sure the residents were getting their needed nutrients. EI #3 also said, if residents got served portions smaller than as specified on the menu, the residents' nutrient needs would not be met and then they could lose weight.

Based on observation, interviews, record review the facility failed to ensure the feeding tube containers for Resident Identifier (RI) #79 were labeled appropriately. This deficient practice affected RI #79; one of three residents sampled receiving tube feedings. Findings Include: RI #79 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis to include Dysphagia following Cerebral Infarction. RI #79's December 2022 Physician's Orders documented, Jevity at 20 CC/HR (cubic centimeter/hour) with flush of 25 CC/HR x 23 HRS. On 12/12/2022 at 9:36 AM, RI #79 was observed lying in bed with head elevated, feeding hanging and machine beeping. The feeding containers were not labeled. On 12/12/2022 at 9:54 AM, an interview was conducted with Employee Identifier (EI) #9, Licensed Practical Nurse (LPN). EI #9 admitted feeding bags/bottles were not labeled. She stated they should be labeled with resident's name, time and date, rate of infusion for milk and water and person who hung the bags. EI #9 stated bags/bottles must be changed every 24 hours. EI #89 stated the concern of not labeling feeding bottles was not knowing how long it had been up there or if it had been changed. On 12/14/2022 at 3:48 PM, an interview was conducted with EI #2, Corporate, RN. EI #2 stated RI #79's feeding bottle should have been labeled with date, time the bag was hung, show rate as well as initial or name of person who hung the bag. EI #2 stated the concern of not being labeled was infection control and the bottle hanging too long.

Based on interviews, medical record review, and a review of a facility policy titled, Change in Medical Condition of Residents, the facility failed to ensure that Resident Identifier (RI) #18's sponsor/family was notified when RI #18's medication, Oxcarbazepine was increased on 08/16/2022. This deficient practice affected RI #18; one of one sampled resident reviewed for notification. Findings Include: A review of facility's policy titled, Change in Medical Condition of Residents, with an effective date of 02/01/2004, documented, .Notification of . legal representative, or interested family member, should occur promptly, according to federal regulations, when there is a change in the resident's condition. A need to alter treatment . RI #18 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include Alzheimer's Disease, Unspecified Mood (Affective) Disorder, Altered Mental Status and Vascular Dementia. RI #18's August 2022 physician orders documented RI #18's Oxcarbazepine (Trileptal) 150 mg (milligram) tablet give 1/2 tablet to equal 75 mg via tube every day. Nursing Notes for RI #18 dated 08/16/2022, documented, . Received new orders. Increase Oxcarbazepine 75 mg to 150 mg QDAY (everyday) BID per tube. This note was signed by Employee identifier (EI) # 12, Licensed Practical Nurse, (LPN). On 12/11/2022 at 5:55 PM, an interview was conducted with RI #18's sponsor. He/She stated that he/she was not notified when RI #18's medication was changed. On 12/14/2022 at 3:56 PM, an interview was conducted with EI #12, LPN. EI #12 stated the representative should be notified when a medication was modified or changed. EI #12 stated notification should be documented in the nurse's notes. EI #12 admitted she did not notify RI #18's representative on 08/16/2022 when his/her Oxcarbazepine was increased. She stated the concern of the representative not being notified was the family not knowing what's going on with the resident.

Based on record review, and interview, the facility failed to ensure Resident Identifier (RI) #6's Nebulizer Treatments were administered in accordance with the physician's orders. This deficient practice affected RI #6, one of three residents sampled for respiratory care. Findings Include: RI #6 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of Chronic Respiratory Failure. RI #6's November 2022 Physician Orders documented, Albuterol Sul (sulfate) 2.5 Mg/3ML (milligram/milliliter) SOLN (solution) -give 3ML Nebulizer treatment every 6 hours. RI #6's November's e-MAR (electronic medication administration record) documented, Albuterol Sul 2.5MG/3 ML SOLN-give 3ML Nebulizer Treatment every 6 hours . Order date 10/25/22. Review of RI #6's November's e-MAR revealed there was no documentation or explanation why RI #6 did not receive his/her nebulizer treatment for the following dates: 11/07/2022 (12 and 6 AM doses), 11/12/2022 (12 AM dose), 11/14/2022 (12 AM dose), 11/16/2022 (12 AM dose), 11/17/2022 (12 AM dose), 11/19/2022 (12 AM dose), 11/20/2022 (12 AM dose), 11/21/2022 (12 AM dose) , 11/22/2022 (12 AM dose), 11/23/2022 (12 AM dose), 11/26/2022 (12 AM, 6 AM and 6 PM dose), 11/28/2022 (12 AM dose) and 11/29/2022 (12 AM dose). On 12/14/2022 at 7:19 PM, an interview was conducted with Employee Identifier (EI) # 2, Corporate Registered Nurse. EI #2 stated RI #6's order for Albuterol was started on 10/25/2022. She stated according to the e-Mar it looked like some doses were not given per physician's order. EI #2 stated the medication should have been given. EI #2 stated the concern of not giving medication per Physician's order was the resident may not have the effect the medication was designed to have if it was not administered correctly. This deficiency was cited as a result of the investigation of compliant/report # AL00042490. Based on record review, and interview, the facility failed to ensure Resident Identifier (RI) #6's Nebulizer Treatments were administered in accordance with the physician's orders. This deficient practice affected RI #6, one of three residents sampled for respiratory care. Findings Include: RI #6 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of Chronic Respiratory Failure. RI #6's November 2022 Physician Orders documented, Albuterol Sul (sulfate) 2.5 Mg/3ML (milligram/milliliter) SOLN (solution) -give 3ML Nebulizer treatment every 6 hours. RI #6's November's e-MAR (electronic medication administration record) documented, Albuterol Sul 2.5MG/3 ML SOLN-give 3ML Nebulizer Treatment every 6 hours . Order date 10/25/22. Review of RI #6's November's e-MAR revealed there was no documentation or explanation why RI #6 did not receive his/her nebulizer treatment for the following dates: 11/07/2022 (12 and 6 AM doses), 11/12/2022 (12 AM dose), 11/14/2022 (12 AM dose), 11/16/2022 (12 AM dose), 11/17/2022 (12 AM dose), 11/19/2022 (12 AM dose), 11/20/2022 (12 AM dose), 11/21/2022 (12 AM dose) , 11/22/2022 (12 AM dose), 11/23/2022 (12 AM dose), 11/26/2022 (12 AM, 6 AM and 6 PM dose), 11/28/2022 (12 AM dose) and 11/29/2022 (12 AM dose). On 12/14/2022 at 7:19 PM, an interview was conducted with Employee Identifier (EI) # 2, Corporate Registered Nurse. EI #2 stated RI #6's order for Albuterol was started on 10/25/2022. She stated according to the e-Mar it looked like some doses were not given per physician's order. EI #2 stated the medication should have been given. EI #2 stated the concern of not giving medication per Physician's order was the resident may not have the effect the medication was designed to have if it was not administered correctly. This deficiency was cited as a result of the investigation of compliant/report # AL00042490.

Based on interview, record review and a facility policy with the subject, Resident Assessment Instrument, the facility failed to ensure a quarterly resident Minimum Data Set (MDS) assessment instrument was transmitted within the required timeframes. This affected Resident Identifier (RI) #61, one out of two residents investigated for resident assessments. Findings Include: A facility policy with the subject, Resident Assessment Instrument, with a revision date of 10/2013, revealed, . PURPOSE: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop a plan of care. PROCESS: . V. MDS Version 3.0 Quarterly Assessment . b) Quarterly assessments are due at least every 92 days, and at a minimum, three quarterly assessments and one comprehensive assessment is required in each twelve-month period. XI. Transmission Requirements a) Within 14 days after completion of a resident's assessment, the facility should be capable of transmitting that data to the QIES (Quality Improvement and Evaluation System) Assessment Submission and Processing System (ASAP). b) The facility should transmit, weekly, encoded, accurate, complete MDS data to CMS (Centers for Medicare and Medicaid Services) for all assessments conducted. RI #61 was admitted to the facility on [DATE] and readmitted [DATE], RI #61's Quarterly MDS with an Assessment Reference Date (ARD) of 10/11/2022 revealed a status of Open. In an interview on 12/13/22 at 5:57 PM, Employee Identifier (EI) #8, Interim MDS Coordinator/Corporate, reported the last accepted MDS for RI #61 was dated 07/11/2022 but there was an open assessment dated [DATE]. EI #8 stated the 10/11/2022 open assessment was supposed to be transmitted by 11/08/2022. EI #8 stated the assessment was not submitted due to an oversight. EI #8 stated the concern in the MDS not being submitted timely was inaccurate information.

