Every finding on record at Cody Regional Health Long Term Care Center

Based on observation, resident and staff interview, and menu and alternative menu review, the facility failed to consider resident preferences for meals in 2 of 2 dining rooms (main dining room, 2nd floor dining room). The census was 51. The findings were:1. Interview with resident #7 on 4/6/26 at 4:05 PM revealed residents were not offered choices for meals and they get what is served. S/he revealed residents could choose an alternative sandwich to eat if they did not want the main meal. 2. Interview with resident #36 on 4/6/26 at 4:41 PM revealed s/he did not feel she could make choices at the facility and there were not alternative meal options given if s/he did not like the food. 3. Observation of meal service in the second-floor dining room on 4/6/26 at 5:02 PM showed the white board indicated the dinner was a turkey and cheddar wrap with lettuce, tomato, and onion, garlic Brussel sprouts, and banana cream pie. There was no evidence of an alternative meal item listed. Interview with dietary staff member #1 at that time revealed if residents did not want the meal, the alternatives were always different types of sandwiches. The staff member revealed there was not any additional alternative menu items. 4. Interview with resident #10 on 4/7/26 at 9:04 AM revealed residents were able to get sandwiches as an alternative meal and there were no other alternatives available. 5. Observation of meal service in the main dining room on 4/7/26 at 12:05 PM showed dietary staff member #2 asked staff member #1 what she should prepare for resident #43. Staff member #1 stated I would make a sandwich for [him/her]. Without providing resident #43 a choice in his/her meal, the dietary staff member made a turkey sandwich with provolone cheese and chips, and gave it to the other staff member to deliver. Continued observation showed an unidentified CNA told dietary staff member an unidentified resident wanted a ground beef sandwich. The dietary staff member indicated she did not have ground beef, but the had chicken salad instead. The CNA stated Yeah, give [him/her] chicken salad. That should be fine. The dietary staff member made the sandwich and gave it to the CNA to deliver without offering an alternative or an option that was available. 6. Observation of meal service in the main dining room on 4/7/26 at 12:21 PM showed a staff member was going around to each table and telling the residents what the meal was. The staff member would then ask if the meal sounded good or if the resident would like a sandwich. No additional meal alternatives were offered. 7. Review of the facility menu showed there was one meal option posted daily; however, review of the alternative menu showed additional items were available for residents to request at all meals. The alternative menu included entrees and sides for breakfast alternatives and salads, soups, deli items, entrees, accompaniments, from the grill, and desserts for lunch and dinner alternatives. 8. Interview with the dietitian on 4/7/26 at 4:46 PM revealed residents should be offered alternative items if they do not like or want the meal that was being served. She revealed alternative items available at all times included sandwiches, pizza, burgers, and anything else available from the grill. She revealed staff should not make decisions for residents without offering alternative items.

Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure adequate monitoring of psychotropic medications for 5 of 5 sample residents (#2, #4, #5, #41, #56) reviewed for unnecessary medications. The findings were:1. Review of the quarterly MDS assessment dated [DATE] showed resident #41 had a BIMS score of 11 out 15, which indicated moderate cognitive impairment, and diagnoses which included anxiety disorder and depression. Further review showed the resident displayed no behaviors and received antidepressant and hypnotic medication. Review of the physician orders showed the resident received temazepam (hypnotic) 7.5 milligrams (mg) by mouth daily at bedtime for insomnia and duloxetine (antidepressant) 40 mg by mouth twice per day for major depressive disorder. Review of the antidepressant medication care plan, last revised on 3/31/26 showed interventions which included Monitor/Document side effects and effectiveness Q [every] shift. The following concern was identified: a. Review of the medical record showed there were no resident specific or medication specific target symptoms identified or monitored for the use of temazepam or duloxetine. 2. Review of the admission MDS assessment dated [DATE] showed resident #2 had a BIMS score of 12 out of 15, which indicated the resident was cognitively intact, and diagnoses which included depression. Further review showed the resident displayed no behaviors and received antidepressant medication. Review of the physician orders showed the resident received duloxetine (antidepressant) 20 mg mouth daily for rheumatoid arthritis and depressive disorders and trazadone (antidepressant) 50 mg by mouth daily for insomnia. Review of the antidepressant medication care plan, last revised on 1/27/26 showed interventions which included Monitor/Document side effects and effectiveness Q shift. The following concern was identified: a. Review of the medical record showed there were no resident specific or medication specific target symptoms identified or monitored for the use of duloxetine or trazadone. 3. Review of the medical record showed resident #56 admitted to the facility on [DATE] with diagnoses which included depression. Review of the physician's orders showed the resident received Adderall (amphetamine-dextroamphetamine) 20 mg by mouth twice a day for hypoactivity with major depressive disorder and fluoxetine (antidepressant) 80 mg by mouth daily for depression. Review of the antidepressant medication care plan, last revised on 4/2/26 showed interventions which included Monitor/Document side effects and effectiveness Q shift. The following concern was identified: a. Review of the medical record showed there were no resident specific or medication specific target symptoms identified or monitored for the use of Adderall or fluoxetine. 4. Review of the annual MDS assessment dated [DATE] showed resident #4 had a BIMS score of 6 out of 15, which indicated the resident was severely cognitively impaired, and had diagnoses which included non-Alzheimer's dementia, anxiety disorder, and depression. Further review showed the resident received antipsychotic and antianxiety medications. Review of the physician orders showed the resident received brexpiprazole (antipsychotic) 0.5 mg every evening by mouth for agitation, lorazepam (antianxiety) 0.5 mg twice daily for agitation and anxiety, and 0.5 mg lorazepam by mouth as needed every 3 hours for agitation and anxiety. Review of the antipsychotic medication care plan, last revised on 12/16/25 showed interventions which included Monitor behaviors of yelling out, cursing at staff, or sexually inappropriate comments. Document observed behavior and attempted interventions. The following concern was identified: a. Review of the medical record showed there were no medication specific target symptoms identified for the lorazepam. 5. Review of the MDS assessment dated [DATE] showed resident #5 had short-term and long-term memory impairment and had diagnoses which included non-Alzheimer's dementia, depression, and bipolar disorder. Further review showed the resident received antipsychotic and antidepressant medications. Review of the physician orders showed the resident received bupropion (antidepressant) 150 mg by mouth daily for major depressive disorder, fluoxetine (antidepressant) 20 mg daily by mouth for bipolar disorder, and olanzapine (antipsychotic) 5 mg daily at bedtime for bipolar disorder. Review of the antidepressant medication care plan, last revised 5/2/25 showed interventions which included Monitor/document for side effects and effectiveness. Review of the antipsychotic medication care plan, last revised 5/2/25, showed interventions which included monitor for side effects and effectiveness. The following concern was identified: a. Review of the medical record showed there were no resident specific or medication specific target symptoms identified for the Bupropion, fluoxetine, or olanzapine. 6. Interview with the DON, SSD, SDC, LPN #1, and the pharmacist on 4/9/26 at 9:01 AM confirmed the facility did not identify or monitor resident or medication specific target symptoms for psychotropic medications. 7. Review of the policy titled Psychotropic Medications provided by the facility on 4/9/26 showed An unnecessary drug is any drug when used . (3) Without adequate monitoring .

