Every finding on record at Clifford Chester Sims State Veterans Nursing Home

Based on observations, interviews, and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 1 resident sampled for non-pressure related skin conditions (Resident #64) and 1 of 2 residents sampled who received insulin (Resident #12). The findings include: 1. Observations were conducted of Resident #64 on 06/23/2026 at 1:24 PM, 06/23/2026 at 2:42 PM, 06/24/2026 at 8:47 AM, and 06/24/2026 at 11:20 AM. Resident #64 was observed with an undated dressing present on his right forearm. It was also noted that Resident #64 was not wearing protective sleeves on his arms during any of the observations. Resident #64 was admitted to the facility on [DATE]. His medical history was significant for hemiplegia and hemiparesis on the dominant side, Alzheimer's disease, and dementia. Review of the Annual Minimum Data Set (MDS), dated [DATE] revealed Resident #64 had a Brief Interview of Mental Status (BIMS) score of 5, indicating he was severely cognitively impaired. This MDS documented Resident #64 was dependent on staff assistance for his activities of daily living. Review of Resident #64's medical record revealed a current physician order dated 06/17/2025 for nursing staff to apply protective arm sleeves every shift. Review of Resident #64's medication administration record for 06/01/2026 to 06/24/2026 revealed the nursing staff had documented each shift that the arm sleeves were applied. The record revealed there was no physician order written for a wound care dressing on Resident #64's right forearm. A Skin Tear Event was documented on 06/15/2026 at 5:55 AM and indicated wound care was conducted and a non-adhesive pad was placed on top of the wound. This note did indicate that the physician and family were notified. A review of the current Comprehensive Plan of Care was conducted. Increased risk for impaired skin integrity (dated 12/19/2018) was present with an intervention that was added on 05/20/2026 for staff to ensure and put on his protective arm sleeves. An interview was conducted with Staff A, Registered Nurse (RN) on 06/24/2026 at 12:02 PM. Staff A confirmed she was responsible for caring for Resident #64 that day and that she was familiar with him. Staff A stated if a resident had a wound dressing, it should be dated and there should be a physician order for the dressing. She stated Resident #64 had not been wearing protective sleeves for months because he would pull them off. Staff A removed the undated dressing from Resident #64's arm to reveal wound closure strips were present, covering a skin tear on the right forearm. Staff A stated she had not notified the physician of the wound. Review of the facility policy titled Skin Management (revised date 06/23/2021) revealed any new skin concerns/risk factor will be addressed and the care plan reviewed and revised as appropriate. 2. An interview conducted with Resident #12 on 06/23/2026 at 10:27 AM. Resident #12 stated the facility staff checked his glucose regularly. However, Resident #12 stated that the blood sugar levels had been so so, but higher than normal. Review of the Minimum Data Set (MDS) revealed Resident #12 had a Brief Interview of Mental Status (BIMS) score of 13, indicating he had no cognitive impairment. His medical history was significant for diabetes. Review of his Plan of Care revealed there was no documentation of uncontrollable blood sugar levels and no documentation that Resident #12 was noncompliant with his diabetic diet. Review of Resident #12's physician orders revealed an order was written on 12/17/2025 for Novolog U-100 Insulin Aspart (this medication is used to regulate blood sugar levels). The order was written for the nursing staff to use a sliding scale for the insulin administration based on Resident #12's blood sugar results. The order instructions were written as follows: if blood sugar is less than 60, call MD (doctor). If Blood Sugar is 150 to 199, give 4 Units (of Novolog Insulin). If Blood Sugar is 200 to 249, give 8 Units. If Blood sugar is 250 to 299, give 12 Units. If Blood Sugar is 300 to 349 give 16 Units. If Blood Sugar is greater than 349, give 20 Units. And if Blood Sugar is greater than 350, Call the MD. A review was conducted of Resident #12's medication administration records (MARs) for the Novolog U-100 Insulin Aspart for the date range of 05/01/2026 to 06/23/2026. It was noted that Resident #12 had blood glucose results above the 350 level 5 times during this period: on 05/27/2026 at 11:30 AM the result was 390; on 05/29/2026 at 4:30 PM the result was 378; on 05/30/2026 at 11:30 AM the result was 395; on 06/20/2026 at 11:30 AM the result was 380; on 06/20/2026 at 4:30 PM the result was 359. It was documented on the MAR that Resident #12 received 20 units of insulin for each of these blood sugar results. The MAR also revealed that a follow-up blood sugar check was not documented for the 5 elevated blood sugars. Further record review revealed that there were no nursing notes, nurse practitioner notes, or physician notes regarding the 5 elevated blood sugar levels above 350. No nursing notes were written indicating that a nurse informed the physician or nurse practitioner of the blood sugar greater than 350. An interview was conducted with Staff B, Licensed Practical Nurse (LPN) on 06/23/2026 at 12:15 PM. Staff B stated that if a resident had a blood sugar level greater than 400, the protocol was for the nurse to call the resident's physician to inform them of the elevated blood sugar. Staff B stated that the physician would advise the nurse to give the sliding scale max dosage or an additional amount of insulin with the sliding scale and to do a follow-up blood sugar check. Staff B stated that they would call the physician with the new blood sugar level after the insulin was administered to see if the administered insulin dosage was effective. She clarified that the nursing staff would wait 30 minutes after the administration of the insulin to recheck the blood sugar level. Staff B also stated that the nurses wrote nursing notes to document an abnormal blood sugar level and to document when the physician was notified of the abnormal blood sugar level. Staff B included that if a resident's blood sugar was continuously high, the care team would adjust the ordered insulin regimen and monitor the resident for any signs or symptoms of hyperglycemia (meaning an elevated blood sugar level outside of the normal range). An interview was conducted with the facility's Director of Nursing (DON) on 06/23/2026 at 12:44 PM. The DON independently reviewed Resident #12's medical record and confirmed there were no progress notes, no physician notes, and no nursing notes documenting the physician was informed of the 5 blood sugar levels greater than 350. The DON stated that if there was a non-emergent need with a resident, the nurse would fill out a paper form for the nurse practitioner. The form would be placed in the nurse practitioner's binder that was located at the Nursing Station. The DON stated the nurse practitioner was present at the facility on Mondays, Wednesdays, and Fridays. The DON included that the nurse practitioner looked at the binder and addressed resident care concerns on those days. The DON confirmed that, per physician's orders for residents with critical results, such as elevated blood sugar levels, the nursing staff needed to contact the physician directly and in a timely manner to inform them of the resident's critical result even if the physician was not present at the facility. A follow up interview was conducted with the DON on 06/23/2026. The DON stated they had contacted the nurse practitioner and doctor and confirmed that neither were notified of Resident #12's two elevated blood sugar levels on 06/20/2026. Review of the facility's policy titled Blood Glucose Monitoring: Clinical Guidelines dated 09/26/2019 was conducted. The policy stated for physician communication, The licensed nurse obtains a physician's order for blood glucose monitoring for diabetic residents, to include parameters for physician notification of finger stick results and the nurse reviews the test results and if outside of the specified parameters, evaluates the resident for signs and symptoms of hypo/hyperglycemia and notifies the physician per order. The policy also stated, The licensed nurse documents physician notification in the medical record, including the resident's condition and response to interventions and/or ordered treatments.