Based on observation, interviews, record review and review of a facility policy Diagnostic Testing Services, the facility failed to ensure a laboratory specimen was picked up timely after orders were received on 12/10/22. This affected one of one resident to which a Urine specimen was observed in the Specimen refrigerator on 12/13/22. Findings Include: A review of a facility policy titled Diagnostic Testing Services with an effective date of February 1, 2004, revealed . PURPOSE: Each resident has the right to receive diagnostic services, in a timely manner, to meet his/her needs for diagnosis, treatment and prevention. Resident Identifier (RI) #48 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of Type 2 Diabetes Mellitus without complications. A review of a handwritten Physician's order dated 12/10/22 revealed ' Urine albumin - creatine ratio Diabetes . On 12/13/22 at 12:55 PM, the surveyor observed a sign on the medication room door indicating a specimen refrigerator inside. An observation was made of the refrigerator with Employee Identifier EI #9, Licensed Practical Nurse. In the refrigerator was a urine specimen for RI #48 which was dated 12/10/22. EI #9 was asked when should the specimen have went out; she said the next day. EI #9 said lab specimens were picked up daily. EI #9 was asked when should the specimen for RI #48 have went out; she said on 12/11/22. On 12/13/22 at 1:05 PM, the Acting DON, EI #2 entered the medication room. The surveyor asked her what lab specimens were in the refrigerator. EI #2 took out the two specimen bags; she said one was to be picked up that day. EI #2 was asked what was the name on the second specimen; she said RI #48, it was a urine specimen dated 12/10/22. EI #2 was asked when should that specimen have went out; she said the day of or the day after it was obtained. EI #2 was asked why was it still there; she said she was not sure. On 12/14/22 at 11:00 AM, EI #10, Registered Nurse, (RN) was asked when did RI #48's specimen go out. EI #10 said if it was collected on 12/10/22 it would not have gone out until Monday at midnight. EI #10 was asked why was the specimen for RI #48 still in the refrigerator on 12/13/22 at 1:05 PM; she said she did not know. EI #10 was asked what was the lab order for; she said albumin and creatine ratio due to diabetes. EI #10 was asked what was the harm in labs not being sent out timely. EI #10 said it could result in not receiving a timely treatment.

Based on observations, interviews, and a facility policy titled Urinary Catheter Care, the facility failed to ensure Resident Identifier (RI) #79's catheter bag was not touching the floor on 12/12/2022. This deficient practice affected one of two residents observed with catheters. Findings Include: A facility Policy titled, Urinary Catheter Care, with an effective date of 02/01/2004, documented, .Process: . i) Catheter tubing and drainage bags are kept off the floor to prevent contamination . RI # 79 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis to include Retention of Urine. RI #79's December's Physician's Orders documented: Catheter for Urinary Retention. On 12/12/2022 at 9:35 AM, RI #79's catheter bag was observed hanging from bed frame and touching the floor. On 12/12/2022 at 9:44 AM, an interview was conducted with Employee Identifier (EI) #11, Certified Nursing Assistant (CNA). EI #11 stated RI #79's catheter bag was on the floor. EI #11 admitted the catheter bag should not have been on the floor. On 12/12/2022 at 9:54 AM, an interview was conducted with EI #9, Licensed Practical Nurse (LPN). EI #9 stated she observed RI #79's catheter bag on the floor. She stated the bag should not be touching the floor. EI #9 stated the concern of the catheter bag touching the floor was infection control. On 12/14/2022 at 3:48 PM, an interview was conducted with EI #2, Corporate Nurse, Registered Nurse (RN). EI #2 stated a catheter bag should never be on the floor. She stated RI #79's bag should not have been on the floor when observed on 12/12/2022. EI #2 stated the concern of a catheter bag being on the floor was it could pose infection control risk for the resident.

Based on observation, interviews, record reviews and a review of the Long-Term Care Facility Resident Assessment Instrument (RAI), the facility failed to ensure Resident Identifier (RI) #79 and RI #90 had a care plan for Foley catheters. This deficient practice affected RI #79 and RI #90, two of four residents sampled for catheters. Findings Include: A review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1 dated October 2019 revealed, . Chapter 4 Care Area Assessment Process and Care Planning . 4.7 . The care plan is driven not only by identified resident issues and/or conditions but also by a resident's unique characteristics, strengths and needs. Develops and implements an intradisciplinary care plan based on the assessment information gathered throughout the RAI process, with necessary monitoring and follow-up; . Provides information regarding how the causes and risks associated with issues and/or conditions can be addressed to provide for a resident's highest practicable level of well-being (care planning); . RI #90 was admitted to the facility on [DATE] with a diagnosis of Chronic Cystitis without Hematuria. A review of RI #90's November and December Physician orders revealed .Order date 11/28/22 . 16 FR (French) with 30 ML (milliliters) BULB FOLEY CATHETER DX (diagnosis): URINARY RETENTION . A review of RI #90's Admission Minimal Data Set (MDS) with an Assessment Reference Date of 12/04/2022 revealed in section H . Appliances:indwelling catheter checked . A review of RI #90's care plans did not reveal a care plan for the foley catheter. On 12/14/2022 at 7:44 AM, an interview with Employee Identifier (EI) #14, MAC (Medical Assistant Certified), verified RI #90 had a foley catheter. 41928 RI #79 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis to include Retention of Urine. RI #79's December's Physician's Orders documented: Catheter for Urinary Retention. A review of RI #79's care plans did not reveal a care plan for the foley catheter. On 12/12/2022 at 9:35 AM, RI #79 was observed with a Foley Catheter. On 12/14/2022 at 6:05 PM, an interview was conducted with EI #8, MDS Coordinator, Registered Nurse (RN). EI #8 stated both RI #79 and RI #90 had catheters, but she did not see a care plan on either resident. She admitted that both residents should have care plans for catheter care. EI #8 stated the concern of not developing a care plan for catheter care was the facility not providing adequate care.

Based on interviews, record review and review of a facility policy titled, SPECIFIC MEDICATION ADMINISTRATION PROCEDURES, the facility failed to ensure EI (Employee Identifier) #6, LPN (Licensed Practical Nurse) did not leave RI (Resident Identifier) #7's medication at the bedside on 10/04/22 unattended. This deficient practice affected RI 7, one of seven sampled residents. Findings Include: A review of a facility policy titled, SPECIFIC MEDICATION ADMINISTRATION PROCEDURES, with a revised date of August 2014, revealed: .ORAL MEDICATION ADMINISTRATION Purpose To administer oral medications in a safe, accurate, and effective manner.Procedures . F. Administer medication and remain with resident while medication is swallowed .Do not leave medication at bedside, . RI #7 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] RI #7's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 08/17/22 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 0 indicating the resident's cognition was severely impaired. Record review of the facility investigation revealed, RI #7's family informed a staff member on 10/4/22 that a cup with unknown liquid was left in the resident's room. A review of a statement written by EI #6 revealed she had pulled the medications but got distracted after setting the medications down. This statement was dated 10/4/22. On 10/14/22 at 11:56 AM an interview was conducted with EI #6. EI #6 was asked did she leave medications in RI #7's room. EI #6 said, yes, she did but did not remember the date, she stated it just happened recently in October. EI #6 was asked where she left EI #7's medications in the room. EI #6 said at the bedside table or nightstand, she could not remember. EI #6 was asked what medications were left in the cup in the room. EI #6 said his/her scheduled 6:00 AM medications. EI #6 was asked what should she had done with the medications if she was unable to administer them at that time. EI #6 said, she should have taken the cup and put them back on the cart and lock the cart. EI #6 was asked should medications be left in a resident's room. EI #6 said, no. EI #6 was asked what was the potential harm of leaving medications in a resident's room. EI #6 said, that the resident could take the medications and harm themselves.