Based on medical record review, resident and staff interview, and grievance log review, the facility failed to ensure reasonable care for the protection of the resident's property from loss or theft for 1 of 4 sample residents (#31) reviewed for missing items. The findings were:1. Interview with resident #31 on 04/06/26 at 4:51 PM revealed s/he stated concerns of a missing short fuchsia colored jacket s/he had only one day and it's been missing since then. The resident stated s/he had mentioned it at the last care plan meeting and nothing had been done.2. Review of a progress notes for resident #31 dated 1/23/26 and timed 2:28 PM showed Per CNA resident refused [his/her] bath and stated I will not take a bath until my purple magnetic jacket is found. Staff has been looking for jacket and laundry has been notified.3. Interview with the SSD on 4/9/26 at 10:38 AM revealed she was not aware of a fuchsia jacket that was missing from resident #31. She stated when clothing went missing the process was to notify laundry.4. Review of the grievance log for the past year revealed no grievances about clothing.5. Interview with the administrator on 4/9/26 at 11:25 AM revealed the facility will be completing a log process for missing clothing, and have that in the care plan meetings. She revealed most clothing items were found quickly and she confirmed there was not a process for identifying missing clothing items.6. Interview with the DON and LPN #1 on 4/9/26 at 11:53 AM revealed they recalled from the last care plan, the jacket in question was obtained by resident #31 from a volunteer, s/he wore it once, and then requested it to be donated. The were unsure what had happened with the jacket after that.

Based on observation, resident record review, staff interview, and policy and procedure review, the facility failed to ensure nursing staff dispensed resident medications according to facility policy and procedure for 1 of 2 resident units (200 unit). The census was 58. The findings were: 1. Observation on 8/19/24 at 5:22 PM showed resident #30 had a medication cup, with medications in it, on the table in front of the resident. Further, observation showed no nurse was present. The resident revealed LPN #1 had dropped it off. 2. Observation on 8/19/24 at 5:55 PM showed resident #47 had a medication cup, with medications in it, sitting in front of resident in dining room. Further, observation showed RN #1 reminded the resident, at 6 PM, to take medication. The RN stated she thought the resident took the medication. 3. Interview with the DON on 8/21/24 at 9:30 AM revealed neither resident was assessed for self-administration of medication and they were not to self-administrator medications. 4. Review of the policy and procedure titled Medication Processing and Administration provided by the facility on 8/21/24 at 10:45 AM by the DON showed .m. a) Process for Administration of Medication .x. The resident is always observed by the licensed nurse during administration to ensure that the dose was completely ingested .

Based on observation, resident record review, staff interview, professional standard review, and policy and procedure review, the facility failed to ensure administered resident medications were taken in the presence of nursing staff for 1 of 2 resident units (200 unit). The census was 58. The findings were: 1. Observation on 8/19/24 at 5:22 PM showed resident #30 had a medication cup, with medications in it, on the table in front of the resident. Further, observation showed no nurse was present. The resident revealed LPN #1 had dropped it off. 2. Observation on 8/19/24 at 5:55 PM showed resident #47 had a medication cup, with medications in it, sitting in front of resident in dining room. Further, observation showed RN #1 reminded the resident, at 6 PM, to take medication. The RN stated she thought the resident took the medication. 3. Interview with the DON on 8/21/24 at 9:30 AM revealed neither resident was assessed for self-administration of medication and they were not to self-administrator medications. 4. Review of the policy and procedure titled Medication Processing and Administration provided by the facility on 8/21/24 at 10:45 AM by the DON showed .m. a) Process for Administration of Medication .x. The resident is always observed by the licensed nurse during administration to ensure that the dose was completely ingested . 5. Review of the National Library of Medicine's Summary of Safe Medication Administration Guidelines, found at https://www.ncbi.nlm.nih.gov/books/NBK593214/table/ch18adminprntlmeds.T.summary_of_safe_med/ on 9/5/24 showed .Follow a standardized procedure when administering medication for every patient .

Based on observation, medical record review, and staff interview, the facility failed to ensure care plans were developed and implemented for 1 of 2 sample residents (#34) observed during personal care. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #34 had a BIMS score of 7 out 15, which indicated severe cognitive impairment, and diagnoses which included renal insufficiency, neurogenic bladder, hypertensive chronic kidney disease, history of traumatic brain injury, and benign prostatic hyperplasia with lower urinary tract symptoms. Further review showed the resident had an indwelling catheter and was dependent on staff for toileting hygiene, personal hygiene, and chair/bed-to-chair transfer. Review of the enhanced barrier precautions care plan initiated on 4/23/24 showed interventions which included .Staff will perform proper donning and doffing of PPE guidelines . The following concerns were identified: a. Observation on 8/21/24 at 10:27 AM showed the resident was seated in his/her wheelchair, in common area, watching television. CNA #2 obtained mechanical lift and attached the lift sling, which was positioned behind the resident, to the lift. The CNA obtained the resident's catheter drainage bag from under the resident's chair, without applying gloves, and attached it to the mechanical lift. After handling the drainage bag, the CNA touched the controls of the mechanical lift, lifted the resident, and positioned him/her over a recliner. The CNA lowered the resident into the recliner and, without applying gloves, removed the catheter drainage bag from the mechanical lift. In addition, the CNA held the drainage bag above the resident's bladder, where urine visible in the tubing flowed toward the resident's bladder, walked it around to the side of the recliner, and placed the drainage bag on the floor next to the recliner. Further observation showed the CNA obtained a blanket and covered the resident, raised the resident's feet, obtained gloves from a box in hanging near the common area and applied them, and wiped down the mechanical lift with sanitizing wipes. b. Review of the indwelling foley catheter care plan last revised on 6/18/24 showed interventions which included Catheter: Position catheter bag and tubing below the level of the bladder . There was no indication the catheter drainage bag should not be positioned on the floor. b. Interview with the DON on 8/21/24 at 3:12 PM revealed the staff member should have donned gloves prior to handling the catheter drainage bag and should not have positioned the bag above the resident's bladder or on the floor. 3. Interview with the DON on 8/22/24 10:13 AM revealed care information should be included on the care plan so staff can know how to provide resident care and staff should follow the care plan.