Based on record review and staff interview, the facility failed to implement the facility's policy for administering COVID-19 vaccinations to 1 of 5 sampled residents (Resident #51). The findings include: Review of Resident #51's medical record revealed they were admitted to the facility on [DATE]. The record revealed Resident #51's responsible party gave consent for them to receive the COVID-19 vaccine on 12/19/2025 and that they had not had a COVID-19 vaccine since 2021. An interview was conducted with the facility's Risk Manager on 06/25/2026 at 8:54 AM. She confirmed the facility's Infection Preventionist was not available for interview. She confirmed Resident #51 had not received the COVID-19 vaccine although the responsible party had consented for the vaccine on admission. The Risk Manager stated Resident #51 would have received the vaccine at the next COVID-19 vaccine offering in July, as the facility offered the vaccine twice a year. She confirmed the facility's policy regarding COVID-19 vaccines indicated the facility should offer the vaccine within 30 days of admission if the resident or their representative gave consent for the vaccine. Review of the facility's policy titled Immunizations: COVID-19, Influenza, and Pneumococcal Vaccines (revised date 11/21/2023) revealed prior to, or upon admission, residents will be assessed for eligibility to receive any COVID-19 immunization. When indicated, the immunization will be offered within thirty days of admission to the facility unless medically contraindicated or the resident has already been vaccinated and has received any recommended booster dose.

Based on observations, interviews, and record review the facility failed to ensure that all grievances were resolved for 2 of 2 residents sampled for personal property. (Resident #11 and #26) The findings include: Resident #11 On 01/29/24 at approximately 1:00 PM, an interview was conducted with Resident #11 concerning personal property. Resident #11 indicated that he had a cell phone go missing a few months ago. He also stated when clothing goes to the laundry, it often goes missing and does not come back. When asked if he had notified the facility, Resident #11 stated that he had. A review was conducted of the facility's grievance logs which revealed no grievance form concerning Resident #11's missing cell phone. On 2/1/24 at approximately 9:57 AM, an interview was conducted with the facility's Social Worker. The Social Worker stated that she was notified of Resident #11's missing cell phone, but that she did not fill out a grievance form because she kept missing items on a log in her computer. A review of the missing item log revealed an entry stating, 12/4/23- [Resident #11] has been missing his phone. There was no resolution or follow up documentation concerning the missing cell phone. When asked about the resolution for the missing cell phone, the Social Worker stated, I did not complete the documentation of the conversation with the family, or that we looked for the phone in laundry and other places, and it could not be found. Social Worker A went on to state that she notified the family, and they were not pleased but the family would buy Resident #11 another phone. On 2/1/24 at approximately 10:42 AM, an interview was conducted with the Administrator concerning missing items. The Administrator indicated that her expectation would be to follow the policy for grievances. 49426 Resident #26 On 01/29/2024 at approximately 1:54 PM, an interview was conducted with Resident #26, who reported that he had bought a jogging suit, a big sweater, a light and heavy weight zip up jacket, and hoodie that had all gone missing about two weeks before Christmas. He stated that he had reported it to the Social Worker, but did not hear anything back. On 01/31/24 at approximately 10:27 AM. a record review was conducted of the facility's grievance logs, which revealed no grievances related to Resident #26. A review of progress notes showed no documentation for missing personal property. On 01/31/2024 at approximately 10:34 AM, an interview was conducted with the Social Worker, where she indicated that Resident #26 did report these items missing to her, but that Resident #26 couldn't tell her if the items had been labeled or not. The Social Worker indicated that she did not complete a grievance log but does have a log for lost items that she keeps up with on her computer. She stated that she has debated on whether to file a grievance for missing items or not but decided to just keep a log on her computer instead. When asked to review the log for lost items, the Social Worker indicated she was not able to locate it right now. She stated she spoke with the son of Resident #26 about the missing items and advised him to notify staff when new items come in so that they can be labeled with the resident's name. On 01/31/2024 at approximately 11:00 AM, the policy titled Resident Grievances (dated 08/24/2009 and last revised date of 10/18/2017) revealed the Social Worker acts as the Grievance Officer. Under Procedures on section 2 of the policy number 3, the policy states, All alleged abuse, mistreatment, neglect, injuries of unknown source, and/or misappropriation of property by anyone furnishing services on behalf of the provider will be reported to the Administrator immediately, and will be referred to the Risk Manager, and/or designee, for investigation and reporting of abuse, neglect and misappropriation of property, as per federal and state law. On 01/31/24 at approximately 11:20 AM, an interview was conducted with the Administrator and the Social Worker. The Administrator indicated that the Delta side of the building has a book for grievance logs and presented the book with grievances for missing items. When asked if Resident #26's grievance would be in this book, she indicated that it would not. She indicated that Alpha side has it's own system of keeping up with missing items and Resident #26 is on the Alpha side. When asked how missing items are followed up, results documented, and/or resident notified of results, the Social Worker indicated that she would go look for her log on her computer and return with it. On 01/31/24 at approximately 11:55 AM, the Social Worker returned with a notebook of printed papers inside that included the name of Resident #26 with missing items noted. There was no follow up, investigation, or tracking record noted on the form. The Social Worker indicated that she mostly keeps up with the missing items and status of the search for them in her head. On 01/31/24 at approximately 01:44 PM, an interview was conducted with the Administrator. When asked what the expectation of the facility is when residents report missing personal property, the Administrator indicated that, when residents first bring it up to them and if it's something small such as a missing shoe, eyeglasses, or a remote, then they should look for it and wait to see if the items can be located. If they can find the personal property, then the issue is resolved and nothing else is done, but if it becomes a pattern then she would expect it to go on grievance form.