Based on interviews and record review, the facility failed to ensure a [MEDICATION(S)] level was completed on Resident Identifier (RI) #1 as ordered by the physician. This deficient practice affected RI #1, one of three residents sampled with [MEDICATION(S)] lab orders. Findings include: RI #1 was admitted to the facility on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #1's August 2022 admission Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #1's care plan titled (name of RI #1) has potential for complications R/T (related to) [CONDITION(S)], with a Problem Onset date of 08/10/2000, revealed the following approach . *Labs as ordered . A review of lab results from Clinical Laboratory Services, Inc, with a date drawn of 08/12/2022 at 3:45 AM, date received 08/12/2022 at 2:26 PM and date reported 08/12/2022 at 4:28 PM, revealed the only labs drawn, received and reported were the CMP, CBC and HGB A1C. There was no evidence the [MEDICATION(S)] level had been done. On 10/14/2022 at 11:34 PM, an interview as conducted with Employee Identifier (EI) #5, the Nurse Practitioner. When asked what he would expect the facility to do when a [MEDICATION(S)] level was ordered, EI #5 said it should be collected and if it was out of range reported to the primary doctor. On 10/14/2022 at 3:30 PM, an interview was conducted with EI #1, the Director or Nursing (DON). The surveyor asked EI #1, according to RI #1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #1 said a CMP, CBC, a Hemoglobin A1C and a [MEDICATION(S)] level. EI #1 said she could not find where the [MEDICATION(S)] level was done. The surveyor asked EI #1 should the [MEDICATION(S)] level have been received and resulted when the other lab results were received. EI #1 said yes. When asked who would be responsible for ensuring the [MEDICATION(S)] level was on the lab requisition along with the other labs, EI #1 said the admitting nurse. EI #1 said she did not know who exactly did the lab slip. The surveyor asked EI #1 what was the reason doctors ordered certain labs. EI #1 said to make sure the medication was in therapeutic range. When asked what the potential for harm was when labs were not drawn, resulted and received, EI #1 said there could be a potential for risk of toxicity or seizures. On 10/14/2022 at 6:44 PM. the surveyor conducted an interview with EI #3, the nurse admitting RI #1 on 08/10/2022. When asked what lab orders was RI #1 admitted with, EI #3 said she did not recall. EI #3 also said she did not recall ordering labs for RI #1. The surveyor asked EI #3 who would have been responsible for ordering RI #1's admitting labs. EI #3 said ordering labs was a team effort.

Based on interviews, record review and review of a facility policy titled SPECIFIC MEDICATION ADMINISTRATION PROCEDURES, the facility failed to provide evidence that the licensed nurses were consistently documenting on the resident's eMARs (electronic Medication Administration Records) the administration of the residents [MEDICATION(S)] medication. This deficient practice affected Resident Identifier (RI) # 1, one of five sampled residents reviewed for documentation of administration of medication. Findings Include: Review of a facility policy titled SPECIFIC MEDICATION ADMINISTRATION PROCEDURES, with a revised date of 08/2014, revealed the following: . Procedures . H. [When finished with each resident . I. Chart medication administration on Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #1 was admitted to the facility on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] RI #1's August 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of RI #1's August 2022 eMAR, revealed there was no documented evidence RI #1 received the [MEDICATION(S)] on 08/15/2022 at 9:00 AM, on 08/16/2022 at 9:00 AM and 9:00 PM, on 08/17/2022 at 9:00 AM and 9:00 PM, on 08/18/2022 at 9:00 AM, on 08/20/2022 at 9:00 AM and on 08/24/2022 at 9:00 AM. On 10/13/2022 at 1:42 PM, an interview was conducted with Employee Identifier (EI) #2, the LPN (Licensed Practical Nurse) assigned to administer medications to RI #1 on 08/16/2022 at 9:00 AM and 9:00 PM, on 08/17/2022 at 9:00 AM and 9:00 PM, on 08/18/2022 at 9:00 AM and on 08/24/2022 at 9:00 AM. The surveyor asked EI #2 where there would be evidence RI #1 had received his/her [MEDICATION(S)] as ordered. EI #2 said on the eMAR. When asked, looking at RI #1's eMAR, did he administer RI #1's [MEDICATION(S)] as ordered, E #2 said he did he just did not document he had on those days. When asked why it would be important to initial or document a resident's medication had been administered, EI #2 said it would show the resident was given his/her medication on time. On 10/13/2022 at 7:09 PM, an interview was conducted with EI #3, the RN (Registered Nurse) assigned to administer medications to RI #1 on 08/15/2022 at 9:00 AM. When asked where there would be evidence RI #1 had received the [MEDICATION(S)] as ordered by the physician, EI #3 said it should be on the eMAR. The surveyor asked EI #3, when looking at RI #1's eMAR, did she see where she initialed or documented on the eMAR the [MEDICATION(S)] had been administered. EI #3 said she did not. EI #3 said she probably just forgot to document she gave it, but she did. When asked why it would be important to initial or document when a medication had been administered, EI #3 said it would show the medication had been administered. On 10/14/2022 at 3:30 PM, an interview was conducted with EI #1, the Director or Nursing (DON). When asked where there would be evidence [MEDICATION(S)] was administered as ordered, EI #1 said on the MARs. The surveyor asked EI #1, looking at RI #1's eMAR, was there evidence the [MEDICATION(S)] was administered every day and shift as ordered. EI #1 said no. On 10/14/2022 at 5:15 PM, a telephone interview was conducted with EI #4, the LPN assigned to administer medications to RI #1 on 08/24/2022 at 9:00 AM. When asked where there would be evidence, he had administered medications to a resident, EI #4 said on the eMAR. The surveyor shared with EI #4, looking at RI #1's eMAR there were no initial or documentation he had administered RI #1 his/her [MEDICATION(S)] on 08/20/2022 at 9:00 AM. EI #4 said he probably forgot to document he had. When asked why it would be important to initial/document when a medication had been administered, EI #4 said it was a check and balance system and it let others know the medication had been given.