Based on observation, medical record review, staff interview, and policy and procedure review, the facility failed to ensure infection prevention practices were implemented for 2 of 2 sample residents (#18, #34) observed during personal care. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #18 had a BIMS score of 11 out 15, which indicated moderate cognitive impairment, and diagnoses which included hemiplegia or hemiparesis, non-Alzheimer's dementia, and weakness. Further review showed the resident was dependent on staff for toileting hygiene, dressing, and personal hygiene. Review of the ADL self-care performance deficit care plan last revised on 6/12/24 showed interventions which included . [resident name] requires total assist with a full lift for toileting and incontinence care. [s/he] wears a full brief . and . [resident name] is totally dependence [sic] by 1 staff with personal hygiene . The following concerns were identified: a. Observation on 8/21/24 at 10:14 AM showed CNA #1 assisted the resident to his/her room, obtained a mechanical lift, and left the room. At 10:18 AM CNA #1 and CNA #2 returned to the room, attached the lift sling, which was positioned behind the resident, to the mechanical lift, and assisted the resident out of the chair and into bed. The CNAs removed the residents lift sling from the lift, assisted the resident to position side to side, and removed the sling from under the resident. The CNAs removed the resident's pants and brief and CNA #1 performed perineal care due to urinary incontinence. Without removing her contaminated gloves, CNA #1 placed a clean brief under the resident, pulled up the resident's pants, and held the resident's hands. Interview with CNA #1 on 8/21/24 at 10:39 AM confirmed the resident had been incontinent of urine. b. Interview with the DON and ADON on 8/21/24 at 3:18 PM revealed gloves should be removed and hand hygiene performed when they are contaminated and after resident care. They revealed clean items should not be touched or applied with the dirty gloves. Further interview confirmed the CNA should have removed her gloves after performing perineal care and everything she touched with contaminated gloves would be contaminated. 2. Review of the quarterly MDS assessment dated [DATE] showed resident #34 had a BIMS score of 7 out 15, which indicated sever cognitive impairment, and diagnoses which included renal insufficiency, neurogenic bladder, hypertensive chronic kidney disease, history of traumatic brain injury, and benign prostatic hyperplasia with lower urinary tract symptoms. Further review showed the resident had an indwelling catheter and was dependent on staff for toileting hygiene, personal hygiene, and chair/bed-to-chair transfer. Review of the enhanced barrier precautions care plan initiated on 4/23/24 showed interventions which included .Staff will perform proper donning and doffing of PPE guidelines . Review of the indwelling foley catheter care plan last revised on 6/18/24 showed interventions which included Catheter: Position catheter bag and tubing below the level of the bladder . The following concerns were identified: a. Observation on 8/21/24 at 10:27 AM showed the resident was seated in his/her wheelchair, in common area, watching television. CNA #2 obtained mechanical lift and attached the lift sling, which was positioned behind the resident, to the lift. The CNA obtained the resident's catheter drainage bag from under the resident's chair, without applying gloves, and attached it to the mechanical lift. After handling the drainage bag, the CNA touched the controls of the mechanical lift, lifted the resident, and positioned him/her over a recliner. The CNA lowered the resident into the recliner and, without applying gloves, removed the catheter drainage bag from the mechanical lift. In addition, the CNA held the drainage bag above the resident's bladder, where urine visible in the tubing flowed toward the resident's bladder, walked it around to the side of the recliner, and placed the drainage bag on the floor next to the recliner. Further observation showed the CNA obtained a blanket and covered the resident, raised the resident's feet, obtained gloves from a box in hanging near the common area and applied them, and wiped down the mechanical lift with sanitizing wipes. b. Interview with the DON on 8/21/24 at 3:12 PM revealed the staff member should have donned gloves prior to handling the catheter drainage bag and should not have positioned the bag above the resident's bladder or on the floor. 3. Review of the policy titled IFC: Standard Precaution provided by the facility on 8/22/24 showed .D. PPE: Always follow hand hygiene protocol before donning and doffing. a. Gloves: 1. Gloves are to be worn when contact with blood, body fluids, secretions, excretions, or contaminated items are anticipated .3. Gloves are to be changed between tasks and procedures on the same patient after contact with material that may contain high concentration of microorganisms. 4. Gloves are to be removed promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another patient .

Based on medical record review, staff interview, incident log review, and incident investigation review the facility failed to ensure basic life support and advance directives were followed in 1 of 5 sample residents (#1) reviewed for advance directives. Corrective measures were implemented by the facility prior to the survey and compliance was determined to be met on [DATE]. The findings were: 1. Review the admission minimum data set (MDS) assessment dated [DATE] showed resident #1 had a brief interview for mental status (BIMS) score of 12 out of 15, which indicated moderate cognitive impairment, and diagnoses which included medically complex conditions, atrial fibrillation or other dysrhythmias, pneumonia, depression, respiratory failure, and anxiety disorder. Review of a provider comprehensive 30 day note dated [DATE] and timed 10:52 AM showed .Code status: Full Code . [S/he] was admitted [DATE] - [DATE] for sepsis due to multifocal community-acquired pneumonia (CAP) with acute hypoxic respiratory failure treated with IV antibiotics . Skilled SNF admission for care and physical therapy. Goal is to return to home with assistance from family . The following concerns were identified: a. Review of a progress note dated [DATE] and timed 9:30 AM showed .Writer stated that if s/he wished to pursue hospice, communication could be sent to Doctor (Dr.) [name] for orders to be evaluated .[Daughter name] stated that she thinks the [facility name] would better suite [residents' name]. This information an [sic] request was discussed with nursing management to begin the process of getting hospice orders and a referral for services . b. Review of a progress noted dated [DATE] and timed 10:37 AM showed . [Daughter name] asked that we review options for hospice and keeping his/her mother/father comfortable. Social worker and writer will review with attending . c. Review of a progress note dated [DATE] and timed 12:02 PM showed .Writer communicated with Dr [name] and updated conversation from daughter [name] and social worker. Dr [name] agreed with request for hospice evaluation . d. Review of a progress note dated [DATE] and timed 9 PM showed .Resident sleeping respiratory rate - 28 . e. Review of a progress note dated [DATE] and timed 9:33 PM showed .Resident stopped breathing at 9:15 PM. House supervisor came, pronounced death at 9:20 PM. Called POA at 9:26 PM. Family wants to come in and view resident . f. Interview with the LPN #1 on [DATE] at 8:25 AM confirmed he was the nurse on shift when resident #1 passed away and revealed he did not know or check the resident's code status at the time of passing. The LPN revealed the resident was in a lot of pain and the LPN was trying to get it under control. The LPN revealed he had heard the resident was on hospice when s/he passed away and his/her respirations were 28 when last checked. The LPN revealed he contacted the unit manager and they both thought the resident was DNR because of hospice. The LPN revealed when he identified the resident's code status was full code, he did not feel it would look good to initiate CPR as the family was already at the facility. 2. Review of the policy and procedure titled Code Blue Procedure provided by the administrator on [DATE] at 4:59 PM showed .In the event of a cardiac arrest or respiratory arrest, verify Code status in electronic medical record (EMR). Once verified, Basic Life Support (CPR) will be initiated per code orders and continued until the EMS arrives . 3. Review of the Advanced Directive Action Plan LTC dated [DATE] showed the following: a. Review of the Incident Report - with Follow-up as of [DATE] showed the facility interviewed the LPN and other staff on duty at the time of the incident. The report showed the staff member did not follow policy/process for code status. The staff member was suspended and terminated. All appropriate agencies were contacted. b. The facility verified all resident code status was correct beginning [DATE]. c. The facility performed in-service and 1:1 education beginning on [DATE]. Staff signatures of attendance were verified during the survey. d. The facility updated the policy on [DATE]. e. The facility initiated resident code status review at each care conference beginning [DATE]. 4. Review of the QAPI monthly agenda showed the facility addressed resident code status in January and February meetings. 5. Reviewed the IDT tracking sheets showed the facility team met 3 times a week and under the orders section of their audit triggered any changes or new orders including code status. 6. Review of the staff education Resident Code Status dated [DATE] showed the facility had educated the staff. Interviews during the survey confirmed staff education was completed.