Based on observations and interviews, the facility failed to maintain a safe environment for staff in the laundry room. The findings include: On 2/1/24 at approximately 12:40 PM, a tour was conducted of the laundry's dirty linen room, which revealed standing water on the floor in front and behind the three industrial washing machines that the facility uses to launder the resident's linens and personal clothing. (Photographic evidence obtained) On 2/1/24 at approximately 12:57 PM, an interview was conducted with the Supervisor of Laundry and Housekeeping concerning the leaking washing machines. The Laundry Supervisor indicated that the washing machines have been leaking for about 2 months now and that she has been reporting the issue to maintanence. The supervisor went on to state that a plumber did come out to look at the washing machines on 1/29/24, but they are still leaking. The Laundry Supervisor stated that they have been notifing the Administrator as well. She stated she tries to keep it mopped up as much as possible and have been putting blankets down to keep the water out of the walk area. On 2/1/24 at approximately 1:00 PM, an interview was conducted with Staff B, a maintenance worker, concerning the leaking washing machines. Maintenance Worker B stated that he had informed his supervisor a couple of weeks ago, and the issue had been looked at by an outside repairman a few days prior, but they could not find a leak. Maintenance Worker B stated that his helper checked the drains and found and removed a knife which helped some. He stated he was going to take a look at the machines again today to see if he could find the leak. On 2/1/24 at approximately 1:30 PM, an interview was conducted with the Administrator, who indicated that they have been working on the issue to try and get it fixed. The Administrator stated that another outside repairman was supposed to look at the machines again soon.

Based on record review, staff interview, and policy review, the facility failed to refer a resident with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident #40) The findings include: Review of Resident #40's medical record revealed the resident was admitted to the facility on [DATE] and had a level I PASARR completed on 7/1/2021. Further review revealed the resident was prescribed [MEDICATION(S)] (an antipsychotic medication) on 8/26/2021 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The record failed to contain evidence of a level II PASARR resident review. An interview was conducted with the facility Licensed Clinical Social Worker on 9/13/2022 at 3:31 PM. She reviewed Resident #40's record and confirmed a level II PASARR had not been completed. She stated she was not aware of the requirement to request a level II if a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility policy for Social Services Practice Guidelines revealed the facility shall Assist in coordination with the Department of Children and Families to submit initial review or additional documentation for PASRR Level II screening.

Based on observation, representative interview, record review, staff interview, and policy review the facility failed to ensure staff follow infection control policies to prevent contamination of urinary catheters for 1 of 2 residents reviewed with catheters. (resident #88) The findings include: An observation of suprapubic catheter care for resident #88 was conducted with employee C (certified nursing assistant) on 11/19/19 at 1:49 PM. Upon entering the resident room the catheter bag was observed to be touching the floor. (Photographic evidence obtained.) Employee C stated the resident is on a low bed and they do not have a hook or anything to keep the catheter off the floor. The licensed practical nurse (employee D) entered the room. Employee C then asked employee D how to keep the resident's catheter off the floor. Employee D stated staff should place the catheter in a basin to keep it off the floor; the nurse confirmed the resident had a history of [REDACTED]. Employee C then washed her hands and donned clean gloves. Employee C performed catheter care for resident #88. Employee C used her soiled, gloved hands to touch the electric bed control and lower the bed. The employee did not remove her gloves and sanitize her hands after performing catheter care, prior to touching the bed control. Employee C confirmed her gloves were the same gloves she used to complete catheter care and she had potentially contaminated the bed control. Review of the resident's record revealed the resident was last diagnosed with [REDACTED]. An interview was conducted with the resident's representative on 11/18/19 at 1:14 PM. She stated the resident gets UTIs often. Review of the facility policy and procedures for suprapubic catheter care (2001 MED PASS revised (MONTH) 2005) revealed staff should remove gloves and discard the gloves in the designated container after performing care, then wash and dry your hands, reposition the bed covers and make the resident comfortable. Place the call light within easy reach of the resident. The facility policy for urinary catheter indication and maintenance (urethral and supra-pubic {policy number 5440 revised 6/9/17}) revealed staff should maintain the catheter tubing and drainage bag off the floor with privacy bag as appropriate.