Based on interviews, record reviews and review of a facility policy titled Change in Medical Condition of Residents, the facility failed to provide evidence that the representative/responsible party was notified when Resident Identifier (RI) #1 developed a pressure area to (his/her) sacrum on 10/13/2021. This deficient practice affected RI #1; one of four residents sampled for notification. Findings include: Review of a facility policy titled, Change in Medical Condition of Residents, with an Effective Date: February 1, 2004, revealed: . STANDARD: Notification of the physician, legal representative, or interested family member, should occur promptly, according to federal regulations, when there is a change in the resident's condition. Change in condition is defined as: . A change in resident's physical, mental or psychosocial status . A need to alter treatment . RI # 1was admitted to the facility on [DATE]. A review of RI #1's medical record revealed a Wound Assessment Report dated 11/3/2021, which documented: . Wound Type Pressure Ulcer Wound Location Sacrum . Date Wound Identified 10/13/2021 . A review of RI #1's Departmental Notes (Nurse's Notes) revealed no documentation regarding notification of the resident's family member of the pressure ulcer to the sacral area on 10/13/2021. On 12/30/2021 at 3:26 PM, an interview was conducted with Employee Identifier (EI) #3, Licensed Practical Nurse (LPN). EI #3 was asked what all should family members be notified about regarding the residents. EI #3 said wounds, even if they are admitted with one, any orders that the Nurse Practitioners or Physicians write or if any medication changes, any incidents, or accidents, such as falls, skin tears, bruising, any appointments, any change in condition or refusals of care. EI #3 was asked did RI #1's family ever complain to her about RI #1 having pressure ulcers and EI #3 stated that RI #1's family did tell her that she did not know or was not told about RI #1 having a wound one time and that she apologized to her and updated her on RI #1's wound. On 12/31/2021 at 11:48 AM, an interview was conducted with Employee Identifier (EI) #1, Registered Nurse (RN)/Director of Nursing (DON). EI #1 was asked when a resident's family should be notified about concerns with a resident and EI #1 said immediately. EI #1 was asked what families should be notified about and EI #1 stated everything; a fall, any incident or accident, medication changes, new wound, any updates of anything going on, and care plan meetings. EI #1 was asked where the notifications should be documented, and she said in the nurse's notes. EI #1 was asked what the concern was with a resident's family not being notified about those things and EI #1 said they would not have the most up to date information about their resident and would be upset about not knowing what was going on. EI #1 was asked to review RI #1's medical record and ask if she could find where the family was notified on 10/13/2021 about a new pressure ulcer on (his/her) sacrum. EI #1 said no, there was no documentation that they were. EI #1 was asked should they have been notified. EI #1 said yes.

Based on observations, interviews, review of medical records, and a facility policy titled, Pressure Ulcers, the facility failed to ensure Resident Identifier (RI) # 1 and RI #3's wound assessments were completed weekly, and their pressure ulcer dressings were changed as ordered. These deficient practices affected RI #1 and RI #3; two of five sampled residents reviewed for pressure ulcers. Findings include: Review of a facility policy titled, Pressure Ulcers, with a revised dated of 11/2021, documented: . II. Wound and Skin Management Protocols . (a) Per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Documentation . (d) The status of ulcers should be recorded weekly in the weekly wound documentation. Any additional information should be documented in the weekly Treatment Note. RI # 1 was admitted to the facility on [DATE]. Review of RI #1's 10/1/2021 through 10/31/2021 TREATMENT ADMINISTRATION RECORD (TAR) was reviewed. There was a directive to SANTYL OINTMENT - CLEANSE SACRUM WOUND WITH NS (NORMAL SALINE) OR WOUND CLEANSER. PAT DRY AND APPLY SANTYL AND COVER WITH DRY DRESSING DAILY UNTIL HEALED Start Date: 10/18/21 2:00 PM There was an N documented for the following dates indicating the treatment was not administered: 10/18, 10/19, 10/20, 10/21, 10/22, 10/24, 10/25, 10/26, 10/27, and 10/28. A review of RI #1's 11/1/2021 through 11/30/2021 TAR revealed the above order continued until a new directive with a start date of 11/3/2021 at 2:00 PM, SANTYL OINTMENT WITH CALCIUM ALGINATE - CLEANSE SACRUM WITH NORMAL SALINE, PAT DRY, APPLY SANTYL TO CALCIUM ALGINATE STRIP, PACK WOUND LIGHTLY, COVER GAUZE THEN DRY DRESSING DAILY. There was an N documented for the following dates indicating the treatment was not administered: 11/1, 11/2, 11/3, 11/4 and 11/5. There were no initials or indication that the dressing was changed on 11/9 and 11/10. RI #1 was discharged to the hospital on 11/11/2021. Further review of RI #1's medical record revealed no wound assessment was completed on 10/13/2021 when a pressure ulcer was identified on (his/her) sacrum. Also, weekly wound assessments for RI #1's sacrum for 10/20 and 10/27/2021 were not completed. On 12/29/2021 at 4:43 PM, an interview was conducted with Employee Identifier (EI) #2, Registered Nurse (RN)/Treatment Nurse. EI #2 was asked according to your facility's policy how often should wound assessments be done. EI #2 said weekly. EI #2 was asked to review RI #1's chart to determine if RI #1's wound assessments had been done per policy. EI #2 said no, they were not. EI #2 was asked what the concern was with wound assessments not being completed and she said there will not be documentation available to see how the wound was doing. EI #2 was asked to review RI #1's TAR for October and November and determine if RI #1's wound care was completed as ordered by the physician and EI #2 said no, it was not. EI #2 was asked how many times it was missed in October and she said a lot, too many. EI #2 was asked what the concern was with wound care orders not being followed. EI #2 said infection and the wound worsening. On 12/31/2021 at 11:48 AM, an interview was conducted with EI #1, RN/Director of Nursing (DON). EI #1 was asked what RI #1's orders were for dressing changes in October 2021. EI #1 said daily and as needed. EI #1 was asked to review RI #1's TAR for October and asked how many times RI #1's dressings were changed in October. EI #1 said five; four on daily and one as needed. EI #1 was asked to review the same information for November, and she said RI #1 received a new order for a different type of dressing, but the frequency remained daily, and it was changed three times before RI #1 was discharged on [DATE]. EI #1 was asked was RI #1's treatment orders for dressing changes followed for October and November and EI #1 said no. EI #1 was asked what the concern was with wound care orders not being followed and she said the wound could get worse and become infected. RI #3 was admitted to the facility on [DATE]. Review of RI #3's 12/1/2021 through 12/31/2021 TREATMENT ADMINISTRATION RECORD (TAR) was reviewed. There was a directive to CLEANSE RIGHT HIP WITH NS (NORMAL SALINE) OR WC (WOUND CLEANSER). PAT DRY. APPLY [MEDICATION(S)] WITH SILVER TO WOUND BED COVER WITH A DRY DRESSING 3 TIMES A WEEK Start Date: 9/29/21 2:00 PM There was an N documented for the following dates indicating the treatment was not administered: 12/1, 12/3, 12/6, 12/10, 12/13, 12/15, 12/17, 12/20, 12/22, and 12/24. A review of RI #3's assessments revealed no wound assessments were completed for 12/8, 12/15, and 12/22/2021. On 12/29/2021 at 4:43 PM, an interview was conducted with EI #2, RN/Treatment Nurse. EI #2 was asked how often RI #3's wound assessments should be completed. EI #2 said weekly. EI #2 was asked to review RI #3's record and answer had RI #3's wound assessments been completed weekly for December. EI #2 said no. EI #2 was asked what the concern was with those assessments not being completed and she said the same, not having documentation of the assessment to know the wound's condition. On 12/31/2021 at 11:48 AM, an interview was conducted with EI #1, RN/DON. EI #1 was asked how often RI #3's dressings were supposed to get changed. EI #1 said three times a week and PRN. EI #1 was asked how many times RI #3's dressing change was missed in December and she said 11. EI #1 was asked what the concern was with dressing changes not being done as ordered. EI #1 said infection and worsening of the wound.

Based on record review, interviews, review of the facility's investigation file and a facility policy titled, Lifting and Transferring Residents, the facility failed to ensure Employee Identifier (EI) #6, Certified Nursing Assistant (CNA) transferred Resident Identifier (RI) #2 using two people. This deficient practice effected RI #2 one of two residents sampled for transfers. Findings included: A facility policy titled, Lifting and Transferring Residents, dated 10/2013, revealed, STANDARD Resident transfers should be performed based on the resident's functional status as determined by the Resident Assessment Process. RI #2 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #2 has diagnosis to include Muscle weakness, and Unspecified [CONDITION(S)]. A review of the RI #2's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/22/21 revealed, Section G Transfer the resident was coded as a two person assist. A review of RI #2's Care Plan revealed, . Problem Onset: 6/11/2012 Potential for injuries/falls . Approaches . Resident to be transferred via hoyer lift along w/ (with) 2 ppl (people) per facility protocol. A review of the facilities investigation revealed, the facility conducted an interview with EI #6 on 10/26/21 at 2:55 PM. When asked about the incident EI #6 stated RI #2 was hurting and ready to get into bed. She states she looked in the hallway to see if there were any CNA's that could help and that she did not see anyone so she told RI #2 she would have to transfer him/her by herself. EI #6 stated she locked RI #2's wheelchair and RI #2 grabbed her around the neck with RI #2's good arm and she grabbed RI #2 around the waist and used the pants to pull the resident towards her so she could transfer RI #2 into bed. EI #6 states that after she transferred RI #2 into bed, the resident leaned back towards the pillow and she picked up the resident's legs and placed them on the bed and covered RI #2 up. An interview was conducted with EI #1, Director of Nursing on 12/31/21 at 11:48 AM. EI #1 was asked about an incident with RI #3. EI #1 stated EI #6 told her she could not find anyone to help her, so she transferred RI #3 by herself. EI #1 stated RI #3 should have been transferred using the proper technique.