Based on observation, staff interview, review of the US Food Code, and policy and procedure review, the facility failed to ensure the food storage equipment was maintained in a clean and sanitary manner in 1 of 1 kitchens. The census was 52. The findings were: 1. Observation on 7/11/23 at 7:04 AM showed the top of the [NAME] oven, Rational Self-Cooking Center, and the Metro c5 1 series proofing cabinet were soiled with dark discolored dust and grime. Further observation showed extra racks were stored on top of the rational self-cooking center and a cookie sheet was stored on top of the [NAME] oven, and had discolored dust and grime on them. 2. Observation on 7/13/23 at 10:53 AM showed the top of the [NAME] oven, Rational Self-Cooking Center, and the Metro c5 1 series proofing cabinet remained soiled with dark discolored dust and grime. Further observation showed the extra racks remained on top of the rational self-cooking center and a cookie sheet remained on top of the [NAME] oven, and continued to have discolored dust and grime on them. 3. Interview with the executive chef on 7/13/23 at 11:19 AM revealed the equipment was scheduled to be cleaned last Sunday; however, he was unable to get them cleaned and put them on the cleaning list for the following Sunday. He confirmed he was the individual who cleaned the ovens; however, he did not clean the top of them. Further interview confirmed the discolored dust and debris were present and could be transferred to food items. 4. Review of policy titled Food Safety and Sanitation provided by the facility on 7/13/23 showed .7. Work surfaced [sic] and equipment should be thoroughly cleaned after each use . 5. According to Food Code 2017, U.S. Public Health Service: 4-601.11 (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch . (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.

Based on observation, staff interview, and policy and procedure review, the facility failed to ensure medications were properly labeled to include expiration dates for 1 of 2 medication storage areas (second floor medication cart). The findings were: 1. Observation on 7/12/23 at 2:26 PM showed a bottle of Carbidopa/levodopa (decarboxylase inhibitor) 25-100 milligrams (mg) capsules and a bottle of hydrochlorothiazide (diuretic) 25 mg tablets for resident #52 did not have expiration dates. Interview with LPN #1 and RN #1 at that time confirmed neither bottle had an expiration date and revealed both medications were being administered to the resident from the bottles. 2. Interview with the administrator on 7/13/23 at 4:06 PM revealed the facility expected the admitting nurse and pharmacist to verify the medication bottles, brought to the facility by residents had proper labels before the medications were administered. 3. Review of the policy titled Medication Processing and Administration, provided by the facility on 7/13/2023, showed .c) Labeling requirements for medication for LTCC residents .b. All medications will be labeled with the following information .i. innovator brand or non-innovator .iv. Expiration date .c. improperly or inaccurately labeled medications are rejected and returned to the dispensing pharmacy .

Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure baths or showers were provided routinely for 1 of 6 sample residents (#109) who required assistance with ADLs. The findings were: 1. Review of the admission MDS assessment dated [DATE] showed resident #109 admitted to the facility on [DATE], had a brief interview for mental status score of 13 out 15 (which indicated the resident was cognitively intact), and diagnoses which included atrial fibrillation, coronary artery disease, heart failure, hypertension, arthritis and osteoporosis. The following concerns were identified: a. Review of the ADL self-care performance care plan last revised on 4/19/23 showed the resident required limited assistance by 1 staff person with bathing/showering as necessary. Further review showed no indication of the resident's bathing preferences related to the frequency of bathing. b. Review of the progress notes showed the resident discharged from the facility on 4/21/23 c. Review of the bathing record from 3/30/23 through 4/30/23 showed the resident received bathing on 3/31/23 and 4/4/23. The resident refused bathing on 4/21/23. There was no other evidence of bathing or refusals for 17 days between 4/4/23 and 4/21/23. d. Interview with the DON on 7/13/23 at 4:27 PM revealed residents should have bathing 2 to 3 times per week and staff should follow the resident preferences. e. Interview with the DON on 7/13/23 at 4:56 PM revealed she checked the bathing lists and found the resident was not on the list during his/her stay. The DON revealed she asked staff about the resident, and to their knowledge, the resident was self-care. She revealed staff gave him/her the supplies and s/he performed the bathing him/herself. Further interview confirmed the facility had no evidence the resident received or refused bathing during his/her stay except on the days documented in the electronic health record (EHR). f. Review of the policy titled Bathing Residents provided by the facility on 7/13/23 showed .2. The Bath Aide will schedule residents for two baths per week. If a resident requests more or less than two baths, the Bath Aide will notify supervisory staff, and this information will be reflected on the resident's care plan. Resident will be given the choice of a bath or shower .14. The Bath Aide is to document all care provided in the eHR .16. The Bath Aide will keep supervisory staff informed on a regular basis of issues that arise, i.e., resident refusal to bath, schedule changes, concerns or complaints .

Based on review of medical records, staff interview and policy review, the facility failed to ensure a monthly medication regimen review was performed by a licensed pharmacist at least once monthly for 1 of 5 sample residents (#8) reviewed for unnecessary medications. The findings were: 1. Review of the electronic health records for resident #8 showed there was no evidence a monthly medication regimen review was performed for the months of April 2023 and June 2023. 2. Interview with the director of pharmacy on 7/13/23 at 8:29 confirmed the monthly medication regimen review was not completed for resident #8 during April 2023 or June 2023 and the medication regimen review should be completed monthly. 3. Review of the policy and procedure titled Medication Regimen Review (MRR) Pharmacy provided by the facility on 7/13/23 showed .A pharmacist will perform a medication regime review and clinical review on each Long Term Care resident at the time of the resident's admission to the facility, at least monthly, and when requested by facility staff or attending/consulting provider .