Based on interviews and record review, the facility failed to ensure a sufficient number of nursing staff to provide care and services and respond to each resident's needs, as determined by resident assessments, for 6 of 6 residents sampled for incontinent care (#4, #5, #6, #2, #7, and #8). The findings are: An interview was conducted with Resident #4's wife on (MONTH) 19, (YEAR) at approximately 1:45pm. She stated she was concerned that there was not enough staff to take care of the residents. She also stated she had visited Resident #4 last week and found him sitting in his wheelchair, in his own feces and urine and a puddle of urine on the floor around his wheelchair. An interview was conducted with Resident #5's son on (MONTH) 19, (YEAR) at approximately 2:22pm. He stated that he came to visit on Saturday, (MONTH) 15th around 7:00pm or 8:00pm. He stated the facility was short staffed, so he told the staff that he would get Resident #5 dressed for bed. He further stated that when he went to get the resident dressed, he found the resident with wet pants, a brief that was soaking and wringing wet, and a wet wheelchair. An interview was conducted with Resident #6's wife on (MONTH) 20, (YEAR) at approximately 9:30 am. She stated that she came in one day around 8:45 am to find the resident still saturated with urine from the overnight shift and the day shift staff had not made it to her husband's room for rounds. She further stated she had put in a grievance last month about finding the resident wet, including his mattress. She stated that the facility responded a month later stating they would tell the staff to do their rounds. An interview was conducted with Resident #2's daughter on (MONTH) 20, (YEAR) at approximately 10:01 am. She stated that she came in on (MONTH) 16th, on the second shift, to find that there was one Certified Nursing Assistant (CNA) working that evening and that her father was soaking wet, and his clothing basket had clothing that was dripping wet. Additionally, she stated the resident's bed was soaking wet and his wheelchair smelled, and was wet with urine and poop. She stated that she cleaned her father and his wheelchair. She further stated that around (MONTH) 7th or 8th, she found her father in the Starlight room, which is an activity room for residents with dementia, around 8:30 pm, sitting in urine and feces. An interview was conducted with Resident #7's sister on (MONTH) 26, (YEAR) at approximately 8:53 am. She stated she frequently comes to visit and finds her brother soiled with urine and feces. She stated that he takes a nap at 2:00 pm and when she visits at around 5:00 pm, he is saturated where his entire outfit has to be changed. An interview was conducted with Anonymous Staff A on (MONTH) 18, (YEAR). This staff stated he/she was only able to make 2 rounds during the shift when there was one CNA on the floor instead of the necessary 3-4 rounds, and that not being able to make the rounds meant the residents sat in urine and feces at times. An interview was conducted with Anonymous Staff B on (MONTH) 18, (YEAR). This staff stated that he/she came to work recently, due to being called in to cover a shift, and found residents sitting in urine and feces. This staff stated that there was a need for more staff and he/she had reported this issue. An interview was conducted with Anonymous Staff E on (MONTH) 18, (YEAR). This staff stated that he/she worked 3-4 shifts a week by themselves, and confirmed there were residents that sat in urine and feces for more than 45 minutes because these residents required two-person assistance. An interview was conducted with Anonymous Staff F on (MONTH) 18, (YEAR). This staff stated that on (MONTH) 15th, Resident #2 was sitting in urine and feces and was found this way by his daughter. This staff further stated residents sat in urine and feces for more than an hour at times. An interview was conducted with Anonymous Staff G on (MONTH) 19, (YEAR). This staff stated that residents are staying wet longer and they had noticed residents soiled with feces and urine for 2-3 hours. An interview was conducted with Anonymous Staff H on (MONTH) 19, (YEAR). This staff stated, when short, we constantly have residents waiting 45 minutes to an hour to get changed. An interview was conducted with Anonymous Staff I on (MONTH) 19, (YEAR). This staff stated that residents were waiting an hour to be changed. An interview was conducted with Anonymous Staff J on (MONTH) 19, (YEAR). This staff stated that when working with one CNA, it took about 2 to 3 hours to complete one round and when the next round started, the residents were wet again, but there was no way to know how long they had been wet or soiled. An interview was conducted with Anonymous Staff K on (MONTH) 20, (YEAR). This staff stated when coming on shift after there had been one staff that worked the overnight shift, residents were still in the bed and sometimes residents are soaked through the brief and bedding is wet. This staff further stated there would be a strong odor and discolored urine stain on the bedding, so they could tell that the urine had been there for more than an hour. A record review for grievances was completed for the months of July, August, & (MONTH) (YEAR). During this review, it was found there was a grievance submitted for Resident #6 and two grievances submitted for Resident #8. These three grievances were about incontinent care not being provided appropriately and the residents being soiled with urine and/or feces. A record review of the Minimum Data Set (MDS) assessments was completed for Residents #2, 4, 5, 6, 7, and 8. This review found that all residents reviewed require some level of staff assistance for completion of ADLs. Resident #2, Quarterly MDS dated [DATE], Section G Functional status - toilet use: level 3 extensive assistance with 2 person assist; transfer - level 3 extensive assistance with 2 person transfer; Section H - frequently incontinent of bowel and bladder. Resident #4, Quarterly MDS, dated [DATE] Section G Functional status - toilet use: level 3 extensive assistance with 2 person assist; transfer - level 4 total assist with 2 person transfer; Section H - always incontinent of bowel and bladder. Resident #5, Quarterly MDS, dated [DATE] Section G Functional status - toilet use: level 3 extensive assistance with 1 person assist; transfer - level 3 extensive assistance with 1 person transfer; Section H - frequently incontinent of bowel and bladder. Resident #6 , Annual MDS, dated [DATE] Section G Functional status - toilet use: level 3 extensive assistance with 1 person assist; transfer - level 2 limited assistance with 2 person transfer; Section H - always incontinent of bladder and frequently incontinent of bowel. Resident #7, Quarterly MDS, dated [DATE] Section G Functional status - toilet use: level 3 extensive assistance with 2 person assist; transfer - level 2 limited assistance with 1 person transfer; Section H - always incontinent of bowel and bladder Resident #8, Quarterly MDS, dated [DATE] Section G Functional status - toilet use: level 3 extensive assistance with 1 person assist; transfer - level 2 limited assistance with 2 person transfer; Section H - always incontinent of bladder and frequently incontinent of bowel