Based on interviews, medical record review and review of Potter and Perry, Fundamentals of Nursing, Ninth Edition, the facility failed to ensure licensed staff followed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected RI #3, one of four residents reviewed for pain management. Findings Include: A review of Potter and Perry, Fundamentals of Nursing, Ninth Edition, Chapter 23, Legal Implications in Nursing Practice, page 311, revealed: .Health Care Providers' Orders .Nurses follow health care providers' orders unless they believe that the orders are in error . RI #3 was admitted to the facility on [DATE]. A review of RI #3's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Order Date 9/29/21 . CLEANSE RIGHT HIP WITH NS (NORMAL SALINE) OR WC (WOUND CLEANSER), PAT DRY, APPLY [MEDICATION(S)] TO PERIWOUND AREA, APPLY [MEDICATION(S)] WITH SILVER TO WOUND BED, COVER WITH A DRY DRESSING 3 (THREE) TIMES A WEEK . Order Date 4/02/21 . [MEDICATION(S)] 5-325 TABLET - GIVE ONE TABLET BY MOUTH PRIOR TO DRESSING CHANGE AND EVERY 6 (SIX) HOURS AS NEEDED DX (DIAGNOSIS): PAIN . A review of RI #3's Medication Administration Record (MAR) for December 2021 revealed RI #3 received [MEDICATION(S)] on 12/4 at 9:22 AM for moaning, 12/8 at 2:19 PM for moaning, 12/19 at 3:11 PM for moaning, and 12/23 at 12:51 AM for moaning. On 12/29/2021 at 4:43 PM, an interview was conducted with Employee Identifier (EI) #2, Registered Nurse (RN)/Treatment Nurse. EI #2 was asked what pressure areas she was treating for RI #3 and she replied right hip. EI #2 was asked to review RI #3's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #2 said before dressing changes and PRN (as needed). EI #2 was asked how often were RI #3's dressing changes. EI #2 said three times a week and PRN. EI #2 was asked to review RI #3's MAR and answer if RI #3 had been receiving (his/her) [MEDICATION(S)] prior to dressing changes. EI #2 said no, (he/she) has not. EI #2 was asked what was the concern with RI #3's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/31/2021 at 9:47 AM, an interview was conducted with EI #4, Licensed Practical Nurse (LPN). EI #4 was asked if the treatment nurse ever asked her to give RI #3 pain medication before she did RI #3's dressing change. EI #4 said not when she was on the cart. EI #4 was asked to look at RI #3's [MEDICATION(S)] order and explain how it should be given. EI #4 said (he/she) should get it before dressing changes and then PRN, but the treatment nurse would have to let them know when she would be doing the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #4 was asked to look at RI #3's December MAR and see how many times (he/she) received [MEDICATION(S)] for the month. EI #4 stated it looked like four to her. EI #4 was asked how often RI #3's dressing should be changed and EI #3 said three times a week. EI #4 was asked how many times RI #3 should have received [MEDICATION(S)] and EI #4 said at least three times a week for dressing changes and then as needed too. EI #4 was asked had RI #3's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #4 was asked what the concern was with not following the pain medication orders and EI #4 said it could cause (him/her) to be in pain when the treatment was being done. On 12/31/2021 at 10:54 AM, an interview was conducted with EI #5, LPN. EI #5 was asked to review RI #3's MAR and explain what the order meant to her. EI #5 said to administer [MEDICATION(S)] before (he/she) gets a dressing change and then PRN. EI #5 was asked how many times RI #3 received [MEDICATION(S)] for the month of December, and she said three. EI #5 was asked how often RI #3 dressing should get changed and EI #5 said three times a week. EI #5 was asked was RI #3's [MEDICATION(S)] order followed in December to be administered prior to dressing changes and EI #5 said no, it was not, and they would not know to give the medication unless the treatment nurse let them know when the treatment was being done. EI #5 was asked what the concern was with the order not being followed and EI #5 said (he/she) could be in pain. On 12/31/2021 at 11:48 AM, an interview was conducted with EI #1, RN/Director of Nursing (DON). EI #1 was asked to review RI #3's [MEDICATION(S)] order and explain what it meant. EI #1 said it meant before going in to change (his/her) dressing give the medication and also it can be given every six hours as needed. EI #1 was asked how often RI #3's dressing was supposed to be changed. EI #1 said three times a week and PRN. EI #1 was asked to look at RI #3's MAR and read how many times (he/she) received [MEDICATION(S)] during the month of December. EI #1 said four. EI #1 was asked was RI #3's order for pain management followed and EI #1 said no. EI #1 was asked what the concern was with RI #3's pain management order not being followed and EI #1 said the resident could be in pain during dressing changes.

Based on interviews, review of Medication Administration Records (MARs), and review of a facility job description titled, LICENSED PRACTICAL NURSE SUPERVISOR JOB DESCRIPTION, the facility failed to ensure Employee Identifier (EI) #2, Registered Nurse (RN)/ Treatment Nurse, documented suctioning provided to Resident Identifier (RI) #5 in the nurse's notes on 12/22/2021, and EI #3, Licensed Practical Nurse (LPN), documented suctioning provided to RI #5 in the nurse's notes on 12/23/2021. This deficient practice affected RI #5; one of five sampled residents reviewed for complete and accurate medical record documentation. Findings include: A review of a facility job description titled, LICENSED PRACTICAL NURSE SUPERVISOR JOB DESCRIPTION, with a Modified Date: 05/03, documented: . Charting and Documentation Functions Duties: Sign, date and perform all routine charting and recordkeeping in accordance with established policies and procedures; . 1) RI # 5 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of RI #5's nursing notes for December 2021 revealed the only documentation of suctioning of RI #5 was on the admission note. There was no other documentation of suctioning of the resident for 12/22/21 or 12/23/21. On 12/28/2021 at 4:04 PM, a telephone interview was conducted with RI #5's responsible party/spouse. RI #5's spouse reported that (he/she) had been suctioned by EI #2 on 12/22/2021 and by EI #3 on 12/22 and 12/23/2021. On 12/29/2021 at 4:43 PM, an interview was conducted with EI #2, RN/Treatment Nurse. EI #2 was asked what care she provided for RI #5 on 12/22/2021. EI #2 said she suctioned RI #5 at (his/her) spouse's request. EI #2 was asked where she documented the care she provided, and she said she did not document it but had told RI #5's nurse. EI #2 was asked what the concern was with not documenting procedures she performed, and she said it did not give a clear picture of the care that was given. EI #2 was asked if the documentation was not in RI #5's medical record was (his/her) record complete and accurate and EI #2 said no, it would be like the procedure did not take place. On 12/30/2021 at 3:26 PM, an interview was conducted with EI #3, LPN. EI #3 was asked did she recall suctioning RI #5 on 12/23/2021, prior to (his/her) transfer to the hospital. EI #3 said yes, she suctioned RI #5 about four times that day. EI #3 was asked where she documented that she suctioned RI #5 on 12/23/2021. EI #3 said when she did her note she did not document it, so it was not in there. EI #3 was asked what the concern was with not documenting care that was provided and she said no one would know what was done if they were not in there at the time. EI #3 was asked if a medical record had missing documentation and did not contain documentation of care provided was it complete and accurate. EI #3 said no. On 12/31/2021 at 11:48 AM, an interview was conducted with EI #1, RN/Director of Nursing (DON). EI #1 was asked should a resident receiving suctioning be documented in the medical record. EI #1 said yes. EI #1 was asked to review RI #5's nurse's notes for documentation that suctioning was provided by EI #2 on 12/22/2021 and by EI #3 on 12/23/2021. EI #1 said no. EI #1 was asked if the two nurses reported that RI #5 was suctioned multiple times should it have been documented and EI #1 said yes. EI #1 was asked what the concern was with care being provided not being documented in the medical record. EI #1 said (his/her) medical record did not give a clear picture of the care (he/she) was provided and was not accurate or complete concerning documentation.