Based on observation, staff interview, and policy and procedure review, the facility failed to ensure appropriate infection prevention practices during observations of care for 1 of 8 sample residents (#35). The findings were: 1. Observation on 7/12/23 at 3:12 PM showed LPN #1 and RN #1 entered the room of resident #35. At 3:13 PM, LPN #1 exited the room wearing gloves and holding her hands at shoulder height. The LPN walked down the hallway to the nurse's station, without touching items in the hall, and encountered a CNA. The CNA obtained a measuring tool from the nurse's station and walked with the LPN to the resident's room. Upon reentry to the resident's room, RN #1 assisted the resident to roll to his/her right side and the LPN lowered the resident's brief. The LPN used the measuring tool to measure a small open area near the resident's coccyx. At that time, the LPN touched the resident's skin with her gloved hands and manipulated the measuring device and the resident's skin, to obtain wound measurements. When she finished measuring the area and without changing gloves, the LPN touched the outside of the resident's brief to pull it to the proper position, and touched the exterior of the resident's pants to pull them up. 2. Interview with the infection preventionist on 7/13/23 at 2:30 PM revealed staff should remove gloves before exiting a room and should not touch clean items after contact with potentially contaminated surfaces. Further interview confirmed the nurse should have removed her gloves before going into the hallway and she should not have touched the resident's clothing with the gloves worn to measure the resident's wound. 3. Interview with the DON on 7/13/23 at 2:39 PM confirmed the nurse should have removed her gloves before exiting the resident room and should not have touched the resident's brief or clothing with potentially contaminated gloves. 4. Review of the policy titled Hand Hygiene provided by the facility on 7/13/23 showed . Indications for Hand Hygiene .5. Hand Hygiene will be performed: Before and after patient contact. After contact with a patient's intact skin (e.g. when taking a pulse or blood pressure, and when lifting a patient). After contact with body fluids or excretions, mucous membranes, non-intact skin, or wound dressings. Before donning sterile gloves when doing an invasive procedure. After removing gloves. Gloves must be changed between patients or when moving from a contaminated site to a clean site, or when moving from an area where gloves were applied .

Based on observation, staff interviews, review of the Centers for Disease Control (CDC) guidance, and policy review, the facility failed to ensure oxygen tubing and nasal cannulas were stored in a way that ensured they were protected from contamination for 2 of 6 sample residents (#8, #27) reviewed for oxygen use. Additionally, the facility failed to ensure appropriate personal protective equipment (PPE) was used during 2 random observations. The census was 59. The findings were: 1. Review of the significant change MDS assessment dated [DATE] showed resident #27 had a BIMS score of 9 out 15, which indicated moderate cognitive impairment, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review showed the resident had shortness of breath or trouble breathing with exertion and used oxygen therapy. Review of the oxygen therapy care plan last revised on 8/10/22 showed interventions which included Oxygen Settings: O2 via nasal cannula. The following concerns were identified: a. Observation on 9/28/22 at 4:30 PM showed oxygen tubing dated 9/13/22 was connected to an inline wall-mounted oxygen regulator. The oxygen tubing was placed in a recliner in the resident's room, and was lying on top of a pair of shoes. The nasal cannula was in direct contact with the bottom of the shoe sole. b. Observation on 9/28/22 at 6:57 PM showed the resident was in his/her room and the nasal cannula, dated 9/13/22, was inserted in the resident's nares. c. Observation on 9/29/22 at 9:38 AM showed the resident was in his/her room seated in the recliner, and the nasal cannula which was dated 9/13/22, was inserted in the resident's nares. 2. Review of the quarterly MDS assessment dated [DATE] showed resident #8 had a BIMS score of 9 out of 15, which indicted moderate cognitive impairment, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review showed the resident required limited physical assistance of 1 person for mobility and transfers and required oxygen therapy. Review of the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review showed the resident received [MEDICATION(S)] solution (0.5-2.5 mg) via nebulizer four times per day and a [MEDICATION(S)] [MEDICATION(S)] 1 inhalation two times per day. Review of the oxygen therapy care plan dated 7/21/21 showed interventions which included oxygen via nasal cannula at 6 liters at night and as needed during the day. The following concerns were identified: a. Observation on 9/28/22 at 9:48 AM showed the resident used oxygen from an E cylinder attached to a wheelchair while out of the room and oxygen from a inline wall-mounted oxygen regulator while in the room. The oxygen tubing connected to the inline wall-mounted oxygen regulator was dated 9/28/22 and the nasal cannula was observed lying on the floor, under the wheelchair wheels. b. Observation on 9/29/22 at 8:19 AM showed the resident was in his/her room and the nasal cannula, dated 9/28/22, was inserted in the resident's nares. 3. Interview with CNA #1 on 9/29/22 at 9:48 AM revealed all oxygen tubing was changed out monthly unless it was dirty or fell on the floor. Further interview revealed when a staff member observed oxygen tubing which was stored incorrectly or dirty, the staff member should change the tubing. 4. Interview with the administrator on 9/29/22 at 9:50 AM confirmed oxygen tubing should be changed if it was dirty or not stored correctly. 5. Review of a LTCC [long term care center] EOC/IFC Rounds Checklist which was un-dated and provided by the facility on 9/29/22 showed .VI A. O2 tubing is changed routinely by CP. O2 signs are posted appropriately. B. O2 tubing is placed in plastic bag when not in use . 6. Observation on 9/26/22 at 5:55 PM showed LPN #1 arrived on the second floor wearing a cloth face mask. The LPN entered a door behind the nurses' station with another staff member. Observation on 9/26/22 at 6:18 PM showed LPN #1 was standing at the nurses' cart and wore a cloth mask. Interview with the LPN at that time confirmed the face mask was cloth and revealed the face mask was not provided by the facility. 7. Observation on 9/26/22 at 6:09 PM showed dietitian #1 wore a cloth mask in the dining room during meal service. 8. Interview with the infection preventionist on 9/28/22 at 12:55 PM revealed anyone doing frontline care was required to wear a medical mask and cloth masks should not be used in resident care areas. Further interview revealed the facility was in COVID outbreak status and the community transmission rate was substantial at that time. 9. Review of the policy titled COVID Response Plan which was un-dated and provided by the facility on 9/29/22 showed .Source Control .HCP [health care personnel] should use surgical masks when masks are required as per CDC Guidance, Community levels and outbreak . 10. Review of the CDC Guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic last revised 9/23/22 showed .Cloth mask: Textile (cloth) covers that are intended primarily for source control in the community. They are not personal protective equipment (PPE) appropriate for use by healthcare personnel .