Based on interviews and record review, the facility failed ensure residents received the necessary care and services to maintain good personal hygiene for 6 of 6 residents sampled for incontinent care (#4, #5, #6, #2, #7, and #8). The findings are: An interview was conducted with Resident #4's wife on (MONTH) 19, (YEAR) at approximately 1:45pm. She stated she was concerned that there was not enough staff to take care of the residents. She also stated she had visited Resident #4 last week and found him sitting in his wheelchair, in his own feces and urine and a puddle of urine on the floor around his wheelchair. An interview was conducted with Resident #5's son on (MONTH) 19, (YEAR) at approximately 2:22pm. He stated that he came to visit on Saturday, (MONTH) 15th around 7:00pm or 8:00pm. He stated the facility was short staffed, so he told the staff that he would get Resident #5 dressed for bed. He further stated that when he went to get the resident dressed, he found the resident with wet pants, a brief that was soaking and wringing wet, and a wet wheelchair. An interview was conducted with Resident #6's wife on (MONTH) 20, (YEAR) at approximately 9:30 am. She stated that she came in one day around 8:45 am to find the resident still saturated with urine from the overnight shift and the day shift staff had not made it to her husband's room for rounds. She further stated she had put in a grievance last month about finding the resident wet, including his mattress. She stated that the facility responded a month later stating they would tell the staff to do their rounds. An interview was conducted with Resident #2's daughter on (MONTH) 20, (YEAR) at approximately 10:01 am. She stated that she came in on (MONTH) 16th, on the second shift, to find that there was one Certified Nursing Assistant (CNA) working that evening and that her father was soaking wet, and his clothing basket had clothing that was dripping wet. Additionally, she stated the resident's bed was soaking wet and his wheelchair smelled, and was wet with urine and poop. She stated that she cleaned her father and his wheelchair. She further stated that around (MONTH) 7th or 8th, she found her father in the Starlight room, which is an activity room for residents with dementia, around 8:30 pm, sitting in urine and feces. An interview was conducted with Resident #7's sister on (MONTH) 26, (YEAR) at approximately 8:53 am. She stated she frequently comes to visit and finds her brother soiled with urine and feces. She stated that he takes a nap at 2:00 pm and when she visits at around 5:00 pm, he is saturated where his entire outfit has to be changed. An interview was conducted with Anonymous Staff A on (MONTH) 18, (YEAR). This staff stated he/she was only able to make 2 rounds during the shift when there was one CNA on the floor instead of the necessary 3-4 rounds, and that not being able to make the rounds meant the residents sat in urine and feces at times. An interview was conducted with Anonymous Staff B on (MONTH) 18, (YEAR). This staff stated that he/she came to work recently, due to being called in to cover a shift, and found residents sitting in urine and feces. This staff stated that there was a need for more staff and he/she had reported this issue. An interview was conducted with Anonymous Staff E on (MONTH) 18, (YEAR). This staff stated that he/she worked 3-4 shifts a week by themselves, and confirmed there were residents that sat in urine and feces for more than 45 minutes because these residents required two-person assistance. An interview was conducted with Anonymous Staff F on (MONTH) 18, (YEAR). This staff stated that on (MONTH) 15th, Resident #2 was sitting in urine and feces and was found this way by his daughter. This staff further stated residents sat in urine and feces for more than an hour at times. An interview was conducted with Anonymous Staff G on (MONTH) 19, (YEAR). This staff stated that residents are staying wet longer and they had noticed residents soiled with feces and urine for 2-3 hours. An interview was conducted with Anonymous Staff H on (MONTH) 19, (YEAR). This staff stated, when short, we constantly have residents waiting 45 minutes to an hour to get changed. An interview was conducted with Anonymous Staff I on (MONTH) 19, (YEAR). This staff stated that residents were waiting an hour to be changed. An interview was conducted with Anonymous Staff J on (MONTH) 19, (YEAR). This staff stated that when working with one CNA, it took about 2 to 3 hours to complete one round and when the next round started, the residents were wet again, but there was no way to know how long they had been wet or soiled. An interview was conducted with Anonymous Staff K on (MONTH) 20, (YEAR). This staff stated when coming on shift after there had been one staff that worked the overnight shift, residents were still in the bed and sometimes residents are soaked through the brief and bedding is wet. This staff further stated there would be a strong odor and discolored urine stain on the bedding, so they could tell that the urine had been there for more than an hour. A record review for grievances was completed for the months of July, August, & (MONTH) (YEAR). During this review, it was found there was a grievance submitted for Resident #6 and two grievances submitted for Resident #8. These three grievances were about incontinent care not being provided appropriately and the residents being soiled with urine and/or feces. A record review of the Minimum Data Set (MDS) assessments was completed for Residents #2, 4, 5, 6, 7, and 8. This review found that all residents reviewed require some level of staff assistance for completion of ADLs. Resident #2, Quarterly MDS dated [DATE], Section G Functional status - toilet use: level 3 extensive assistance with 2 person assist; transfer - level 3 extensive assistance with 2 person transfer; Section H - frequently incontinent of bowel and bladder. Resident #4, Quarterly MDS, dated [DATE] Section G Functional status - toilet use: level 3 extensive assistance with 2 person assist; transfer - level 4 total assist with 2 person transfer; Section H - always incontinent of bowel and bladder. Resident #5, Quarterly MDS, dated [DATE] Section G Functional status - toilet use: level 3 extensive assistance with 1 person assist; transfer - level 3 extensive assistance with 1 person transfer; Section H - frequently incontinent of bowel and bladder. Resident #6 , Annual MDS, dated [DATE] Section G Functional status - toilet use: level 3 extensive assistance with 1 person assist; transfer - level 2 limited assistance with 2 person transfer; Section H - always incontinent of bladder and frequently incontinent of bowel. Resident #7, Quarterly MDS, dated [DATE] Section G Functional status - toilet use: level 3 extensive assistance with 2 person assist; transfer - level 2 limited assistance with 1 person transfer; Section H - always incontinent of bowel and bladder Resident #8, Quarterly MDS, dated [DATE] Section G Functional status - toilet use: level 3 extensive assistance with 1 person assist; transfer - level 2 limited assistance with 2 person transfer; Section H - always incontinent of bladder and frequently incontinent of bowel

Based on interviews and record review, the facility failed to make prompt efforts to resolve grievances for 2 or 3 residents regarding incontinence care (#6 and #8). The findings are: An interview was conducted with Resident #6's wife on (MONTH) 20, (YEAR) at approximately 9:30 am. She stated that she had put in a grievance last month about finding the resident soiled with urine, including his mattress, and stated that the facility responded a month later stating they would tell the staff to do their rounds. A record review for grievances was completed for the months of July, (MONTH) & (MONTH) (YEAR). During this review, it was found there were grievances submitted for Resident #6 and two grievances submitted for Resident #8. These three grievances were about incontinent care not being provided appropriately and the residents being soiled with urine and/or feces. The grievance for Resident #6 was filed on (MONTH) 19, (YEAR). The facility responded to this grievance on (MONTH) 18, (YEAR). One grievance for Resident #8 was filed on (MONTH) 19, (YEAR). There facility responded to this grievance on (MONTH) 12, (YEAR) An interview was conducted with the Staff L, Social Services Director, on (MONTH) 20, (YEAR) at approximately 10:20 am. This staff stated that it was her expectation to see the concern completed and back to her desk within 5-6 days. She also stated that the concerns are talked about during the morning meetings. She further stated that she has mentioned during these morning meetings that staff are not returning the concerns promptly.