Based on observation, interview and review of the facility policy, FOOD FROM OUTSIDE SOURCES, the facility failed to ensure food brought into the facility from friends and family was labeled with each resident's name or date on which the food was received and stored, as well as the date it should be discarded. This involved the residents' refrigerator on the West Wing nursing station, one of two Nursing Units observed. Findings include: The facility policy, FOOD FROM OUTSIDE SOURCES with a revision date of 10/2017, specifies the following: . Food that is brought to residents from family, visitors or volunteers is handled in a safe and sanitary manner. .4. b. iii. The label includes the resident's name and room number, the date it is received and stored, and the date it should be discarded. On 12/12/19 at 11:35 AM, the surveyor viewed the contents of the West Hall Nursing Station refrigerator, identified by the Charge Nurse (Employee Identifier/EI #1) as used by staff to store resident food brought in from outside sources. EI #1 opened the freezing compartment to reveal a 1/2 gallon container of commercially prepared Homemade Vanilla Ice Cream. No name or room number was listed on the container, which was 1/2 full. The refrigeration unit contained a box of Popeye's chicken labeled for a resident, with no date of receipt or discard date. The surveyor questioned EI #1, who stated all stored items should have a name and date, and be kept no more than 24 hours to ensure safety, contrary to what was observed.

Based on observations, interviews, and the facility's administrative plan for the Quality Assurance and Performance Improvement Plan (QAPI), dated 09/2017, the facility failed to ensure call light cord wires were not exposed on the call lights of three residents. The facility further failed to ensure 19 resident overbed tables and one resident bedside table did not have exposed particle board and rough/sharp edges. In addition the facility failed to ensure a resident's wall did not have gouges in the wall. This affected 21 of 116 residents in the facility. Findings Include: The facility's administrative plan for the Quality Assurance and Performance Improvement Plan (QAPI), dated 09/2017 included the following: . SERVICES . Maintenance . Preventative maintenance . ensure that necessary repairs are completed . On 03/06/18 at 11:15 AM, an overbed table in Room Locator (RL) #17 was observed with rough edges that were a result of exposed particle board. There were also two quarter-sized areas of exposed particle board on the surface of overbed table that were rough to touch. On 03/07/18 at 5:07 PM, RL #1 was observed to have an overbed table with particle board exposed on one corner of the surface, which was rough to touch. On 03/07/18 at 5:10 PM, RL #2 was observed to have a call light with exposed wires just below the hand-grip of the call light and with black electrical tape hanging loosely from the exposed wires, which had been used to cover the missing outer sheath of the call light cord. On 03/07/18 at 5:10 PM, RL #3 was observed to have electrical wires exposed at the base of the call light hand-grip with loosened electrical tape attached that had been used to cover the missing outer sheath of the call light cord. Also the overbed table had exposed particle board on one side, which was rough to touch. On 03/07/18 at 5:24 PM, RL #4 was observed to have a call light with wires exposed, due to a missing section of the outer sheath of the call light cord at the base of the call light hand-grip. On 03/07/18 at 5:30 PM, RL #5 was observed to have an overbed table with a top exterior edge that was rough to touch, due to exposed particle board. On 03/07/18 at 5:31 PM, RL #6 was observed to have an overbed table with edges around the top surface that were rough to touch, due to exposed particle board. On 03/07/18 at 5:34 PM, RL #7 was observed to have an overbed table with a small spot on the exterior edge that was rough to touch, due to the damaged plastic edging. On 03/07/18 at 5:38 PM, RL #8 was observed to have an overbed table with rough top exterior edges from particle board being exposed and an exposed area of particle board on the table surface. On 03/07/18 at 5:39 PM, RL #9 was observed to have an overbed table with exposed particle board around the surface edges of the table, which made it rough to touch. On 03/07/18 at 5:40 PM, RL #11 was observed to have an overbed table with a corner of the surface veneer broken off to expose the particle board beneath and making it rough to touch. On 03/07/18 at 5:40 PM, RL #12 was observed to have an overbed table with damage to the plastic side edging in one spot. On 03/07/18 at 5:42 PM, RL #10 was observed to have an overbed table with damage to the plastic side edging in one spot. On 03/07/18 at 5:49 PM, RL #13 was observed to have an overbed table with particle board exposed on one corner of the table surface, which made it rough to touch. On 03/07/18 at 5:49 PM, RL #14 was observed to have an overbed table with rough edges, due to exposed particle board. On 03/08/18 at 8:27 AM, the overbed table in RL #15 had one corner with sharp edges exposed, as the plastic side edging/bumper had become pulled away from the table at that spot. On 03/08/18 at 8:28 AM, RL #21 was observed to have an overbed table with a chipped edge, which was approximately 2 1/2 inches long and 1/2 inch wide. The resident was sitting up in a wheelchair and eating breakfast from a meal tray placed on the damaged overbed table. On 03/08/18 at 8:38 AM, RL #20 was observed to have an overbed table with rough edges around the top surface, due to exposed particle board. On 03/08/18 at 8:44 AM, RL #18 was observed to have an overbed table with particle board exposed on one part of the surface edge to cause a rough surface. RL #18 also had a bedside table with particle board exposed on the front surface edge, which was rough to touch. In addition, RL #18 had ten vertical gouges in the wall behind the bed headboard. On 03/08/18 at 8:45 AM, RL #19 was observed to have an overbed table with rough edges around the table top. On 03/08/18 at 11:24 AM, RL #16 was observed to have an overbed table with all four surface edges rough to touch, due to exposed particle board. On 03/08/18 from 2:24 PM to 2:50 PM, Employee Identifier (EI) #2, the Maintenance Director, viewed the areas of concern in RL #1 through RL #21 with the surveyor. During some of the observations, EI #2 said liquid had gotten under the pressboard, which caused the particle board to splinter/separate in the overbed tables. EI #2 said the facility had purchased some overbed tables and had been swapping out the damaged overbed tables for the new ones. During the tour of the identified areas, EI #2 was asked if the damaged overbed tables and bedside tables were acceptable for resident use. EI #2 said the damaged tables were not acceptable and that they either needed to be repaired or replaced. EI #2 further said the tables could possibly damage skin. During the observation of the wall in RL #18, EI #2 said the condition of the wall was not acceptable. EI #2 said it was caused by staff putting the bed too close to the wall. EI #2 said he would need to sand the wall, patch it with sheetrock mud, sand the wall again, and then paint it. EI #2 further said he would place pads on the back of the headboard frame to prevent future damage to the wall.