Based on medical record review, staff interview, and review of policy and procedure, the facility failed to ensure appropriate behavior monitoring and interventions were in place for 2 of 5 sample residents (#7, #55) reviewed for unnecessary medications. The findings were: 1. Review of the admission MDS assessment dated [DATE] showed resident #7 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact, and had diagnoses which included non-Alzheimer's dementia and [CONDITION(S)]. Further review showed the resident had mild depression with a severity score of 2 out of 30 and no additional coded behaviors. Review of the physician orders showed the resident received [MEDICATION(S)] (antidepressant) 50 milligrams (mg) by mouth daily at bedtime for adjustment disorder with depressed mood. Review of the depression care plan last revised on 8/2/22 showed interventions which included .Document/report PRN any risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness, impaired judgement or safety awareness .Document/report PRN any s/sx [signs or symptoms] of depression, including: hopelessness, anxiety, sadness, [CONDITION(S)], anorexia, verbalizing negative statements, repetitive anxious or health-related complaints, tearfulness . The following concerns were identified: a. Review of the medication administration record (MAR) and treatment administration record (TAR) for July 2022, August 2022, and September 2022 showed the facility had monitoring in place for withdrawal symptoms related to the use of [CONDITION(S)] medication; however, there was no evidence the facility was monitoring the resident for identified target symptoms. b. Interview with the administrator on 9/29/22 at 9:35 AM confirmed behavior symptoms related to medication withdrawal were listed on the TAR; however, there was no monitoring of identified target symptoms for the medication. c. Review of the CNA Behavior Monitoring and Interventions report from 6/28/22 through 9/28/22 showed panic was observed on 7/24/22, expressions of frustration/anger, other behaviors not directed at others, and refusing care was observed on 9/3/22, anxious/restless and refusing care was observed on 9/12/22, and expressions of frustration/anger, agitation, and withdrawn/isolation was observed on 9/17/22. No other behaviors were observed during the time period and resident-specific identified target symptoms identified on the care plan were not monitored. d. Review of the behavior care plan last revised on 8/2/22 showed no identified non-pharmacological interventions related to identified target symptoms. 2. Review of the significant change MDS assessment dated [DATE] showed resident #55 had a BIMS score of 9 out of 15, which indicated the resident had moderate cognitive impairment, and had diagnoses which included depression, and [CONDITION(S)]. Further review showed the resident had mild depression with a severity score of 5 out of 30 and no additional coded behaviors. Review of the physician orders showed the resident received [MEDICATION(S)] (antidepressant) 10 mg by mouth daily for major depressive disorder and [MEDICATION(S)] (sedative-hypnotic) 3 mg by mouth at bedtime for [CONDITION(S)]. Review of the depression care plan last revised on 8/5/22 showed interventions which included .Document/report PRN any risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness .Document/report PRN any s/sx of depression, including: hopelessness, anxiety, sadness, [CONDITION(S)], anorexia, verbalizing negative statements, repetitive anxious or health-related complaints, tearfulness . The following concerns were identified: a. Review of the medication administration record (MAR) for July 2022, August 2022, and September 2022 showed no evidence the facility was monitoring the resident for identified target symptoms. b. Review of the sedative/hypnotic care plan last revised 8/8/22 showed no resident-specific target symptoms for use of the medication or identified non-pharmacological interventions. c. Review of the depression care plan last revised on 8/5/22 showed no identified non-pharmacological interventions related to identified target symptoms. d. Interview with the DON, SSD, and first floor unit manager on 9/29/22 at 8:44 AM revealed the resident was on as needed behavior monitoring and was not being monitored for target symptoms unless the symptoms occurred. 3. Interview with the DON, SSD, and first floor unit manager on 9/29/22 at 8:42 AM revealed resident care plans should have the target symptoms identified for each medication. Behavior tracking is performed by the CNAs in ADL charting; however, specific identified target symptoms were not part of the CNA tracking. Further interview revealed the facility staff should utilize progress notes for charting of target symptoms. 4. Review of the policy titled Monitoring Chemical/Physical Restraints which was un-dated and provided by the facility on 9/29/22 showed .A .2. Upon recognizing a specific behavior that does/or could adversely affect a patient, the RN/LPN or C.N.A. observing the behavior will start a Behavior Monitor. Place the Behavior Monitor in the Medication Administration Review (MAR) notebook. A Behavior Monitor from [sic] will be initiated before a new order (or change in an order) for a psychoactive medication is started. The Social Worker will review behavior monitors on an ongoing basis and will recommend any further approaches to be used for behavior management .B .1. Before a resident is started on psychoactive medication, nursing service will document specific behaviors on the Behavior Monitor form. 2. If a new psychoactive medication is ordered or a medication change is begun, the Behavior Monitor will also be used. The resident's behavior will be monitored to assess change, including side effects and adverse reactions .