Based on interviews and record review, the facility failed to develop and implement an appropriate plan of action to correct identified quality deficiencies regarding staffing and resident care for 2 of 2 units in the facility. The findings are: An interview was conducted with the Senior Staff Clerk on (MONTH) 18, (YEAR) at approximately 7:55 am. She stated that staffing has been a concern due to the number of people calling in and not coming to work. She stated that at full 120 resident census the staffing numbers should be as follows: Fifteen Certified Nursing Assistants (CNAs) on the day shift, fourteen CNAs on the evening shift, and nine CNAs on the overnight shift, but the numbers had been running lower due to call-ins. This staff stated that families had been complaining to the Director of Nursing (DON) and the nurses on the halls about the staffing shortage. She stated that she had also reported staffing concerns and the large amount of call-ins to the DON and the Administrator. A record review of the Senior Staff Clerk's call-in sheet was completed. During the month of July, there were 160 call-ins. During the month of August, there were 138 call-ins. From (MONTH) 1 - 18, there were 96 call-ins. An interview was conducted with the Human Resources Coordinator on (MONTH) 19, (YEAR) at approximately 9:51 am. She stated that there were over 100 call-ins so far for the month of September, and there had been an all staff meeting in (MONTH) and call-ins were discussed and staff were encouraged to come to work. She further stated that staff who exceeded the 3 call-ins in 30 days were not being disciplined appropriately according to policy. An additional interview was conducted with the Senior Staff Clerk on (MONTH) 19, (YEAR) at approximately 10:39 am. She stated from (MONTH) 1 - (MONTH) (YEAR), there were 12 employees that had exceed the 3 call-ins in 30 day rule and of those 12 employees, only one employee was written up. An interview was conducted with the DON on (MONTH) 19, (YEAR) at approximately 10:54 am. She stated that the issue with staff calling in to work was not being addressed by the facility's Quality Assurance and Performance Improvement (QAPI) Committee at that time. She stated that she knew there was an issue, but had not officially documented it. She further stated the staffing issues and call-ins had been going on in great extent for about 2 years. She stated they had talked about the issue in staff meeting but had not brought it to an action plan in QAPI.

Based on observations, staff interview and record review the facility failed to follow the current care plan interventions for transfers for 1 (#111) of 3 sampled residents related to falls. The findings are: Record Review for resident #111 revealed the resident was assessed on the MDS (Minimum Data Set) for a quarterly review as recently as 3/9/12 to have had a fall with injury. The resident's most recent Fall Risk assessment dated [DATE] also placed the resident at high risk for falls with a score of 13. A score of 10 or above places a resident at high risk for falls. The resident had a care plan developed with a problem listed as "Potential for falls D/T (due to) hx (history) of falls, cognitive impairment with poor safety awareness, dx (diagnosis) of Alzheimer's. The goal of the care plan was for the resident to have minimal risk for injury due to falls through the next review date. There were several approaches listed on the care plan. The care plan was last updated on 3/26/12 stating "Use 2 person to transfer resident." The resident was observed on the following dates at the following times: 4/17/12 at 1:30 P.M., 4/18/12 at 8:25 A.M., 8:45 A.M., 9:45 A.M., 12:00 P.M. and 2:50 P.M. During all observations either the chair alarm or bed alarm was attached appropriately. Interview with the resident's 7-3 certified nursing assistant (CNA) "H" on 4-18-12 9:50 A.M. revealed her to say the resident has a pressure alarm in his chair because he has history of trying to get on the toilet by himself. He also has a pressure alarm while in bed. She stated the resident requires 2 people to transfer and the resident does not use a Hoyer Lift (a device used by staff to transfer a resident). Shortly after that interview the CNA was asked how she knows how to care for the resident and/or any other resident she might be assigned in the facility. She related at that point that the CNA's have a book that contains all the information they need to know how to care for a resident. At that point she showed the surveyor the book and the resident's "Nurse Aide's Information Sheet" was reviewed and it also revealed for the resident to "Use 2 people transfer--be ext (extremely) gentle when touching and assisting. If becomes combative ensure safety-give time to calm down-re-approach." The resident 7-3 nurse "J" an LPN, was interviewed on 4/18/12 at 10:03 A.M. She stated at the time the resident was a two person assist with transfers. Both the resident's 7-3 CNA and Nurse were aware the resident had a care plan for being at risk for falls and both would report any change in the resident's condition to the proper persons. Interview with the facility physical therapist on 4/18/12 at 1:45 P.M. revealed her to say she re-evaluates the resident each time he has a fall and record review of her documentation revealed this was done. It was her documentation on 3/26/12 that suggested the resident be transferred "using 2 people for safety. Nsg (Nursing) informed." Interview with the Risk Manager at 2:10 P.M. on 4/18/12 revealed her to be aware of all the resident's falls and for her to have documentation of each fall and new interventions put into place. She also stated at the time that the resident was to be transferred by 2 people effective 3/26/12. Interview with the resident's 3-11 CNA "I" on 4/18/12 at 3:05 P.M. revealed her to say the resident was a Hoyer Lift for transfers. She was not aware the resident had a care plan to be transferred by 2 person's at all times. She also stated there was not always staff available for a two person transfer although she did say two people were always used to transfer the resident by Hoyer Lift. At approximately 3:26 P.M. on 4/18/12 the facility Director of Nursing (DON) was advised of the above CNA interview. She was aware the resident was to be transferred by 2 people at all times and that the resident was not a Hoyer Lift.