Based on observations, interviews, medical record review and review of facility policies titled, Administering Medications via Nasogastric/Gastrostomy Tube and Universal Precautions, the facility failed to ensure licensed staff: 1. rinsed and dried Resident Identifier (RI) #4's piston syringe before storing it in a plastic bag after administration of RI #4's medication per gastrostomy tube, 2. Employee Identifier (EI) #3 did not use gloves from her pocket for use during and cleaning of RI #4's gastrostomy tube site, 3. EI #4 did not use gloves from her pocket for use during RI #259's Fingerstick Blood Sugar (FSBS), and 4. EI #4 washed her hands when removing her gloves after obtaining RI #259's FSBS. These deficient practices affected RI #4 and RI #259, two of nine residents and two of six nurses observed during medication pass observation. Findings Include: A review of a facility policy titled, Administering Medications via Nasogastric/Gastrostomy Tube with an Effective Date: (MONTH) 1, 2004, revealed: .PR[NAME]ESS: .6. Administer medications using a 60 cc (cubic centimeter) syringe. .9. Rinse, dry and store a 60cc syringe in a plastic bag. A review of a facility policy titled, Universal Precautions with an Effective Date: (MONTH) 1, 2004, documented: PURPOSE: To minimize the danger of environmental contamination and the possible spread of infections to employees and residents. .PR[NAME]ESS: .10. Remove gloves . 11. Wash hands . 1.) RI #4 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 03/07/18 at 2:45 p.m., during medication pass observation for RI #4, the surveyor observed Employee Identifier (EI) #3, Registered Nurse (RN) administer medication through RI #4's gastrostomy tube using a piston syringe. EI #3 was observed placing the syringe back inside a plastic bag without rinsing or drying the syringe. The surveyor then observed EI #3take gloves from her pocket to use while cleaning RI #4's gastrostomy tube site. On 03/08/18 at 5:03 p.m., a telephone interview was conducted with EI #3. EI #3 was asked, was her pocket considered clean. EI #3 said, no. EI #3 was asked, should she use gloves from her pocket. EI #3 replied, no. The surveyor asked EI #3, did she use gloves from her pocket when she cleaned RI #4's gastrostomy tube site. EI #3 answered, yes. EI #3 was asked, did she rinse and dry RI #4's piston syringe before she put it back in the plastic bag after she administered RI #4's medication. EI #3 said, no. EI #3 was asked, what was the concern with putting something wet in a plastic bag and using gloves from her pocket. EI #3 answered, infection control. 2.) RI #259 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 03/07/18 at 4:36 p.m., EI #4, Licensed Practical Nurse (LPN), was observed obtaining RI #259's Fingerstick Blood Sugar (FSBS). The surveyor observed EI #4 wash her hands and take gloves from her pocket to obtain RI #259's FSBS. EI #4 was then observed removing her gloves after obtaining the FSBS without washing her hands. On 03/07/18 at 4:56 p.m., an interview was conducted with EI #4. EI #4 was asked, was her pocket considered clean. EI #4 said, no. EI #4 was asked, did she use gloves from her pocket to obtain RI #259's FSBS. EI #4 said, yes. EI #4 was asked, should she have used gloves from her pocket to take RI #259's FSBS. EI #4 replied, no. EI #4 was asked when she should wash her hands when using gloves. EI #4 answered, before she put them on and after she takes them off. EI #4 was asked, how long after removing her gloves should she wash her hands. EI #4 replied, immediately. EI #4 was asked, did she wash her hands after taking off her gloves when she took RI #259's FSBS. EI #4 answered, no, she came on out of the room. EI #4 was asked, what is the concern with using gloves from her pocket and not washing her hands when removing her gloves. EI #4 said, infection control. On 03/08/18 at 5:23 p.m., an interview was conducted with EI #5, RN/Assistant Director of Nursing/Infection Control Coordinator. EI #5 was asked, was a nurse's pocket considered clean. EI #5 said, no ma'am. EI #5 was asked, should a nurse use gloves from her pocket to provide gastrostomy site care or obtain a FSBS. EI #5 replied, no. EI #5 was asked, what should be done with a piston syringe after medication administration. EI #5 answered, wash it out, dry it and separate it in a bag. EI #5 was asked, when should a nurse wash her hands after obtaining a FSBS. EI #5 said, after removing her gloves. EI #5 was asked, what was the concern with these issues. EI #5 answered, infection control.

Based on interview and record review, the facility failed to ensure a Significant Change Minimum Data Set (MDS) assessment was done on Resident Identifier (RI) #13 after declines were identified on the Quarterly MDS dated [DATE], in the areas of personal hygiene and bowel and bladder. The facility further failed to ensure a Significant Change MDS was done on RI #4 after improvements were identified on the Quarterly MDS dated [DATE], in the areas of transfers, dressing, personal hygiene and bowel and bladder. This affected two of 16 sampled residents whose MDS's were reviewed. Findings Include: 1) RI #13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #13's Admission MDS, dated [DATE], documented in Section G- Functional Status, RI #13 required supervision with personal hygiene. In Section H- Bowel and Bladder, RI #13 was assessed as only being occasionally incontinent. RI #13's Quarterly MDS dated [DATE], documented in Section G- Functional Status, RI #13 had declined in personal hygiene from supervision to extensive assistance. In Section H- Bowel and Bladder, RI #13 declined from occasionally incontinent to frequently incontinent. On 01/26/17 at 2:45 p.m., Employee Identifier (EI) #1, the MDS/Care Plan Coordinator was asked what warranted a Significant Change MDS. EI #1 replied, it has to be in three or more areas. EI #1 was asked did she compare RI #13's Quarterly MDS to the Admission MDS. EI #1 replied no ma'am. EI #1 was asked why not. EI #1 replied she could not say. EI #1 was asked when comparing RI #13's Quarterly MDS to the Admission MDS did that warrant a Significant Change MDS. EI #1 replied, no ma'am. EI #1 was asked why not. EI #1 replied it was her understanding that it was in one area and that she did not know each section was separate. 2) RI #4 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Quarterly MDS assessment with an Assessment Reference Date (ARD) of 06/01/2016, assessed RI #4 in Section G Functional Status to require extensive assistance of one person for transfers, ambulation did not occur and required extensive assistance of one person for dressing and personal hygiene. In Section H Bladder and Bowel, RI #4 was assessed to be occasionally incontinent of bladder function and frequently incontinent of bowel function. A Quarterly MDS assessment with an ARD of 09/09/2016, assessed RI #4 in Section G Functional Status to require supervision of one person for transfers, ambulation and dressing. RI #4 required limited assistance of one person for personal hygiene. In Section H Bladder and Bowel RI #4 was assessed to be always continent of bladder and bowel function. On 01/26/17 at 03:10 p.m., EI #1, the MDS/Care Plan Coordinator reviewed Section G and Section H on RI #4's Quarterly assessment dated [DATE], and the Quarterly Assessment for 09/09/2016. EI #1 was asked, when a resident has an improvement between two assessments, what should be done. EI #1 stated, Significant Change. EI #1 was asked if a Significant Change Assessment had been done on RI #4. EI #1 stated, No. EI #1 was asked if she had any documentation of a judgment from the MDS team not to do a Significant Change. EI #1 stated, I don't have that. EI #1 was asked if she felt that she had followed regulatory guidelines in this procedure. EI #1 said, no.