Based on observation, staff interview, review of professional standards, review of manufacturer recommendations, and policy and procedure review, the facility failed to ensure appropriate infection control practices were implemented. Specifically, the facility failed to ensure blood glucose monitors were disinfected between uses during 1 of 5 observations (resident #2). This failure resulted in an unacceptable risk to resident health and a determination of immediate jeopardy. In addition, the facility failed to ensure appropriate infection prevention practices during 1 of 1 observations of wound dressing changes (which affected resident #111). The findings were: Regarding blood glucose monitoring: 1. Observation on 8/25/21 at 11:43 AM showed LPN #1 obtained a blood glucose reading for resident #24 using a glucometer. After obtaining the result, the LPN did not clean the glucometer. The LPN then entered the main dining area to find the remaining residents on whom she needed to check blood glucose levels. At 11:49 AM the nurse loaded a glucometer strip into the glucometer and approached resident #2. The nurse set the supplies down on the resident's table, and cleaned the resident's finger. Once it became apparent the nurse was going to utilize the same glucometer without disinfection, the surveyor intervened to stop the glucose check. 2. Interview with LPN #1 on 8/25/21 at 11:49 AM revealed she was going to obtain all the residents' blood glucose measurements before she sanitized the glucometer. At that time, the LPN left the cart and obtained a Dispatch (bleach disinfectant towels) wipe to sanitize the glucose monitor. She stated the Dispatch contact time (time the disinfectant must remain wet in are being disinfected) was 3 minutes. 3. Interview with the DON on 8/25/21 at 12:20 PM revealed it was the facility's expectation for staff to clean the glucometer between each resident use. Staff were to use the Sani-wipes with the contact time of 1-3 minutes. 4. Review of the manufacturer recommendations showed . Cleaning the exterior surface of the Precision Xceed Pro Monitor daily recommended. Follow your facility's policies and procedures for infection control, which may require more frequent cleaning.Bleach or [MEDICATION(S)] based cleaners will fade the monitor keypad .wipes are not recommended . 5. Review of the policy and procedure titled Glucometer Use Guidelines provided by the facility on 8/25/21 showed .7. c. Proficiency Testing: i. Proficiency tests are performed quarterly by those that routinely use the system .8. Cleaning of the glucometer units: a. Cleaning of glucometer units is performed after each patient use. b. Glucometer units are cleaned with the PDI Super Sani-Cloths. Instruments will be wiped thoroughly until visibly wet and must sit for at least 2 minutes before being used on another patient. a. Review of LPN #1's FreeStyle Precision Pro Blood Glucose and B-[MEDICATION(S)] Monitoring System Learning Assessment showed the LPN was last assessed for proper use and disinfecting of the glucometer on 5/21/19. 6. Review of the CDC's Frequently Asked Questions (FAQs) regarding Assisted Blood Glucose Monitoring and Insulin Administration(found at https://www.cdc.gov/injectionsafety/providers/blood-gluecose-monitoring_faqs.html and retrieved on 8/25/21) showed .Blood Glucose Meters .Infectious agents, such as HBV, can be transmitted through indirect contact transmission, even in the absence of visible blood [4]. 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].With some blood glucose meters that require pre-loading of the test strip, the device may come into direct or close contact with the patient's finger stick wound. If blood is transferred from the patient to the meter, and the meter is not cleaned and disinfected after use, subsequent patients can be exposed to this blood when the meter is used on them. Indirect contact transmission can also occur even if the patient never directly contacts the meter. Healthcare personnel's 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 [3, 4]. Contamination of equipment and transmission of HBV can also occur if healthcare personnel fail to change their gloves and perform hand hygiene between patients. 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 . On 8/25/21 at 2:05 PM the administrator was informed of an immediate jeopardy situation in the area of infection control related to a failure to disinfect blood glucometers between resident uses. The facility submitted an action plan which included the following immediate changes: 1. Both glucometers were disinfected immediately by the Interim DON: The first floor machine at 1425 [2:45 PM] with a super sani cloth wet time 2 minutes and at 1445 [2:45 PM] the second floor unit was cleaned with super sani cloth wet time 2 minutes. 2. All licensed nurses currently on duty will be re-educated immediately by the DON or RN Manager designee and competencies checked on proper disinfecting of glucometers between use. 3. All licensed nurses not currently on duty will be re-educated and competencies checked of the same by the Interim DON and/or Nurse Supervisors prior to their next scheduled shift. 4. Verification of compliance-any licensed nurse who conducts a glucometer check will document that disinfecting of the machine occurred before and after use with a resident and a second staff member must also witness and document verification the disinfecting occurred. The 2 Nurse managers will conduct 10 random observations per week of the licensed nurses conducting glucometer check to verify ongoing compliance after re-education is completed. The action plan was accepted on 8/26/21 at 9:30 AM. The implementation of the action plan was removed on 8/26/21 at 2:15 PM; however, verified and immediate jeopardy was deficient practice remained at a scope and severity of D. Regarding infection prevention practices during dressing changes: 1. Observation of on 8/25/21 at 9:59 AM showed LPN #1 entered the room of resident #111. The LPN set her wound care supplies out on the, without placing a barrier down, donned gloves, and removed the dressing to the resident's right lower leg. She cleaned the wound with a solution and 4X4's and cut the dressing supplies before placing her shears on top of the resident's belongings on the over bed table, without a barrier. The LPN placed a blue chux on the floor under the resident right lower leg, and moved the supplies for the dressing change down to the blue chux on the floor. The nurse obtained tape from the resident's night stand and placed the roll on the blue chux between applications. No hand hygiene or doffing of gloves was performed until the completion of the dressing change. 2. Interview with LPN #1 on 8/25/21 at 10:15 AM revealed she always performed wound care on the resident in the manner observed. 3. Interview with the DON on 8/26/21 at 9:45 AM revealed the facility expectation was to change gloves and perform hand hygiene upon entry to the resident room, between dirty and clean dressing changes, and before leaving the resident room. Further interview revealed supplies should be stored in areas where clean items can not be contaminated by dirty items. 4. Review of the policy and procedure titled Infection Prevention and Control - LTCC provided by the facility on 8/26/21 showed .Hand hygiene will be consistent with acceptable standards of practice-using hand washing versus alcohol-based hand rub (ABHR) (Standard Precautions Policy) .Resident care to include catheters, skin/wound care, point-of care testing .(Lippincott). 5. Review of Nursing Interventions & Clinical Skills (6th edition) by P.A. Perry - 2016, pages 688 - 689, showed . 3. Apply clean gloves.Draping provides access to wounds while minimizing exposure. Avoids contamination of supplies. 4. Gently remove tape, bandages . 8. Apply clean gloves, remove gauze cover over wound, and then cleanse wound . 11.Dispose of gloves. Perform hand hygiene. 12. (1) Apply clean gloves. Apply dressing.

Based on the facility assessment review and staff interview the facility failed to conduct the annual assessment for 1 of 1 facility. The findings were: Review of facility assessments showed the facility completed assessments for the years of 2018, 2019, and partially completed the assessment for 2021. Further review showed the facility failed to complete the assessment for 2020. Interview with the administrator on 8/26/21 at 9:40 AM revealed the last facility assessment was completed in 2019. Further interview revealed she had just finished the 2021 facility assessment.

Based on observation, staff interview, and medical record review, the facility failed to ensure bed rail assessments indicated safe use for 3 of 5 sample residents (#34, #44, #52) with bed rails. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #34 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review showed the resident required extensive physical assistance of 2 or more people for bed mobility and extensive physical assistance of 1 person for transfers and personal hygiene. The following concerns were identified: a. Observation on 8/24/21 at 11:43 AM showed the resident was in bed and enablers/assist bars were in place to the bilateral upper portion of the bed. b. Observation on 8/25/21 at 9:18 AM showed the resident was in bed and enablers/assist bars were in place to the bilateral upper part of bed. c. Observation on 8/26/21 at 11 AM showed the enablers/assist bars were designed with two separate gaps which maintenance staff #1 measured as 6 1/2 inches by 3 7/8 inches, and 12 1/4 inches by 3 7/8 inches. d. Review of the medical record showed no evidence the enablers/assist bars were assessed for entrapment risk. 2. Review of the quarterly MDS assessment dated [DATE] showed resident #44 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review showed the resident required extensive assistance of 2 or more people for bed mobility and transfers and extensive assistance of 1 person for personal hygiene. The following concerns were identified: a. Observation on 8/24/21 at 2 PM showed the resident was in bed and enablers/assist bars were in place to the bilateral upper part of the bed. b. Interview with CNA #1 on 8/25/21 at 6:52 PM revealed the resident was not able to reposition him/herself. c. Observation on 8/26/21 at 11:02 AM showed the enablers/assist bars were designed with two separate gaps which maintenance staff #1 measured as 6 1/2 inches by 3 7/8 inches, and 12 1/4 inches by 3 7/8 inches. d. Review of the medical record showed no evidence the enablers/assist bars were assessed for entrapment risk. 3. Review of the admission MDS assessment dated [DATE] showed resident #52 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a BIMS score of 14, which indicated s/he was cognitively intact. Review of current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Emery. Two times a day for R ankle fracture. The following concerns were identified: a. Observation on 8/23/21 at 4:54 PM showed the resident seated in his/her wheelchair next to his/her bed, and enablers/assist bars were in place to the bilateral upper part of the bed. b. Observation on 8/26/21 at 11:06 AM showed the enablers/assist bars were designed with two separate gaps measured by maintenance staff #1 as 6 1/2 inches by 3 7/8 inches, and 12 1/4 inches by 3 7/8 inches. c. Review of the medical record showed no evidence the enablers/assist bars were assessed for entrapment risk. 4. Interview with the DON on 8/26/21 at 11:06 AM revealed the facility did not assess the rails for entrapment risk and the use of the devices should be on the care plan.