Based on staff interview, record review of laboratory tests and physician orders, and policy review, the facility failed to monitor lab values for the use of [MEDICATION NAME] for 1 of 10 residents sampled for unnecessary drugs, #110. The findings are: Record review revealed resident #110 was admitted to the facility on [DATE]. The resident received [MEDICATION NAME] 125mg 2 capsules twice a day beginning 12/10/11 until the order was changed to increase the [MEDICATION NAME] to 250 mg PO ( by mouth) in AM and 500 mg PO at 4 P.M. on 1/20/12. The resident was receiving the [MEDICATION NAME] to control [MEDICAL CONDITION] with Behavioral Disturbances and Aggressive Behavior. The last progress note by the facility psychiatrist was 1/11/12 at which time he recommends to continue with the current medications-one of which at that time was [MEDICATION NAME] 250 mg BID (twice a day). Review of the physician orders [REDACTED]. Interview with the facility Director Of Nurses (DON) on 4/17/12 at 3:00 P.M. revealed her to say " We do obtain [MEDICATION NAME] levels for resident's that receive the medication for behavior issues not to determine therapeutic levels but to assure we aren't over-medicating the resident. " She stated on 4/18/12 at approximately 10:00 A.M. there had been no [MEDICATION NAME] levels drawn since admission on this [AGE] year old gentleman. Interview with the facility pharmacist on 1/18/12 at 11 A.M. revealed him to say [MEDICATION NAME] levels had not been drawn on resident #110 since his admission 4/1/10. He also stated at that time that the facility does not have a policy developed by which they would monitor the [MEDICATION NAME] levels of residents that received the drug for Behavior issues. A review of FDA Approved Labeling Text dated October 7, 2011 for [MEDICATION NAME] revealed 5.14 " since valproate may interact with concurrently administered drugs which are capable for enzyme induction, periodic plasma concentration determinations of valproate and concomitant drugs are recommended " . Also 5.1 Hepatotoxicity : " liver function tests should be performed prior to therapy and at frequent intervals thereafter, especially during the first 6 months. "

Based on observation of breakfast service, staff interview, and policy review, the facility failed to serve buttered toast in a sanitary manner to 3 of 4 randomly sampled residents on the Alpha unit. The findings include: On 4/16/12 beginning at approximately 7:40 am, a dining observation was conducted on the Alpha unit. Four residents were observed to request that staff spread butter and/or jelly on their toast. On 4/16/12 at approximately 7:46 am Certified Nursing Assistant- E (CNA) was observed to assist a randomly sampled resident by buttering his toast. The resident asked her to spread butter on his toast. CNA E was observed to pick up the toast and place it in the palm of her bare hand. On 4/16/12 at approximately 7:59 am CNA- D was observed taking a food tray into room #141. The CNA picked up the resident's toast with her bare hands. The same CNA was observed assisting the resident in room #147 at approximately 8:04 am. The CNA again, picked up the toast and placed it in the palm of bare hand. On 4/17/12 at approximately 12:53 pm an interview was conducted with CNA- E. The CNA confirmed that staff was not suppose to touch the food with their bare hands. On 4/17/12 at approximately 12:56 pm an interview was conducted with CNA- D. The CNA confirmed that staff was not suppose to the food with their bare hands. On 4/17/12 at approximately 1:01 pm an interview was conducted with the Director of Nursing (DON). The DON confirmed that resident's food should not be touched with bare hands. The facility's policy on 'Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices' was reviewed. The policy stated "contact between food and bare (ungloved) hands is prohibited". The 'United States Public Health Service Food and Drug Administration' (FDA) 2009 Food Code was reviewed. Section 3-301.11 Preventing Contamination from Hands stated: (B) Except when washing fruits and vegetables as specified under ? 3-302.15 or as specified in ? (D) of this section, food employees may not contact exposed, ready-to-eat foods with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment.

Based on staff interview, pharmacist interview, review of laboratory tests and physician orders [REDACTED].. The pharmacist also failed to advise the physician to obtain recommended drug serum levels of Depakote. This affected 1 (#110) of 10 residents sampled for unnecessary drug review. The findings are: Record review revealed the Registered Pharmacist (RPh) recommended on 9/27/11 that the labs for BMP (Basic Metabolic Profile) and CBC (Complete Blood Count) be reviewed for resident #110. Interview with the facility Pharmacist on 4/18/12 at 11:00 A.M. revealed him to say he did not know why the physician chose not to do the lab tests at that time. Interview with the RPH on 4/18/12 at 12:10 P.M. revealed him to say he was not sure why the labs were not done. Further interview revealed him to say "Liver enzymes should be done twice a year but at least once a year." He stated the Depakote was basically a valproric acid but a safer formulation of the drug. The Pharmacist also stated he had never recommended a Depakote level be obtained from resident #110 who is [AGE] years old and has been on Depakote 125 mg, 2 capsules twice a day since 12/21/10 with an increase in the Depakote on 1/20/12 to 125 mg two capsules in the A.M. and four capsules at 4 pm. Interview with the Director of Nurses, (DON) on 4/18/12 at 12:30 P.M. revealed her to say "I can produce no evidence or documentation of why the physician did not follow the recommendations of the RPH on 9/27/11." She further stated that she assumed because during that time the physician discontinued the Tylenol maybe he felt there was no need to act upon the recommendations of the RPH but she had no documentation offer. Further record review revealed this resident has lived in the facility since 4/1/10 and at no time were laboratory tests obtained regarding either liver enzyme levels or Depakote levels. Resident #110 lives on the Delta Unit. Interview on 4/18/12 at 1:00 P.M. with the unit manager revealed her to say "an order for [REDACTED]. by the facility psychiatrist." She further stated the reason for this order was because the surveyor was asking about the Depakote levels. She had previously stated on 4/17/12 at 2:30 P.M. that it was not facility practice to order Depakote levels for residents taking the medication for behavior issues-as was resident #110. A review of FDA Approved Labeling Text dated October 7,2011 for Depakote revealed 5.14 " since valproate may interact with concurrently administered drugs which are capable for enzyme induction, periodic plasma concentration determinations of valproate and concomitant drugs are recommended " . Also 5.1 Hepatotoxicity : " liver function tests should be performed prior to therapy and at frequent intervals thereafter, especially during the first 6 months. "