Based on record reviews and interviews, the facility failed to treat Resident Identifier (RI) #1, a resident with a [DIAGNOSES REDACTED]. The normal range for a blood glucose level is 65-100. The facility did not address or treat this elevated blood glucose level. On 4/2/2016, RI #1 was found to be unresponsive in the facility and transferred to a local hospital. At the local hospital, RI #1's blood glucose level was greater than 1000 and the resident was diagnosed as hyperglycemic. [MEDICAL CONDITION] is defined as having a high blood glucose (blood sugar). The facility further failed to ensure RI #3's blood glucose testing was done as ordered by the physician. These deficient practices affected RI #1 and RI #3, two of four sampled residents identified by the facility as having a [DIAGNOSES REDACTED]. Findings include: On 6/22/2016, the State Agency received a complaint which alleged RI #1 was transferred to a local hospital on [DATE] and the resident had a blood sugar greater than 1000. The complainant stated she was not aware of what the nursing facility did to manage the resident's blood sugar. RI #1 was admitted to the facility on [DATE], with a medical history to include a [DIAGNOSES REDACTED]. RI #1's physician's orders [REDACTED]. CMP (Complete Metabolic Profile) (a laboratory test) on admit & annual . HgbA1C (a laboratory test) on admit & 4xs (times) a year . According to www.webmd.com . The hemoglobin A1c test . is an important blood test that shows how well your diabetes is being controlled. Hemoglobin A1c provides an average of your blood sugar control over the past 2 to 3 months and is used along with home blood sugar monitoring to make adjustments in your diabetes medicines . People with diabetes should have this test every 3 months to determine whether their blood sugars have reached the target level of control . RI #1's laboratory report indicated on 12/14/2015, RI #1's blood glucose level was outside the normal range at 162. According to the report, the normal range was 65-100. A review of RI #1's medical record did not include any treatment for [REDACTED]. RI #1's laboratory report indicated on 12/15/2015, RI #1's HGB A1C level was drawn. RI #1's level was outside the normal range at 6.7. According to the report, the normal range for a diabetic resident was less than 6.5. A review of RI #1's medical record did not include any treatment for [REDACTED]. RI #1's laboratory report indicated on 1/6/2016, RI #1's blood glucose level was outside the normal range at 144. According to the report, the normal range was 65-100. A review of RI #1's medical record did not include any treatment for [REDACTED]. RI #1's nutritional assessment dated [DATE] documented . Current Nutrition Prescription [MEDICATION NAME] 1.5 @ (at) 55cc/hr x23hrs (hours) . Biochemical Data . This assessment further indicated on 1/16/2016, RI #1's labs revealed the resident had a glucose level that was high at 144 and a [DIAGNOSES REDACTED]. The product information for [MEDICATION NAME] 1.5 Cal updated 10/30/2015 indicated there are 48.2 grams of carbohydrate (sugar) in an eight-ounce can. RI #1's laboratory report indicated on 2/2/2016, RI #1's blood glucose level was outside the normal range at 406. According to the report, the normal range was 65-100. A review of RI #1's medical record did not include any treatment for [REDACTED]. RI #1's nutritional assessment dated [DATE] documented . Current Nutrition Prescription [MEDICATION NAME] 1.5 @ (at) 55cc/hr x23hrs (hours) . Biochemical Data . Nutritional Intervention 1) Change TF (tube feeding) formula to [MEDICATION NAME] 1.5 @ same rate and flush . This assessment further indicated on 2/2/2016, RI #1's labs revealed the resident had a glucose level that was high at 406 and a [DIAGNOSES REDACTED]. The product information for [MEDICATION NAME] 1.5 Cal updated 10/2/2015 indicated there are 51.1 grams of carbohydrate (sugar) in an eight-ounce can. In a telephone interview on 6/23/2016 at 6:00 PM, EI #3, the Registered Dietician was asked what the potential harm would be for RI #1, a diabetic resident, to receive [MEDICATION NAME] 1.5. EI #3 stated it could cause the resident's blood sugar to go up. When asked if she was aware that RI #1's elevated blood glucose level of 406 that was done on 2/2/2016 was not addressed, EI #3 said no. EI #3 acknowledged that she was not aware the facility was not checking RI #1's blood sugar. A review of RI #1's physician's orders [REDACTED].#1's blood sugar. There were no orders for blood sugar checks or medications to treat RI #1's Type 2 Diabetes Mellitus. RI #1's 'Departmental Notes dated 4/2/2016 2:31 PM, documented . This nurse was called to room . resident was noted to have labored breathing, and minimal jerking of R (right) arm, resident was alert but nonresponsive to verbal communication. Vitals at this time was as follows: BP (blood pressure) 102/60 Resp (respiration) 22 P (pulse) 90 Temp (temperature) 100.5. MD (medical doctor) notified and gave n/o (new order) to send resident to hospital. Sponsor present and aware. Resident left facility at 1345 via stretcher in ambulance with 2 paramedics present to (local hospital). In an interview on 6/23/2016 at 5:15 PM, Employee Identifier (EI) #2, the Director of Nursing was asked, if she was aware RI #1's blood glucose level on 2/2/2016 was 406. EI #2 said she became aware on 6/23/2016. When asked why the elevated blood sugar was not treated, EI #2 could not explain why it wasn't. EI #2 was asked, what harm could be caused from an elevated blood sugar that was not treated. EI #2 explained that RI #1 had a history of [REDACTED]. In an interview on 6/23/2016 at 5:39 PM, EI #1, RI #1's attending nursing home physician, was asked why RI #1 was ordered blood sugar checks or medication to treat the resident's Diabetes. EI #1 stated he was more concerned with RI #1's blood pressure and End Stage Alzheimer's. The local hospital report dated 4/2/2016 for RI #1 documented . Patient (RI #1) . presented with AMS (altered mental status) . (RI #1) found to be hyperglycemic > (greater than) 1000. Patient was given fluid resuscitation and started on Insulin drip . 2) RI #3 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #3's MEDICATION RECORD for April 2016 documented . BLOOD GLUCOSE TESTING TEST EVERY WEEK ON THURSDAY . There was no documentation to indicate RI #3's blood sugar was checked on 4/14/2016, 4/21/2016 and 4/28/2016. RI #3's MEDICATION RECORD for May 2016 documented . BLOOD GLUCOSE TESTING TEST EVERY WEEK ON THURSDAY . There was no documentation to indicate RI #3's blood sugar was checked on 5/19/2016 and 5/26/2016. RI #3's MEDICATION RECORD for June 2016 documented . BLOOD GLUCOSE TESTING TEST EVERY WEEK ON THURSDAY . There was no documentation to indicate RI #3's blood sugar was checked on 6/16/2016. An interview was conducted with EI #2, the DON, on 06/23/2016 at 5:25 PM. EI #2 was asked if RI #3's blood sugar was monitored. She replied, yes every week on Thursday at 6 AM. EI #2 was asked to review RI #3's Medication Record for April, May and June 2016 and tell the surveyor why there was no documentation for the above mentioned dates. She replied, that she did not know why. This deficiency was cited as a result of the investigation of complaint/report number AL 502.

Based on record review and interview, the facility failed to develop a plan of care to address how the facility would monitor and/or treat Resident Identifier (RI) #1's blood glucose (blood sugar) level. On 4/2/2016, RI #1 was found to be unresponsive in the facility and transferred to a local hospital. At the local hospital, RI #1's blood glucose level was greater than 1000 and the resident was diagnosed as hyperglycemic. [MEDICAL CONDITION] is defined as having a high blood glucose (blood sugar). Findings include: On 6/22/2016, the State Agency received a complaint which alleged RI #1 was transferred to a local hospital on [DATE] and the resident had a blood sugar greater than 1000. The complainant stated she was not aware of what the nursing facility did to manage the resident's blood sugar. RI #1 was admitted to the facility on [DATE], with a medical history to include a [DIAGNOSES REDACTED]. A review of RI #1's medical record did not reveal there was a care plan to address how the facility would monitor and/or treat RI #1's [DIAGNOSES REDACTED]. In an interview on 6/23/2016 at 5:15 PM, Employee Identifier (EI) #2, the Director of Nursing was asked, if RI #1 had a care plan to address RI #1's [DIAGNOSES REDACTED].#2 replied, no. In an interview on 6/23/2016 at 5:39 PM, EI #1, RI #1's attending nursing home physician, was asked why RI #1 was ordered blood sugar checks or medication to treat the resident's Diabetes. EI #1 stated he was more concerned with RI #1's blood pressure and End Stage Alzheimer's. The local hospital report dated 4/2/2016 for RI #1 documented . Patient (RI #1) . presented with AMS (altered mental status) . (RI #1) found to be hyperglycemic > (greater than) 1000. Patient was given fluid resuscitation and started on Insulin drip . This deficiency was cited as a result of the investigation of complaint/report number AL 502.