Based on medical record review, staff interview, and review of the CMS MDS 3.0 Resident Assessment Instrument (RAI) manual, the facility failed to ensure a significant change assessment was completed 1 of 3 sample residents (#44) with an identified change in condition. The findings were: 1. Review of the annual MDS assessment dated [DATE] showed resident #44 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS showed the resident had a brief interview for mental status (BIMS) score of 13 out of 15, which indicated the resident was cognitively intact. The resident required supervision with set-up help for eating. Further review showed the resident had no identified weight loss, was at risk for pressure ulcers, and had no identified pressure ulcers at the time of the assessment. The following concerns were identified: a. Review of the quarterly MDS assessment dated [DATE] showed the resident required extensive assistance of 1 person for eating and had weight loss of 5% or more in the last month or a loss of 10% or more in the last 6 months which was not physician prescribed. Further review showed the resident had an unstageable pressure ulcer, which was not previously coded. b. Interview with the MDS coordinator on 8/26/21 at 9:43 AM confirmed the quarterly MDS assessment should have been a significant change assessment because of the identified areas. c. Review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual version 1.17.1 last revised October 2019 showed .A 'significant change' is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered 'self limiting'; 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan .

Based on medical record review and staff interview, the facility failed to ensure Preadmission Screening and Resident Review (PASARR) requirements were met for 2 of 4 residents (#11, #44) reviewed. The findings were: 1. Review of the 5/29/21 MDS quarterly assessment showed resident #11 was admitted to the facility on [DATE], and had no identified psychiatric diagnoses. The following concerns were identified: a. Review of the medical record showed the resident received a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review showed no PASARR level I or PASARR level II were completed for the new psychiatric diagnosis. b. Interview with the social services director on 8/26/21 at 1:37 PM confirmed delusional disorders was a psychiatric diagnoses, and required an evaluation of the resident through the PASARR Level 1 screening. Further interview confirmed neither the PASARR level I, nor the level II, were completed for the new diagnosis. 2. Review of the annual MDS assessment dated [DATE] showed resident #44 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The following concerns were identified: a. Review of the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review showed the resident received a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . b. Review of a PASARR level I completed on 10/5/17 showed no psychiatric diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the electronic medical record showed no other PASSARs were completed for the resident. c. Interview with the MDS coordinator on 8/26/21 at 10:32 AM revealed the facility did not complete a new PASSAR when the resident received a new psychiatric diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, staff interview, and medical record review, the facility failed to ensure resident safety and/or supervision for 1 resident (#1) of the facility who was allowed to smoke. Review of a facility-resident contract and letter of policy violation showed the facility was aware the resident was not safe to smoke; however, allowed the unsafe practice to continue. Therefore, this resulted in an immediate jeopardy for this resident. The findings were: Review of the 1/9/13 physician progress notes [REDACTED]. The physician also noted the resident continued to smoke "about four cigarettes a day. (S/he) is admonished not to smoke when (s/he) has (his/her) oxygen on." Review of the resident care plan showed a problem identified was "risk of injury while using oxygen and smoking." The review dates documented with this care plan were: 4/5/12, 4/16/12, 7/5/12, 10/4/12, and most currently 1/3/13. The goal was for the resident to have no injuries related to smoking. The documented interventions showed "educate and remind (resident) of risks and safety precautions quarterly at minimum." The care plan showed no other interventions had been added or discontinued. Review of the 1/4/13 quarterly assessment note related to the resident's cognition and socialization, showed the resident had moderate impairment based on a tool used to determine mental status known as "BIMS" (brief interview for mental status) score of 8 out of 15. The note further showed this was a decline in cognition based on his/her previous score of 14 out of 15. Additionally, this assessment note showed the "social worker re-educated the resident on hazards of smoking while oxygen is in use." The following concerns were identified related to safety for this resident: a. Observation on 2/25/13 at 1:02 PM showed resident #1 was outside on the sidewalk about 50 feet from the facility entrance smoking a cigarette while his/her oxygen was in use. The resident had an oxygen canister affixed to the back of his/her wheelchair and used a nasal cannula (tube like apparatus which is inserted into nostrils) to breath the oxygen flowing from the tank. Within a minute into the observation, RN #2 walked out the main entrance and turned off the resident's oxygen tank. The RN did not stay with the resident, and the resident was not supervised by any other staff at that time. b. Review of a document titled "Release of Responsibility For Smoking" showed the resident and facility representative signed the release on 3/9/12. Review of the release showed the facility policy did not allow smoking anywhere in the building or on the property. However, the document further showed the resident was assuming "all risks" related to choosing to smoke. The risks were shown as "may include, but are not limited to: burns, falls, fracture, injury by vehicle, respiratory disease and infections, and other risks including possible death from injury, accident, or illness." c. Review of a letter to the resident dated 6/26/12 from the facility showed on 6/21/12 the resident had been found smoking in his/her room in the facility. The letter described the violation to the smoking policy and advised the resident that "Any further occurrences...will result in immediate removal of all smoking materials from your possession, and possible further action to discharge you from the facility." d. Interview with the DON on 2/26/13 at 3:15 PM verified she was aware the resident went outside and smoked multiple times daily. The DON further revealed the resident had signed the release and the facility felt that this was okay and they did not provide staff to supervise the resident because it would take staff away from other residents. However, the DON acknowledged this was an unsafe practice because the resident did not always turn off the oxygen when smoking and serious injury could result. She further verified the resident did not keep his/her own smoking materials, they were kept at the nurses' desk and the resident had to ask for them. e. Interview with CNA #1 on 2/26/13 at 2:40 PM, RN #2 on 2/26/13 at 4:45 PM, and the administrator on 2/26/13 at 4 PM, all revealed it was commonly known the resident smoked daily without supervision, and at times did so with his/her oxygen in use. Furthermore, they all three verified the plan of care was to allow the resident to do so at his/her own risk. On 2/26/13 at 4 PM, the administrator was notified of the immediate jeopardy. The nursing facility's action plan included immediate changes to include: a. An assessment of the resident's smoking and safety completed 2/26/13. b. Agreement by the resident to immediately stop smoking, with all smoking materials removed from the resident on 2/26/13. c. The resident's family was advised and agreed to not provide the resident with any future smoking materials involving ignition source such as matches or lighters. d. The resident was offered and accepted the option to use a battery operated electronic cigarette. e. The facility staff were educated on the new practice/care plan for the resident related to smoking. f. The facility policy and procedure that smoking is not permitted anywhere in the building or on the grounds is and will be strictly followed. The action plan was accepted on 2/27/13 at 10:17 AM, and the immediate jeopardy was removed on 2/27/13 at 12:30 PM. However, deficient practice remianed at a scope and severity of D (No actual harm with potential for more than minimal harm this is not immediate jeopardy).