Based on observation, staff interview, and record review of inservice training the facility failed to properly sanitize a point of care device (glucometer) after usage for 1 of 1 sampled resident, #34. The findings include: On 4/17/12 at approximately 4:21 pm Nurse- G was observed performing a bedside blood glucose test on resident #34. The nurse did not sanitize the glucometer prior to usage. After performing the blood glucose test the nurse was observed placing the glucometer back into the medication cart without first sanitizing the meter. An interview was conducted immediately following this observation with Nurse- G about the facility's policy on sanitation of the glucometer. Nurse- G stated that the 11-7 shift cleans the glucometers with Super-Sani wipes and once the glucometer is placed in a new plastic bag it is an indication to the oncoming staff that the meter is cleaned and ready for use. On 4/18/12 at approximately 1:00pm an interview with Director of Nursing (DON) on the cleansing of glucometers. The DON stated that it is the facility's policy to clean glucometers after each use, and that staff would be re-inserviced immediately. A facility inservice training on 'Infection Control: Glucometer Sanitization' dated 2/3/12 was reviewed. The description of the in-service stated that the Glucometer would be sanitized after each use with a germicidal disposable Wipe. Documentation showed that Nurse G attended the inservice. The Centers for Disease Control and Prevention (CDC) recommendations regarding glucometers (blood glucose meter) were reviewed. The CDC recommended: Blood Glucose Meters 1. How can hepatitis B virus (HBV) be transmitted through the meter? If the blood glucose meter never touches the patient, why does it need to be cleaned and disinfected after each use? Infectious agents, such as HBV, can be transmitted through indirect contact transmission, even in the absence of visible blood (<http://www.cdc.gov/injectionsafety/providers/blood-glucose-monitoring_faqs.html>). Indirect contact transmission is defined as the transfer of an infectious agent (e.g., HBV) from one patient to another through a contaminated intermediate object (e.g., blood glucose meter) or person (e.g., healthcare personnel hands) (12 <http://www.cdc.gov/injectionsafety/providers/blood-glucose-monitoring_faqs.html>). Indirect contact transmission can also occur even if the patient never directly contacts the meter. Healthcare personnel hands can become contaminated with blood at various points while performing assisted blood glucose monitoring including pricking the patient ' s finger or handling the test strip. Blood can then be transferred to the meter when healthcare personnel handle the meter to obtain the reading. If the meter is not cleaned and disinfected after use, the blood remaining on the meter can be transferred to subsequent patients via healthcare personnel hands when they handle the meter and then assist with fingerstick procedures. Numerous outbreaks have implicated this mechanism in the spread of HBV infections (<http://www.cdc.gov/injectionsafety/providers/blood-glucose-monitoring_faqs.html>, <http://www.cdc.gov/injectionsafety/providers/blood-glucose-monitoring_faqs.html>). Contamination of equipment and transmission of HBV can also occur if healthcare personnel fail to change their gloves and perform hand hygiene between patients. A multi-hospital study of blood glucose meters found that 30% were contaminated with blood; contamination was identified at the test strip insertion site as well as on the outside surfaces of meters (13 <http://www.cdc.gov/injectionsafety/providers/blood-glucose-monitoring_faqs.html>). Further, HBV has been demonstrated to remain infectious in dried blood on environmental surfaces for at least 7 days (14 <http://www.cdc.gov/injectionsafety/providers/blood-glucose-monitoring_faqs.html>). For these reasons, blood glucose meters should be cleaned and disinfected after each use, unless they are dedicated to a single patient and appropriately stored to prevent inadvertent contamination (See Question 3 under Blood Glucose Meters <http://www.cdc.gov/injectionsafety/providers/blood-glucose-monitoring_faqs.html>).

Based on observation and interview the facility failed to ensure the environment remained free from accident hazards for 1 of 6 medication carts observed. (alpha red cart) The findings include: An observation of the medication cart on the alpha red unit was conducted on 10/3/2011 at approximately 11:55 AM. The cart contained a sharps container full above the indicated line with 2 exposed insulin syringes protruding from the opening. The Licensed Practical Nurse (LPN) left the medication cart unattended to pass medications. A second observation of the medication cart was conducted at approximately 12:20 PM and the syringes remained protruding from the opening of the sharps container. A male resident was observed propelling himself near the medication cart and the cart was again left unattended. An interview was conducted with the LPN on 10/3/2011 at approximately 12:20 PM. The LPN stated they change the sharps containers when they are full and the cart was supposed to have a lid but it was missing. She then used a plastic spoon to force the syringes into the sharps container. The surveyor asked the LPN to remove the sharps container from the cart. The container was observed to be filled above the line that stated "Do not fill above this line." The LPN acknowledged the sharps container was full above the indicated line. An interview was conducted with the Director of Nursing (DON) on 10/3/2011 at approximately 12:43 PM. The DON acknowledged the sharps container should have been emptied and stated she has checked all other med cart containers and implemented a correction on the alpha red cart.

Based on observation, interview and policy review the facility failed to provide pharmaceutical services to ensure accurate administration of all drugs for 1 of 11 sampled residents observed during medication administration. (#5) The findings include: Medication pass was observed on the alpha red unit on 10/3/2011. At approximately 9:50 AM the Licensed Practical Nurse (LPN) administered Synthroid 50mcg by mouth to resident #5. The medication box label read Synthroid 150mcg give one tablet by mouth every morning and was last filled on 9/30/2011. At approximately 11:20 AM the medication box was observed in the presence of the LPN to contain 29-Synthroid 50mcg tablets and 1-Synthroid 150mcg tablet. The LPN confirmed the physician's orders [REDACTED]. The facility policy for medication administration was reviewed on 10/3/2011. #8 of the policy states: The individual administering the medication must ensure that the right medication, right dose, the right time and the right method of administration are verified before the medication is administered.